Economic impact of preoperative frailty in patients undergoing cytoreductive surgery

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) is a complex and costly treatment for peritoneal surface malignancies. While preoperative frailty is known to worsen postoperative outcomes, its economic impact in CRS + HIPEC remains underexplored. This study evaluated the association between preoperative frailty and in-hospital costs in this population.

A retrospective cohort study was conducted at a tertiary center in Sydney, Australia, including adults who underwent CRS + HIPEC from May 2017 to June 2024. Frailty was assessed using the Clinical Frailty Scale (CFS), with scores of 4 or higher classified as frail. Patient characteristics, surgical outcomes, and in-hospital cost data, including staff, intensive care, diagnostics, theatre, ward, and other services, were collected. Mann-Whitney U tests and chi-square tests were used for comparisons. Multivariable linear regression identified cost drivers in frail patients.

Among 466 patients, 60 (12.9%) were classified as frail. Frail patients were significantly older than non-frail patients. Cost differences were particularly evident in staffing, diagnostics, and ward-related care, with frail patients incurring higher expenses across all categories. Total in-hospital costs were significantly higher in frail compared to non-frail patients (median AU$115,282 vs AU$106,938; p = 0.005). Multivariate analysis identified intensive care unit stay as the primary driver of total in-hospital cost within the frail cohort.

Preoperative frailty is independently associated with increased in-hospital costs among patients undergoing CRS + HIPEC. These findings highlight the value of incorporating frailty assessment into preoperative evaluation and suggest a need for targeted perioperative strategies to optimise outcomes and resource use in frail surgical populations.