Development and validation of risk stratification tool for prediction of increased dependence using preoperative frailty after hepatopancreatic surgery

  • Priya Pathak
    Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH

    Pancreatic Multidisciplinary Clinic, Johns Hopkins Sydney Kimmel Comprehensive Cancer Center, MD
    Search for articles by this author
  • Kota Sahara
    Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH

    Department of Gastrointestinal Surgery, Yokohama City University School of Medicine, Yokohama, Japan
    Search for articles by this author
  • Gaya Spolverato
    Department of Surgical, Oncological, and Gastroenterological Sciences, University of Padova, Italy
    Search for articles by this author
  • Timothy M. Pawlik
    Reprint requests: Timothy M. Pawlik, MD, MPH, PhD, Professor and Chair, Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University, Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH 43210.
    Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH
    Search for articles by this author
Published:April 25, 2022DOI:



      Despite the known association between frailty and postoperative morbidity, the use of preoperative frailty in surgical practice remains limited. We sought to develop a risk tool to predict postoperative increase in functional dependence.


      Patients of ≥65 years in the National Surgical Quality Improvement Project database who had a primary hepatopancreatic surgery between 2015 and 2019 were used to identify predictors of increased dependence and development of a simplified tool to calculate the risk stratification score for increased discharge care level (


      Among 31,338 patients who underwent primary hepatopancreatic surgery, 4,259 (13.6%) had an increased level of care at discharge compared to their preadmission care. Patients with increased discharge care had a higher proportion of patients with a modified frailty index of at least 2 (n = 1496; 35.1%) compared with individuals with unchanged care (n = 6,760; 25.0%). In addition, 12.3% (n = 3,858) were discharged to a skilled nursing or rehabilitation facility. Of note, the odds of increased care at discharge were increased by 1.41 (95% confidence interval: 1.32–1.50), 1.11 (95% confidence interval :1.11–1.12), and 1.95 (95% confidence interval:1.86–2.04) times with every unit increase in modified frailty index, age beyond 65 years, and the number of in-hospital complications, respectively. Area under receiver operative curve for the parsimonious model used to develop the risk calculator was 0.7486 (95% confidence interval: 0.7405–0.7566) (all P < .001).


