Implementation of a Preoperative Frailty Screening and Optimization Pathway for Vascular Surgery Patients is Associated with Decreased 30-Day Readmission.

Abstract

Objective: Frailty is characterized by reduced physiologic reserve and vulnerability to adverse events in the presence of a stressor such as surgery. We prospectively implemented a preoperative frailty screening and optimization pathway for vascular surgery patients and assessed its impact on postoperative outcomes.

Methods: As part of an ongoing quality improvement initiative, surgical frailty was assessed prospectively in all patients undergoing inpatient surgery using the Risk Analysis Index (RAI). Baseline data were collected from May to July 2022. Frail patients (RAI score ≥ 37) were referred to an anesthesia optimization clinic, nutrition consultation, and case management evaluation in the intervention phase (August 2022 to July 2023). Primary outcomes were postoperative hospital length of stay, 30-day readmission, and 30-day mortality. Secondary outcomes included ICU admission, ICU length of stay, discharge disposition, and non-home discharge. Two-way analyses compared frail vs non-frail patients and pre- vs post-intervention groups using Student t-test or Wilcoxon rank sum test for continuous variables and chi-squared or Fisher's exact test for categorical outcomes.

Results: Of all patients scheduled for elective inpatient vascular surgery procedures at a single institution (N=225), 216 completed frailty screening [mean age 72 years, 68.5% male, 54.6% white, mean RAI 28.9, 18.5% frail]. Of these, 15 had surgeries cancelled, and 201 ultimately underwent surgery with 36 (17.9%) identified as frail. Overall, frail patients had significantly longer ICU (median [IQR] 4.0 [2.5, 13.5] vs 2.0 [1, 4] days, P=.001) and hospital length of stay (2.45 [1.51, 5.67] vs 1.23 [1.0, 2.10] days, P=.001), higher non-home discharge (30.6% vs 4.2%, P<.0001), and higher 30-day readmission (22.2% vs 6.7%, P=.009) compared to non-frail patients. Comparing pre- and post-intervention groups, 30-day readmission for the overall cohort declined significantly (22.2% to 7.5%, P=.03). Amongst frail patients, there was a trend to reduced hospital length of stay (4.73 to 2.14 days), non-home discharge (57.1% vs 24.1%), and 30-day readmission (42.9% to 17.2%); however, these did not reach statistical significance. Overall, 30-day mortality was 1.5% with all 3 deaths (2 frail, 1 non-frail) occurring post-intervention (0% pre vs 1.7% post, P=1.0).

Conclusions: Successful implementation of a preoperative frailty screening and optimization pathway for patients undergoing elective vascular surgery led to a significant decrease in overall 30-day readmission and a trend toward reduced hospital length of stay, non-home discharge, and 30-day readmission for frail patients. Further expansion to all surgical clinics has the potential to improve quality metrics for the healthcare system.