C. C. McQuestion1, M. Ballacchino2, L. M. Harris1, H. H. Dosluoglu1, N. D. Nader1,2 1State University Of New York At Buffalo, Surgery, Buffalo, NY, USA 2State University Of New York At Buffalo, Anesthesiology, Buffalo, NY, USA
Introduction: In an effort to decrease mortality rates in our hospital, a mandatory assessment by a multidisciplinary surgical pause committee (MDSPC) composed of Cardiology, Anesthesiology, Pulmonary, Ethicist and the surgeon, with additional specialists as needed, for medically very high-risk patients in all surgical specialties was initiated in 2009. Frailty scores for perioperative morbidity and mortality assessment have been increasingly used in recent years. Our goal was to assess the potential value and impact of the VA frailty score screening tool (Risk Analysis Index, RAI) as a selection criterion for identifying patients for an in-depth clinical assessment by MDSPC to reduce postoperative adverse outcomes.
Methods: All patients who were referred to MDSPC between 10/2011 to 04/2023 in VA WNYHCS were identified. Patient demographics and clinical presentation with early and late follow-up data were collected. RAI scores using the VA frailty screening tool were calculated. Patients were considered “Frail” if their scores were ≥37. The recommendations of the committee were G1: Proceed with the "planned surgery", G2: May proceed after a period of medical "optimization"; G3: "Alter" the surgical/anesthesia plan to reduce the invasiveness; and G4: A "non-surgical approach" to address the clinical problem. Receiver-operating characteristics analyses were performed to calculate the RAI cutoff values in predicting mortality and adopting a non-surgical treatment approach.
Results: A total of 394 patients (382 male) were included (mean age 71±11 years). ASA class III and IV comprised 87.2%. The RAI scores were 36.4±9.6 in G1, 37.6±11.0 in G2, 41.0±10.0 in G3 and 43.9±9.6 in G4 (p<.001, G1/G2 vs G3/G4). The RAI cutoff value for patients with a prohibited surgical approach was 40.5. 30-day mortality was 6.6% in G1, 8.2% in G2, 15.2% in G3 and 17.4% in G4 (p=.021) Mean survival was 35±33 mo in G1, 38±37 mo in G2, 20±29 mo in G3 and 18±22 mo in G4 (p<.001, G1/G2 vs G3/G4, Figure).
Conclusions: Detailed clinical assessment by MDSPC is efficient for correctly identifying patients with an elevated risk of fatality following surgical patients, and the RAI tool is beneficial in screening the high-risk patients to be evaluated and possibly identifying those with prohibitive surgical risk.
