Long-term Survival Among Older Adults with Frailty Undergoing Elective Vascular Surgery Procedures.

Abstract

Objectives: The Vascular Quality Initiative Frailty Index (VQI-FI) was developed using 7 variables captured in all VQI registries and combined with procedure risk to provide a simple mortality risk assessment tool for preoperative decision making. This study was designed to validate the ability of the VQI-FI within a subgroup population for discriminating long-term mortality risk among Medicare beneficiaries undergoing common elective vascular procedures.

Methods: The VISION VQI-Medicare linked database (2010-19) was used to assess survival among Medicare beneficiaries undergoing elective vascular procedures from 7 arterial VQI registries. After stratifying patients into 3 groups based on degree of frailty using VQI-FI (<0.26, non-frail; 0.26-0.50, mild frailty; >0.50, moderate to severe frailty) we analyzed 1-year and 5-year mortality with Kaplan-Meier method and Cox proportional hazard models.

Results: We identified 109,400 patients who underwent an elective vascular procedure (34% CEA, 7% CAS, 16% EVAR, 2% OAR, 3% TEVAR, 8% INFRA, 2% SUPRA, and 28% PVI), of which 13% were mildly frail and 2% were moderate to severely frail. Patients with mild and moderate to severe frailty were more likely to be of black race or Hispanic ethnicity, non-ambulatory, and living at a nursing facility at the time of surgery when compared to non-frail patients (P<0.0001 for all comparisons within both 1-year and 5-year follow-up cohorts). Mortality at 1-year and 5-years after surgery was significantly higher among mildly and moderate to severely frail patients as compared to non-frail patients. In risk-adjusted Cox regression models, there was a significant increase in 5-year mortality among mildly frail (HR:2.7; P<0.0001) and moderate to severely frail (HR:5.9; P<0.0001) patients relative to non-frail patients.

Conclusions: Long-term survival is poor among frail Medicare patients undergoing elective vascular procedures with up to 6x higher mortality than non-frail patients. These results highlight the need to identify frail patients before surgery, address modifiable risk factors, and provide realistic expectations about long-term outcomes after elective vascular surgery.