1

Hung Nguyen, PhDPostdoctoral fellow

Baylor College of Medicine

Michael E. DeBakey Department of Surgery

Division of Vascular Surgery and Endovascular Therapy

www.bcm.edu/icamp

Application of wearable to predict adverse events and track postoperative changes in patients undergoing vascular interventions

Improving perioperative surgical

decision making by assessing frailty

“If it were not for the great variability among individuals, medicine might as well be a science and not an art” (Sir

Willam Osler, 1892)

Sir William Osler, Physician, 1849-1919

Allen D. Roses (2000), Pharmacogenetics and the practice of medicine, Nature

“The role of physicians in making the necessary judgements about the medicines that they prescribe is often referred to as an art, reflecting the lack of objective data available to make decisions that are tailored to individual patients” ( Allen Rose, 2000)

Medicine is an art

www.bcm.edu/icamp

“We Can’t Manage What We Can’t Measure”

Fall Risk

@ acute

care Unit

Well being

for

Well built

Stress in

Resident,

Wound

healing

Frailty

Assessment

Geriatric

Assessment

Mild Cognitive

Impairment, Alzheimer,

Parkinson, Cancer, HIV,

Diabetics, Hemodialysis

Diabetic

Wound

Care

Ulcer

Prevention

How people move through the world ↔ Quality of life

1. Yang et al. Geriatr Orthop Surg Rehabil. 2011; 2: 56-64

2. Etzioni DA et al. Am Surg. 2003; 69: 961-5

53%

1 in 2of older adults (> age of 65) will

require surgery once in their lives1

of all surgeries in US are performed

on older adults (> age of 65)1

48%of days of inpatient care

in geriatric patients (> age of 65)2

Changing demographicSurgical intervention in geriatric population

More geriatric patients are receiving

surgical intervention

Current gapsFunctional outcomes post revascularization

Oresanya et al.(2015).

"Functional outcomes after lower extremity revascularization: a national cohort study" (2015)

82%Died or became

non-ambulatory

Cohort

63%Died or became

non-ambulatory

Ambulatory Non-Ambulatory

89%Died or remained

non-ambulatory

Need to screen patient for long-term harm after surgery

“It was hard to tell why patients were selected for this intervention and what were the individual and or family goals.” (Dr. Michael Conte)

What is frailty?It is a geriatric syndrome – a measure of resilient

Could be good from outside but bad from inside!

Consequences of frailtyHigher risk for the vulnerable

Frailty is a state of increased vulnerability to

poor health outcomes after a stressful event

resulting in:

▪ Decreased reserve in multiple

physiologic systems

▪ Not identical to disability, comorbidity,

or advanced old age

Fried LP et al. J Gerontol A Biol Sci Med Sci. 2004; 59: 255-63

Lally F et al. Postgrad Med J. 2007; 83: 16-20

Alvrez-Nebreda et al. Perioperative care, 2017

Major determinant of health status and treatment outcomes

Consequences of frailtyFrailty assessment in a community dwelling population (n=5317)

▪ Frailty prevalence 6.9%

▪ Overlap, but no concordance, in the occurance of frailty, comorbidity, and disability

▪ Frailty is high-risk state predictive for a range of health adverse health outcomes:▪ Death

▪ Hospitalization

▪ Incidence of falls

Fried et al 2001

Survival curve estimate over 7 years follow-up by frailty status at baseline:

higher mortality in frail compared to non frail

A frail person is at increased risk of disability

and death from minor external stresses (Campell 1997)

4x

Measuring frailtyConventional method for assessing frailty

Frailty phenotypes

Fried et al (2001), J Gerontol A Bio Sci

Weakness(Grip strength <20 percentile)

Slowness(Walking time/15feet)

Exhaustion(Self-report)

Physical activity

(kCal/week)

Weight loss(>4.5 kg in the prior year)

0 1-2 3+

Positive for presence of phenotype

Limitations▪ Time consuming (~15-30min)

▪ Impractical in busy clinics, homes, and those with

mobility limitation

▪ Not sensitive to change (unable to detect decline over short

period of time)

Frailty phenotype Assessment Limitation

Current Tools Our Solution

Frailty assessment

without the need of walking test

In-Hospital Reality

Current frailty phenotype assessment tools often require a walking assessment.

However, these are impractical for inpatient geriatrics or mobility-impaired patients.

• Slowness as measured by speed of movement

• Weakness as measured by power and moment on arm

• Exhaustion as measured by reduction in speed of movement and speed variability

• Flexibility as measured by elbow range of motion

“Frailty phenotypes”

Toosizadeh et al. J Am Coll Surg. 2016;

223:240-8

Toosizadeh et al. JAGS. 2015

Joseph et al. Gerontology. 2017

Frailty Meter (FM)A phenotypic frailty assessment by 20-second rapid arm flexion-extension

Improving pre-operative surgical decisionFrailty Meter (FM) during clinical visit

Quick 20 second test

Frailty assessment - peripheral artery diseasePre-operative decision making in vascular surgery

Purposes of pre-operative frailty assessment:

▪ to stratify patients in risk in undergoing a procedure

▪ to identify modifiable factors to improve the patients

likelihood of successful outcome

N=93Screened/Consented

N=84

N = 1: refuse to participate after consenting (withdrew)

N = 5: Missed the baseline assessment (due to change in

operation time and unavailability of study coordinator)

but complete follow

N = 4: Limited time.

N = 2 Other reasons (e.g. unable to follow instruction,

technical failure, )

Baseline Assessment

Follow-Up

Day 1

N=23

Completed

W2/Month1

N=26

Completed

M3

N=5

Completed

M6

N=2

Completed

M12

N=1

Completed

In Progress

Peripheral Artery DiseaseUndergoing lower limb revascularization

30 day AE monitoring

N=77

AE, N=15

Functional

Recovery

SF12, FM

Death

Stroke

Major Amputation

Re-intervention

Re-Admission

58.8 %Walking aid/wheel chair

Patients demographic and clinical characteristics

Demographic

N = 84 Mean(SD )/ n(%)

Age 67.4(11.1) years

BMI 28.6(5.8) kg/m2

Gender (female) 36(42.3%)

History of Foot Ulcer 34(40.5%)

Diabetes 63(75.0%)

Hypertension 70(86.4%)

Tobacco History 59(83.3%)

Frail

Severe FrailFrailty Assessment using Frailty MeterStatus Frailty Index (FI) Numbers of patient

Non-Frail FI< 0.27 33(39.2%)

Frail 0.27 ≤FI< 0.4 25(29.8%)

Severe-Frail FI ≥ 0.4 26(31.0%)61%

PAD

Risk

Factors

Age is not a predictor of AE

Ag

e(y

ea

rs)

70

68

66

64

62

60

66.3

66.9

AENon AE

diff=0.90%,

P=0.882, d = 0.04

Pre-op frailty index

+adjusted for age

diff=51%,

p<0.001, d = 1.36

A very large effect size (d=1.36) in FI was observed at baseline between two groups

Frailty meter is sensitive to predict AE

of patient with adverse events were classified as

frail or severe frail

80%

Frailty index could be used in pre-operative care to predict adverse event

Frailty meter is sensitive to change

▪ Non AE rebounds after surgical intervention

▪ Lack of increase in AE FI after surgery might indicate the limit of physiological reserve

20

Conclusions

▪ Frailty index measured by FM is sensitive to change unlike traditional frailty screening tools

▪ The slope of change of FI immediately Post-op could also serve as a more reliable predictor

to poor outcomes/AE Post-op

▪ Tracking the changes in FI using FM may assist in management of post operative care

21www.bcm.edu/icamp

Thank you!