Long-term survival among older adults with frailty undergoing elective vascular surgery procedures

Abstract

Objective

The Vascular Quality Initiative Frailty Index (VQI-FI) was developed using seven 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 (2010-2019) was used to assess survival among Medicare beneficiaries undergoing elective vascular procedures from seven arterial VQI registries. After stratifying patients into three 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% carotid endarterectomy, 7% carotid artery stenting, 16% endovascular aortic repair, 2% open aortic repair, 3% thoracic endovascular aortic repair, 8% infrainguinal bypass surgery, 2% suprainguinal bypass surgery, and 28% peripheral vascular intervention), 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 with non-frail patients (P < .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 with non-frail patients. In risk-adjusted Cox regression models, there was a significant increase in 5-year mortality among mildly frail (hazard ratio, 2.7; P < .0001) and moderate to severely frail (hazard ratio, 5.9; P < .0001) patients relative to non-frail patients.

Conclusions

Long-term survival is poor among frail Medicare patients undergoing elective vascular procedures with up to six times 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.