      Approximately, 1 in 7 patients required an increased level of care at the time of discharge compared with their preadmission status. A simplified web-based risk tool can be used in clinical practice as a surgical decision aid in post-discharge planning after complex elective surgery.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Søreide K.
        • Wijnhoven B.P.L.
        Surgery for an ageing population.
        Br J Surg. 2016; 103: e7-e9
        • Audisio R.A.
        Tailoring surgery to elderly patients with cancer.
        Br J Surg. 2016; 103: e10-e11
        • Ethun C.G.
        • Bilen M.A.
        • Jani A.B.
        • Maithel S.K.
        • Ogan K.
        • Master V.A.
        Frailty and cancer: Implications for oncology surgery, medical oncology, and radiation oncology.
        CA Cancer J Clin. 2017; 67: 362-377
        • Chen L.M.
        • Norton E.C.
        • Banerjee M.
        • Regenbogen S.E.
        • Cain-Nielsen A.H.
        • Birkmeyer J.D.
        Spending on care after surgery driven by choice of care settings instead of intensity of services.
        Health Aff Proj Hope. 2017; 36: 83-90
        • Hyer J.M.
        • Paredes A.Z.
        • Cerullo M.
        • et al.
        Assessing post-discharge costs of hepatopancreatic surgery: an evaluation of Medicare expenditure.
        Surgery. 2020; 167: 978-984
        • Paredes A.Z.
        • Hyer J.M.
        • Tsilimigras D.I.
        • et al.
        Skilled nursing facility (SNF) utilization and impact of SNF star-quality ratings on outcomes following hepatectomy among Medicare beneficiaries.
        HPB. 2020; 22: 109-115
        • Paredes A.Z.
        • Hyer J.M.
        • Beal E.W.
        • et al.
        Impact of skilled nursing facility quality on postoperative outcomes after pancreatic surgery.
        Surgery. 2019; 166: 1-7
        • Arya S.
        • Long C.A.
        • Brahmbhatt R.
        • et al.
        Preoperative frailty increases risk of nonhome discharge after elective vascular surgery in home-dwelling patients.
        Ann Vasc Surg. 2016; 35: 19-29
        • Dalmacy D.M.
        • Hyer J.M.
        • Diaz A.
        • Paro A.
        • Tsilimigras D.I.
        • Pawlik T.M.
        Trends in discharge disposition following hepatectomy for hepatocellular carcinoma among Medicare beneficiaries.
        J Gastrointest Surg. 2021; 25: 2842-2850
        • Ramesh H.S.J.
        • Jain S.
        • Audisio R.A.
        Implications of aging in surgical oncology.
        Cancer J. 2005; 11: 488-494
        • Peng P.
        • Hyder O.
        • Firoozmand A.
        • et al.
        Impact of sarcopenia on outcomes following resection of pancreatic adenocarcinoma.
        J Gastrointest Surg. 2012; 16: 1478-1486
        • Collard R.M.
        • Boter H.
        • Schoevers R.A.
        • Oude Voshaar R.C.
        Prevalence of frailty in community-dwelling older persons: a systematic review.
        J Am Geriatr Soc. 2012; 60: 1487-1492
        • Siegel R.L.
        • Miller K.D.
        • Jemal A.
        Cancer statistics, 2017.
        CA Cancer J Clin. 2017; 67: 7-30
        • Song X.
        • Mitnitski A.
        • Rockwood K.
        Prevalence and 10-year outcomes of frailty in older adults in relation to deficit accumulation.
        J Am Geriatr Soc. 2010;
        • Vermeiren S.
        • Vella-Azzopardi R.
        • Beckwée D.
        • et al.
        Frailty and the prediction of negative health outcomes: a meta-analysis.
        J Am Med Dir Assoc. 2016; 17: 1163.e1-1163.e17
        • Clegg A.
        • Young J.
        • Iliffe S.
        • Rikkert M.O.
        • Rockwood K.
        Frailty in elderly people.
        Lancet. 2013; 381: 752-762
        • Handforth C.
        • Clegg A.
        • Young C.
        • et al.
        The prevalence and outcomes of frailty in older cancer patients: a systematic review.
        Ann Oncol. 2015; 26: 1091-1101
        • Makary M.A.
        • Segev D.L.
        • Pronovost P.J.
        • et al.
        Frailty as a predictor of surgical outcomes in older patients.
        J Am Coll Surg. 2010; 210: 901-908
        • Tsiouris A.
        • Hammoud Z.T.
        • Velanovich V.
        • Hodari A.
        • Borgi J.
        • Rubinfeld I.
        A modified frailty index to assess morbidity and mortality after lobectomy.
        J Surg Res. 2013; 183: 40-46
        • Shin J.I.
        • Keswani A.
        • Lovy A.J.
        • Moucha C.S.
        Simplified frailty index as a predictor of adverse outcomes in total hip and knee arthroplasty.
        J Arthroplasty. 2016; 31: 2389-2394
        • Leven D.M.
        • Lee N.J.
        • Kothari P.
        • et al.
        Frailty Index is a significant predictor of complications and mortality after surgery for adult spinal deformity.
        Spine. 2016; 41: E1394-E1401
        • George E.M.
        • Burke W.M.
        • Hou J.Y.
        • et al.
        Measurement and validation of frailty as a predictor of outcomes in women undergoing major gynaecological surgery.
        BJOG Int J Obstet Gynaecol. 2016; 123: 455-461
        • Rockwood K.
        • Howlett S.E.
        • MacKnight C.
        • et al.
        Prevalence, attributes, and outcomes of fitness and frailty in community-dwelling older adults: report from the Canadian Study of Health and Aging.
        J Gerontol Ser A. 2004; 59: 1310-1317
        • Subramaniam S.
        • Aalberg J.J.
        • Soriano R.P.
        • Divino C.M.
        New 5-Factor Modified Frailty Index using American College of Surgeons NSQIP data.
        J Am Coll Surg. 2018; 226: 173-181.e8
        • Dunitz M.
