Feasibility of Frailty Assessment Before Cardiac Surgery

M. J.. Pienta¹, C. He², M. J.. Clark³, J. Fanning⁴, F. Azoury⁵, P. Theurer⁶, R. Alnajjar⁷, A. L.. Pruitt⁸, F. D.. Pagani^9
1Michigan Medicine, Ann Arbor, Michigan ²Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Michigan ³Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Pinckney, Michigan ⁴Spectrum Health, Grand Rapids, Michigan ⁵Ascension St-John Detroit, Grosse Pointe Shores, Michigan ⁶Arbor Lakes, Plymouth, Michigan ⁷Henry Ford Health, Bloomfield Hills, Michigan ⁸Michigan Heart & Vascular Institute - CT Surgeons of Ann Arbor, Ypsilanti, Michigan ⁹University of Michigan, Ann Arbor, Michigan

Purpose: The Clinical Frailty Scale (CFS) is a tool to assess a patient’s frailty and has been shown to correlate with outcomes after percutaneous coronary intervention and transcatheter aortic valve replacement. We assessed feasibility of preoperative clinical frailty assessment and association with outcomes after cardiac surgery in the State of Michigan.

Methods: Patients undergoing cardiac surgery at 27 hospitals participating in the Michigan Society of Thoracic and Cardiovascular Quality Collaborative from January to March 2024 were assessed with the Clinical Frailty Scale (CFS). The CFS is a semiquantitative tool that provides a global score ranging from 1 (very fit) to 9 (terminally ill). Preoperative CFS assessments were performed by surgeons, nurse practitioners, or physician assistants during a preoperative clinic appointment. Patients with CFS ≥5 were classified as frail. CFS data were merged with hospital data from The Society of Thoracic Surgeons (STS) Adult Cardiac database. Patient characteristics were compared between patients with and without frailty assessment, and between frail and non-frail patients. Perioperative complications and mortality rates were also compared between groups. The correlation between CFS, 5-meter walk (488/1150 (42.4%) of the patients assessed with CFS), and STS predicted risk of mortality (PROM) was analyzed using Spearman correlation coefficient.

Results: A total of 2311 patients underwent cardiac surgery between 01/01/2024, and 03/31/2024, of which 1193 (51.8%) underwent coronary artery bypass (CABG), 221 (9.6%) aortic valve replacement (AVR), 166 (7.2%) AVR/CABG. White patients were more likely to have a CFS assessment (917/1971; 46%) relative to Black patients (54/114; 32%; p=0.004). There was no difference in incidence of major complications or mortality between patients with a CFS assessment and those without (p=0.56). The frequency of frailty by CFS was similar between men and women (65/765; 8.5% vs. 29/284; 10.2%; p= 0.38). Frail patients by CFS assessment were more likely to be Black and more likely to be NYHA class III/IV. The observed operative mortality rate was higher among frail patients (6/94; 6.38%) compared to non-frail patients (16/956; 1.67%; p=0.002). Major morbidity was more common in frail patients (22/94; 23.2%) versus non-frail patients (99/956; 10.4%; p=0.0002), driven by higher incidence of prolonged ventilation (18/94; 19.2% vs. 69/956; 7.2%; p< 0.001), and reoperation (10/94; 10.6% vs 40/956; 4.2%; p=0.005). The CFS demonstrated weak correlation with a 5-meter walk test (Spearman correlation coefficient 0.24 (95% CI 0.16 to 0.32) and a moderate correlation with STS PROM (Spearman correlation coefficient 0.46 (95% CI 0.41 to 0.51).

Conclusion: This quality improvement project demonstrated that preoperative frailty assessment by surgeons and advanced practice providers using the CFS is feasible. The higher rates of major morbidity and 30-day mortality in frail patients highlight the utility of the CFS as a prognostic adjunct to inform patients and providers.

Identify the source of the funding for this research project: Michigan Society of Thoracic and Cardiovascular Surgery Quality Committee Coordinating Center