Preoperative Frailty Risk Analysis

Index to Stratify Patients Undergoing

Carotid Endarterectomy

Melin, Alyson A.1,2; Schmid, Kendra K.2; Lynch,

Thomas G.1; Kappes, Steven3; Pipinos, Iraklis I.1,2;

Longo, G. Matthew 1,2; Gupta, Prateek K.4;

Johanning, Jason M.1,2

1. NWI VA Medical Center, Omaha, NE, United States.

2. University of Nebraska Medical Center, Omaha, NE, United States.

3. Aurora Healthcare System, Milwaukee , WI, United States.

4. University of Wisconsin, Madison, WI, United States.

Introduction

• No disclosures

Introduction

• Carotid endarterectomy is under increased

scrutiny

• The value of carotid endarterectomy is

dependent on outcomes

• How can we improve outcomes in carotid

endarterectomy?

– Technical

– Patient Selection

Introduction

• How do we best select patients to undergo

carotid endarterectomy?

• Frailty is a syndrome with decreased

physiologic reserves arising from cumulative

comorbid conditions. 1, 2

1. Rockwood K, Mitnitski A. Frailty defined by deficit accumulation and geriatric medicine defined by frailty. Clin

Geriatr Med. 2011;27(1):17-26

2. Fried LP, Ferrucci L, Darer J, Williamson JD, Anderson G. Untangling the concepts of disability, frailty, and

comorbidity: implications for improved targeting and care. J Gerontol A Biol Sci Med Sci. 2004;59(3):255-263.

1. Makary M, Sergev D, Pronovost P, et al. Frailty as a Predictor of Surgical Outcomes in Older Patients. J Am Coll Surg. 2010:

210 (6)

RISK ANALYSIS INDEX (RAI)

1. Age ____ Score with Cancer _____ (13-20)

Score without Cancer _____ (2-9)

2. Sex Female = 0/ Male = 5 _____ (5)

1. Renal Insufficiency No = 0/ Yes = 6 _____ (6)

2. Congestive Heart Failure No = 0/ Yes = 4 _____ (4)

3. Shortness of Breath at Rest No = 0/ Yes = 8 _____ (8)

4. Weight Loss (>10 lbs) in last 3 Months No = 0/ Yes = 5 _____ (5)

5. Poor Appetite No = 0/ Yes = 4 _____ (4)

6. Residence Other than Independent Living No = 0/ Yes = 8 _____ (8)

7. Cognitive Decline in last 3 Months No / Yes

1. Activities of Daily Living With Cognitive Decline _____(-2-21)

Without Cognitive Decline _____ (0-16)

TOTAL SCORE _____ (0-85)

75

4

5

6

0

0 0

0

8

2

25

1. Johnson M, Bailey T, Schmid K, et al. A frailty index identifies patients at high risk of mortality after tracheostomy. Otolaryngol Head Neck Surg. 2014; 150

(4): 568

2. Dwyer J, Reynoso J, Seevers G, et al. Assessing preoperative frailty utilizing validated geriatric mortality calculators and their association with

postoperative hip fracture mortality risk. Geriatr Orthop Surg Rehabil. 2014; Submission accepted

3. Ernst K, Lynch TG, Lavaden P, Seevers G, Schmid KK,Johanning JM, . Surgical palliative care consultations over time in relation to system wide frailty

screening. JAMA Surg. 2014; Submission accepted.

Study Design

• All patients in NSQIP database who underwent

CEA from 2005 – 2011 (n = 44,832)

• A quality and frailty team matched variables

from RAI to preoperative NSQIP parameters

• Primary outcome measures: Stroke, MI, Death,

Length of Stay

RAI Score Breakdown

17898

23233

1748 1290 417 156 58 25 5 2

0

5000

10000

15000

20000

25000

All Patients

7353

8137

908 858

243 126 45 20 4 2 0

1000

2000

3000

4000

5000

6000

7000

8000

9000

Symptomatic Patients

10545

15096

840 432 174 30 13 5 1 0 0

2000

4000

6000

8000

10000

12000

14000

16000

Asymptomatic Patients

92%

88% 94%

All Patients

0%

10%

20%

30%

40%

50%

60%

Stroke (p = 0.0001)

Death (p < 0.0001)

MI (p = 0.0002)

* p = Cochran-Armitage Trend Test

Symptomatic Patients

0%

10%

20%

30%

40%

50%

60%

Stroke (p = 0.009)

Death (p <0.0001)

MI (0.002)

* p = Cochran-Armitage Trend Test

Asymptomatic Patients

0%

5%

10%

15%

20%

25%

Stroke (p = 0.22)

Death (p < 0.0001)

MI (p = 0.04)

* p = Cochran-Armitage Trend Test

Length of Stay

0

2

4

6

8

10

12

14

16

18

All Patients

Symptomatic Patients

Asymptomatic Patients

RISK ANALYSIS INDEX (RAI)

1. Age ____ Score with Cancer _____ (13-20)

Score without Cancer _____ (2-9)

2. Sex Female = 0/ Male = 5 _____ (5)

1. Renal Insufficiency No = 0/ Yes = 6 _____ (6)

2. Congestive Heart Failure No = 0/ Yes = 4 _____ (4)

3. Shortness of Breath at Rest No = 0/ Yes = 8 _____ (8)

4. Weight Loss (>10 lbs) in last 3 Months No = 0/ Yes = 5 _____ (5)

5. Poor Appetite No = 0/ Yes = 4 _____ (4)

6. Residence Other than Independent Living No = 0/ Yes = 8 _____ (8)

7. Cognitive Decline in last 3 Months No / Yes

1. Activities of Daily Living With Cognitive Decline _____(-2-21)

Without Cognitive Decline _____ (0-16)

TOTAL SCORE _____ (0-85)

75

4

5

6

0

0 0

0

8

2

25

Administer RAI in Clinic

Low RAI Score

Excellent Outcomes

Poor Outcomes

Surgical Techniques

Hospital Practices

High RAI Score

Further Workup

Comprehensive Geriatric

Assessment

Alternative Treatment

Appropriate Patient

Counseling

Thank you. Questions?