        The Brisbane 2000 terminology of liver anatomy and resections. HPB 2000;2:333–339.
        HPB. 2002; 4: 99-339
        • Sahara K.
        • Paredes A.Z.
        • Merath K.
        • et al.
        Evaluation of the ACS NSQIP Surgical Risk Calculator in elderly patients undergoing hepatectomy for hepatocellular carcinoma.
        J Gastrointest Surg. 2020; 24: 551-559
        • Fuchshuber P.R.
        • Greif W.
        • Tidwell C.R.
        • et al.
        The power of the National Surgical Quality Improvement Program: achieving a zero pneumonia rate in general surgery patients.
        Perm J. 2012; 16: 39-45
        • Carter B.
        • Law J.
        • Hewitt J.
        • et al.
        Association between preadmission frailty and care level at discharge in older adults undergoing emergency laparotomy.
        Br J Surg. 2020; 107: 218-226
        • van Stralen K.J.
        • Stel V.S.
        • Reitsma J.B.
        • Dekker F.W.
        • Zoccali C.
        • Jager K.J.
        Diagnostic methods I: sensitivity, specificity, and other measures of accuracy.
        Kidney Int. 2009; 75: 1257-1263
        • Wagner D.
        • Büttner S.
        • Kim Y.
        • et al.
        Clinical and morphometric parameters of frailty for prediction of mortality following hepatopancreaticobiliary surgery in the elderly.
        Br J Surg. 2016; 103: e83-e92
        • Gani F.
        • Cerullo M.
        • Amini N.
        • et al.
        Frailty as a risk predictor of morbidity and mortality following liver surgery.
        J Gastrointest Surg. 2017; 21: 822-830
        • Quine S.
        • Morrell S.
        Fear of loss of independence and nursing home admission in older Australians.
        Health Soc Care Community. 2007; 15: 212-220
        • Paredes A.Z.
        • Hyer J.M.
        • Tsilimigras D.I.
        • et al.
        Predictors and outcomes of nonroutine discharge after hepatopancreatic surgery.
        Surgery. 2019; 165: 1128-1135
        • Merath K.
        • Chen Q.
        • Johnson M.
        • et al.
        Hot spotting surgical patients undergoing hepatopancreatic procedures.
        HPB. 2019; 21: 765-772
        • Paredes A.Z.
        • Hyer J.M.
        • Tsilimigras D.I.
        • et al.
        Hospice utilization among Medicare beneficiaries dying from pancreatic cancer.
        J Surg Oncol. 2019; 120: 624-631
        • McGirt M.J.
        • Parker S.L.
        • Chotai S.
        • et al.
        Predictors of extended length of stay, discharge to inpatient rehab, and hospital readmission following elective lumbar spine surgery: introduction of the Carolina-Semmes Grading Scale.
        J Neurosurg Spine. 2017; 27: 382-390
        • Aznar-Tortonda V.
        • Palazón-Bru A.
        • Gil-Guillén V.F.
        Using the FRAIL scale to compare pre-existing demographic lifestyle and medical risk factors between non-frail, pre-frail and frail older adults accessing primary health care: a cross-sectional study.
        PeerJ. 2020; 8e10380
        • Hanlon P.
        • Nicholl B.I.
        • Jani B.D.
        • Lee D.
        • McQueenie R.
        • Mair F.S.
        Frailty and pre-frailty in middle-aged and older adults and its association with multimorbidity and mortality: a prospective analysis of 493 737 UK Biobank participants.
        Lancet Public Health. 2018; 3: e323-e332
        • Kanaan S.F.
        • Yeh H.W.
        • Waitman R.L.
        • Burton D.C.
        • Arnold P.M.
        • Sharma N.K.
        Predicting discharge placement and health care needs after lumbar spine laminectomy.
        J Allied Health. 2014; 43: 88-97
        • Slover J.
        • Mullaly K.
        • Karia R.
        • et al.
        The use of the Risk Assessment and Prediction Tool in surgical patients in a bundled payment program.
        Int J Surg. 2017; 38: 119-122
        • Gharacholou S.M.
        • Roger V.L.
        • Lennon R.J.
        • et al.
        Comparison of frail patients vs non-frail patients ≥65 years of age undergoing percutaneous coronary intervention.
        Am J Cardiol. 2012; 109: 1569-1575
        • Santa Mina D.
        • Scheede-Bergdahl C.
        • Gillis C.
        • Carli F.
        Optimization of surgical outcomes with prehabilitation.
        Appl Physiol Nutr Metab. 2015; 40: 966-969
        • Carli F.
        • Zavorsky G.S.
        Optimizing functional exercise capacity in the elderly surgical population.
        Curr Opin Clin Nutr Metab Care. 2005; 8: 23-32
        • Barberan-Garcia A.
        • Ubré M.
        • Roca J.
        • et al.
        Personalised prehabilitation in high-risk patients undergoing elective major abdominal surgery: a randomized blinded controlled trial.
        Ann Surg. 2018; 267: 50-56
        • Carli F.
        • Bousquet-Dion G.
        • Awasthi R.
        • et al.
        Effect of multimodal prehabilitation vs postoperative rehabilitation on 30-day postoperative complications for frail patients undergoing resection of colorectal cancer: a randomized clinical trial.
        JAMA Surg. 2020; 155: 233-242
        • Mahvi D.A.
        • Pak L.M.
        • Fields A.C.
        • Urman R.D.
        • Gold J.S.
        • Whang E.E.
        Prediction of discharge destination following major hepatectomy.
        HPB. 2019; 21: 1462-1469
        • Davenport D.L.
        • Bowe E.A.
        • Henderson W.G.
        • Khuri S.F.
        • Mentzer R.M.
        National Surgical Quality Improvement Program (NSQIP) risk factors can be used to validate American Society of Anesthesiologists Physical Status Classification (ASA PS) levels.
        Ann Surg. 2006; 243 (discussion 641–644): 636-641