No Such Thing as Low-Risk Surgery in Frail Patients: Operative Stress and Loss of Independence

BackgroundOperative stress and frailty impact perioperative loss of independence (LOI); however, their combined effect on LOI remains unclear.Materials and MethodsA single institution retrospective study was conducted using prospective data from patients aged >50 years undergoing elective inpatient surgery. Stress was categorized by operative stress score (OSS) as high (OSS 4, 5) or low (OSS 1, 2, 3), and frailty was defined as risk analysis index (RAI) ≥ 31. Loss of independence was defined as a discharge disposition other than home. Univariate and multivariate logistic regression analyses were used to understand the independent and combined effects of OSS, frailty, and covariates on LOI.ResultsA total of 13,674 patients were included: 557 (4%) experienced LOI. Demographics were similar between patients with and without LOI (median age 66 years, 50% female, 96% White). Most patients (80%) underwent low-OSS procedures. On univariate analysis, age >65 years (OR 1.8), frailty (OR 4.2), and high OSS (OR 2.4) were associated with LOI. Among patients undergoing low-OSS procedures, frailty remained strongly associated with LOI (OR 4.6; 11% LOI rate in frail patients). On multivariate subset analysis for patients in the high-OSS population, age >65 (OR 2.1) and frailty (OR 3.5) were associated with LOI.DiscussionThe risk for LOI is >10% for frail patients undergoing low-stress procedures. Age >65 years, frailty, and higher OSS were all independently associated with elevated odds for postoperative LOI.