Frailty and Long-Term Health Care Utilization After Elective General and Vascular Surgery
Authors: Dossabhoy Shernaz S. , Graham Laura A. , Kashikar Aditi , George Elizabeth L. , Seib Carolyn D. , Tamura Manjula Kurella , Wagner Todd H. , Hawn Mary T. , Arya Shipra 
Published: December 2024

Importance

Surgical quality improvement efforts have largely focused on 30-day outcomes, such as readmissions and complications. Surgery may have a sustained impact on the health and quality of life of patients considered frail, yet data are lacking on the long-term health care utilization of patients with frailty following surgery.

Objective

To examine the independent association of preoperative frailty on long-term health care utilization (up to 24 months) following surgery.

Design, Setting, and Participants

This retrospective, observational cohort study included patients undergoing elective general and vascular surgery performed in the Veterans Affairs (VA) Surgical Quality Improvement Program with study entry from October 1, 2013, to September 30, 2018. Patients were followed up for 24 months. Patients with nursing home visits prior to surgery, emergent cases, and in-hospital deaths were excluded. Data analysis was conducted from September 2022 to May 2024.

Exposures

Preoperative frailty as assessed by the Risk Analysis Index (RAI-A) score: robust, less than 20; normal, 20 to 29; frail, 30 to 39; and very frail, 40 or more.

Main Outcomes and Measures

The primary outcome was health care utilization through 24 months, defined as inpatient admissions, outpatient visits, emergency department (ED) visits, and nursing home or rehabilitation services collected via Corporate Data Warehouse and Centers for Medicare &amp;amp; Medicaid Services data. χ2 Tests and analysis of variance were used to assess preoperative frailty status, and a Cox proportional hazards model was used to calculate the adjusted association of preoperative frailty on each postdischarge health care utilization outcome.

Results

This study identified 183 343 elective general (80.5%) and vascular (19.5%) procedures (mean [SD] age, 62 [12.7] years; 12 915 females [7.0%]; 28 671 Black patients [16.0]; 138 323 White patients [77.3%]; 94 451 Medicare enrollees [51.5%]) with mean (SD) RAI-A score of 22.2 (7.0). After adjustment for baseline characteristics and preoperative use of health care services, frailty was associated with higher inpatient admissions (frail: hazard ratio [HR], 1.75; 95% CI, 1.70-1.79; very frail: HR, 2.33; 95% CI, 2.25-2.42), ED visits (frail: HR, 1.39; 95% CI, 1.36-1.41; very frail: HR, 1.70; 95% CI, 1.65-1.75), and nursing home or rehabilitation encounters (frail: HR, 4.97; 95% CI, 4.36-5.67; very frail: HR, 7.44; 95% CI, 6.34-8.73). For patients considered frail and very frail, health care utilization was higher after surgery and remained significant through 24 months for all outcomes (using piecewise Cox proportional hazards modeling).

Conclusions and Relevance

In this study, frailty was a significant risk factor for high long-term health care utilization after surgery. This may have quality of life implications for patients and policy implications for health care systems and payers.