Implementation of a preoperative frailty screening and optimization pathway for vascular surgery patients is associated with decreased 30-day readmission.

Abstract

Objective: Frailty is characterized by decreased physiological reserve and vulnerability to adverse events in the presence of a stressor such as surgery. We prospectively implemented a preoperative frailty screening and optimization pathway for patients undergoing vascular surgery and assessed its impact on postoperative outcomes.

Methods: As part of an ongoing quality improvement initiative, surgical frailty was assessed prospectively in all patients undergoing inpatient surgery using the Risk Analysis Index (RAI). Baseline data were collected from May to July 2022. Frail patients (RAI score of ≥37) were referred to an anesthesia optimization clinic, nutrition consultation, and case management evaluation in the intervention phase (August 2022 to July 2023). Primary outcomes were postoperative hospital length of stay, 30-day readmission, and 30-day mortality. Secondary outcomes included intensive care unit (ICU) admission, ICU length of stay, discharge disposition, and nonhome discharge. Two-way analyses compared frail vs nonfrail patients and preintervention vs postintervention groups using the Student t test or Wilcoxon rank-sum test for continuous variables and the χ² or Fisher's exact test for categorical outcomes.

Results: Of all patients scheduled for elective inpatient vascular surgery procedures at a single institution (n = 225), 216 completed frailty screening (mean age, 72 years; 68.5% male; 54.6% White; mean RAI, 28.9; 18.5% frail). Of these, 15 had surgeries cancelled, and 201 ultimately underwent surgery with 36 (17.9%) identified as frail. Overall, frail patients had significantly longer ICU (median, 4.0 days [intertquartile range (IQR), 2.5-13.5 days] vs median, 2.0 days [IQR, 1-4 days]; P = .001) and hospital length of stay (median, 2.45 days [IQR, 1.51-5.67 days] vs median, 1.23 days [IQR, 1.0-2.1 days]; P = .001), higher nonhome discharge (30.6% vs 4.2%; P < .0001), and higher 30-day readmission (22.2% vs 6.7%; P = .009) compared with nonfrail patients. Comparing preintervention and postintervention groups, the 30-day readmission rates for the overall cohort decreased significantly (from 22.2% to 7.5%; P = .03). Among frail patients, there was a trend toward a reduced hospital length of stay (from 4.73 to 2.14 days), nonhome discharge (from 57.1% to 24.1%), and 30-day readmission (from 42.9% to 17.2%); however, these differences did not reach statistical significance. Overall, the 30-day mortality rate was 1.5% with all three deaths (two frail, one nonfrail) occurring during the postintervention period (0% pre vs 1.7% post; P = 1.0).

Conclusions: Successful implementation of a preoperative frailty screening and optimization pathway for patients undergoing elective vascular surgery led to a significant decrease in overall 30-day readmission and a trend toward reduced hospital length of stay, nonhome discharge, and 30-day readmission for frail patients. Further expansion to all surgical clinics has the potential to improve quality metrics for the health care system.