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Will My Patient Survive an Anastomotic Leak? Predicting Failure to Rescue Using the Modified Frailty Index
Richard T Spence1, Dhruvin H Hirpara1, Sachin Doshi2
1Department of Surgery, University of Toronto, Toronto, Canada.
Importance:
Failure to rescue (FTR), or death after major complications, has emerged as a marker of hospital-level quality of care.
Objective:
To evaluate the predictive performance of the ACS-NSQIP modified frailty index (mFI) in determining FTR following an anastomotic leak (AL) after a colectomy for colorectal cancer.
Design:
Retrospective cohort study.
Setting:
Multicenter interrogation of the 2012-2016 American College of Surgeons (ACS) colectomy procedure targeted National Surgical Quality Improvement Program (NSQIP) database.
Patients And Methods:
A total of 50,944 patients who underwent colectomy for colorectal cancer.
Exposure:
Frailty as measured by: (1) Age, ASA, and emergency status (model 1), (2) Age, ASA, emergency status, and mFI (model 2), (3) ACS-NSQIP mortality prediction (model 3).
Main Outcome And Measure:
Primary outcome was FTR after AL.
Results:
A total of 1755 patients experienced an AL (3.46%) with a FTR rate of 6.44%. The mean age was 65.6 years (95% CI 65.28-65.58 years), median ASA was 3 (IQR 2-3), 51 patients (2.92%) were partially or totally dependent, 366 (20.86%) were diabetic, 105 (5.98%) had a history of chronic obstructive pulmonary disease (COPD), 32 (1.82%) had a history of congestive heart disease (CHD), and 966 (55.04%) were on hypertensive treatment. The performance of model 1 (AUROC 0.77; 95% CI 0.72-0.81), model 2 (AUROC 0.77; 95% CI 0.73-0.82), and model 3 (AUROC 0.79; 95% CI 0.75-0.83) to predict FTR was not different (p = 0.44).
Conclusions And Relevance:
Age and ASA remain the most reliable predictors of failure to rescue anastomotic leak after colectomy for colorectal cancer. Addition of the modified frailty index, or all variables collected by NSQIP, did not significantly improve predictive performance.
Insights
Age and ASA are the best predictors of failure to rescue after colectomy for colorectal cancer. The modified frailty index (mFI) did not improve prediction of failure to rescue (FTR) after anastomotic leak (AL).
Area of Science:
- Surgical Quality Improvement
- Colorectal Cancer Surgery
- Patient Outcomes
Background:
- Failure to rescue (FTR) is a key indicator of hospital quality.
- Predicting FTR after colectomy for colorectal cancer is crucial for patient outcomes.
Purpose of the Study:
- To assess the predictive accuracy of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) modified frailty index (mFI) for FTR following anastomotic leak (AL) after colectomy.
- To compare the predictive performance of mFI with traditional predictors like age and ASA classification.
Main Methods:
- Retrospective analysis of 50,944 patients undergoing colectomy for colorectal cancer from the 2012-2016 ACS-NSQIP database.
- Evaluated three models: Model 1 (age, ASA, emergency status), Model 2 (Model 1 + mFI), and Model 3 (ACS-NSQIP mortality prediction).
- Primary outcome was FTR after AL.
Main Results:
- Anastomotic leak (AL) occurred in 3.46% of patients, with a 6.44% FTR rate.
- Model 1 (AUROC 0.77) and Model 2 (AUROC 0.77) showed similar predictive performance for FTR.
- Model 3 (AUROC 0.79) also did not significantly outperform the simpler models (p=0.44).
Conclusions:
- Age and ASA classification remain the most robust predictors of FTR after colectomy for colorectal cancer.
- Incorporating the mFI or other NSQIP variables did not substantially enhance the prediction of FTR following AL.
- These findings emphasize the continued importance of fundamental patient factors in surgical outcomes prediction.
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