improving perioperative surgical decision making by ... · fried lp et al. j gerontol a biol sci...
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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
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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
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Thank you!