Frailty and Survival for Diagnoses Feasibly Managed Operatively or Nonoperatively.

OBJECTIVE Compare outcomes, stratified by frailty, of patients with eight common conditions with plausible operative and nonoperative management strategies. SUMMARY BACKGROUND DATA A surgical pause, evaluating potential adverse outcomes among frail patients, improves postoperative outcomes; however, the outcomes among patients opting for nonoperative management are unknown. METHODS In an observational cohort study across a multi-hospital healthcare system including adults presenting to outpatient surgical clinics (2016-2023) for evaluation of eight conditions feasibly managed operatively or nonoperatively as defined by modified Delphi consensus. In a landmarked analysis, we compared 2-year survival by management strategies across frailty categories (robust, normal, frail, very frail) as defined by the Risk Analysis Index (RAI). Secondarily we compared 365-day hospital free days (HFD-365), postoperative length of stay, and discharge disposition. RESULTS Among 49,169 patients (mean±SD age, 60.4±14.6 y; 54.6% female), operative management was associated with lower observed and adjusted mortality (1.3% vs 2.5%; aHR=0.55 [95% CI, 0.47-0.66], P<0.0001) overall and among all frailty categories expect the very frail (8.1% vs 12.1%, P=0.1). Additionally, operative management was associated with fewer HFD-365 again overall which was specifically prominent among the very frail (median 365 [IQR, 358-365] vs 361 days [IQR, 357-363], P<0.0001). Postoperatively, frailty portended more protracted recoveries with greater postoperative lengths of stay (1.7±2.6 vs 1.2±2.1) days, P<0.0001) and fewer discharges home (370 [85.1%] vs 5,087 [91.8%], P<0.0001; odds ratio=2.0 [95%CI 1.5-2.6]). CONCLUSIONS Considering the protracted postoperative recovery of very frail patients, nonoperative management might be the preferred treatment option for those presenting with these eight clinical conditions.