SLR - November 2020 - Piroska Schlesinger

Association of Frailty and Postoperative Complications with Unplanned Readmissions after Elective Outpatient Surgery

Reference: Rothenberg KA, Stern JR, George EL, Trickey AW, Morris AM, Hall DE, Johanning, JM, Hawn MT, Arya S. Association of Frailty and Postoperative Complications with Unplanned Readmissions after Elective Outpatient Surgery JAMA Network Open. 2019;2(5): e194330. 1-13

Level of Evidence: II

Scientific Literature Review

Reviewed By: Piroska Schlesinger, DPM
Residency Program: Southern Arizona VA Health Care System – Tucson, AZ

Podiatric Relevance: Hospital readmission after inpatient surgical procedures poses a noteworthy additional cost to patient care. Previous studies have paid more attention to inpatient readmissions, however only a few studies have focused on the financial burden associated with postsurgical complications in an outpatient setting in the frail and elderly population. This study provides an accurate definition for ‘frailty’ as a syndrome which is measured by The Risk Analysis Index (RAI). The goal of this study was to identify the relationship/correlation between frailty in the outpatient surgical population, and the 30-day post-surgical unexpected readmission.

Methods: The National Surgical Quality Improvement Program (NSQIP) database from 2012 to 2013 was retrospectively analyzed, and identified patients undergoing elective outpatient surgery. Qualified patients were categorized according to INOUT=outpatient, and ELECTSURG=elective surgery. The study defined “Frailty” according to the Risk Analysis Index score which included: sex, age, disseminated cancer, weight loss, renal failure, congestive heart failure, dyspnea, transfer status, cognitive status, functional status. Patients who did not have all the information to assess frailty, length of stay status, and who died during the elective surgery were excluded. Post-operative complications were divided into major and minor categories. The outcome variable was UNPLANNED READMISSION.

Results:  A total of 417,840 patients undergoing elective outpatient surgery were evaluated, identified, and defined as frail and non-frail patients. Both frailty, and complications were associated with frailty. Frail patients had higher rates of comorbidities such as insulin dependent Type 2 diabetes, hypertension, and congestive heart failure. Overall, post-operative complications were more frequent in frail patient than in non-frail patients regarding both minor and major complications. Frail patients had more unplanned readmission than non-frail patients in both cohorts (LOS=0 8.3 percent vs 1.9 percent, LOS≥1 8.5 percent vs 3.2 percent)  regardless of no complication, minor or major complications. Most commonly, surgical site infections, bleeding, GI-complications, renal and cardiac complications were reasons for readmissions among frail patients. 

Conclusions: The study concluded that frail patients have an increased rate of readmission, and that this is partly due to post-operative complications. The study suggests that preoperative evaluation, identification of frail patients, better perioperative care, and preoperative rehabilitation could lead to less readmissions in this population, thus possibly less cost to patients, and the healthcare system. 

Educational Opportunities