Improving Upon Postoperative Outcomes Through Prospective Frailty Screening Using the Risk Analysis Index

February 1, 2022

A multidisciplinary team of researchers from UPMC and the University of Pittsburgh has published their findings on the use of the Risk Analysis Index (RAI) as a means of screening surgical patients for frailty. The study was published in December 2021 in the journal Annals of Surgery.

Surgical patients exhibiting frailty are at increased risk for a range of perioperative morbidities, and they present a higher mortality risk, particularly individuals over the age of 65. Consistently and rapidly identifying these patients prior to surgery is a highly desirable goal to help improve perioperative outcomes in a vulnerable surgical patient population.

While the RAI has been studied and used successfully in the past as a means for identifying frailty and thus prompting presurgical interventions to improve patient outcomes after surgery, there has been little evidence available for how such a tool could be refined and implemented at a large, multi-hospital health care system across surgical disciplines, nor has there been good evidence for how well RAI scores in this setting correlate with postsurgical outcomes in individuals identified as being frail.

The new study was designed first to understand how the RAI could be adapted for use within the large and diverse UPMC system. Once a deployable system was in place for integrating the RAI [in modified form, see below] across the system for surgical patients, the study team conducted a prospective investigation to determine how well the RAI and its scoring system associated with clinical outcomes in surgical patients at UPMC

Study Highlights and Key Learnings

The UPMC and University of Pittsburgh team, through an iterative process with key stakeholders in surgical departments, quality improvement leadership, and patient input, modified the RAI for use within the hospital system and integrated it into the electronic health record. After testing and staff training,  RAI screening for frailty was launched on July 1, 2016. 

Patient data was captured for this analysis from July 1 to December 31, 2016. A total of 36,261 unique surgical patients were screened for frailty using the RAI, and a subsequent 8,172 patients underwent surgery during the seven-month study period for a wide variety of indications. The age of surgical patients captured in the study ranged from less than 20 years to greater than 90 years, with the highest volumes of cases coming from the 55 to 59; 60 to 64; and 65 to 69 cohorts.

Upon analysis, it was found that the RAI was highly effective at predicting and correlating with 180-day mortality rates. The analysis further found a dose-dependent association with RAI scores in perioperative metrics, including mortality, length of hospital stay and length of stay in the intensive care unit, and rates of 30-day and 90-day unplanned readmissions.

Scores higher than 37 on the RAI were predictive of a 60% higher rate of readmissions at 30 and 90 days. These individuals with greater than 37 scores also were found to have a length of stay nearly twice as long (14 days), and  ICU stays nearly twice as long as individuals with lower RAI frailty scores.

The study team also compared the metrics from the RAI against other risk assessment protocols, including the ASA and AUC, and found no statistically significant variations between assessment tools relative to the patient data in this study.

Ultimately the study was successful in that the data show a modified version of the RAI customized to a large and diverse health care systems’ needs could be successfully implemented without undue burden on clinic and surgical teams or patients, and that such a measure could reliably and accurately predict perioperative surgical outcomes in patients deemed to be frail based on index score.

Improving surgical outcomes for frail patients is a high priority for every health care system. Predicting with accuracy who the most vulnerable patient population are prior to surgery can allow care teams to more effectively communicate risks and benefits with the patient and to develop and deploy interventions designed to buttress the patient against potential morbidities and mortalities that can have far-reaching and lasting consequences on patient health and quality of life.

Please see the following reference to learn more about the study and its findings.

Reference

Varley PR, Borrebach JD, Arya S, Massarweh NN, Bilderback AL, Wisniewski MK, Nelson JB, Johnson JT, Johanning JM, Hall DE. Clinical Utility of the Risk Analysis Index as a Prospective Frailty Screening Tool With a Multi-Practice, Multi-Hospital Integrated Healthcare System. Ann Surg. 2021; 274 (6): e1230-e1237.