Simplifying Hospital Quality Comparisons for Vascular Surgery Using Center-Level Frailty Burden Rather Than...

Area of Science:

• Vascular Surgery
• Health Services Research
• Quality Measurement

Background:

• Failure to rescue (FtR) is a key hospital quality indicator, yet current risk adjustment relies on comorbidity scores, not patient frailty.
• Significant variation exists in the proportion of frail patients across hospitals, potentially skewing quality comparisons.

Purpose of the Study:

• To evaluate the impact of incorporating patient frailty into risk-adjustment algorithms for hospital quality measurement.
• To assess frailty as a means of improving risk adjustment for failure to rescue.

Main Methods:

• Analysis of 63,143 patients undergoing major vascular procedures from the Vascular Quality Initiative (VQI) (2003-2019).
• Multivariable logistic regression with center-level hierarchical modeling to predict in-hospital death.
• Comparison of hospital FtR observed/expected ratios using comorbidity-based vs. frailty-based risk adjustment.

Main Results:

• Frailty was significantly associated with failure to rescue (scaled OR 1.9, P < 0.001).
• Frailty-based and comorbidity-based models demonstrated similar predictive performance (C-statistics 0.82-0.85).
• Twenty-three percent of hospitals improved their ranking by ≥5 positions when using frailty for risk adjustment, particularly high-volume centers.

Conclusions:

• A simple frailty-adjusted model is comparable to comorbidity-focused models for predicting FtR and influencing reimbursement.
• Preoperative frailty assessment can guide quality improvement initiatives for high-risk patients.
• Risk adjustment strategies incorporating frailty benefit centers with higher volumes of frail patients and vascular surgery procedures.