There is no foolproof way to predict the outcome of even the most routine surgery. There is always risk, regardless of the skill of the surgical team or the quality of care hospital staff provide after the procedure.
Health care teams recognize this and routinely assess factors that could increase patients’ surgical risk, including their age, comorbidities like heart problems, and lifestyle choices like smoking. There is also the question of a patient’s overall condition. Does the individual have deep enough physical reserves to withstand and recover from the shock of surgery?
It’s a question that D. Ryan Ormond, MD, has considered – and with good reason. As a neurosurgeon and director of the Brain Tumor Program at UCHealth’s University of Colorado Hospital, he often opens patients’ skulls to remove tumors, both benign and malignant. He’d like to make a crystal-clear assessment of his patients’ risk before such sensitive surgeries, but that’s not always easy.
“Sometimes I get the impression that one patient might do worse than another,” Ormond said. The warning signs can be subtle, he added. “We look at cardiac risk, for example,” he said. “Sometimes there is none, but I still have the impression that the patient won’t do well.”
To firm up those impressions, Ormond is leading a study at UCH that measures the frailty of patients with brain tumors – weakened grip, difficulty walking or physical exhaustion, for example – before neurosurgery. The goal: assess how well frailty predicts undesirable outcomes of the surgeries, including complications, longer hospital stays, and discharges to places other than home.
Signs of weakness
It’s the first time that a study has looked at frailty as a factor in predicting surgical risk for brain tumor patients. But the idea that patients’ physical capacity should be considered independently in assessing risks to health was established in a 2001 study of 5,300 elderly patients. The work isolated five criteria for frailty (see box) and developed a scale for measuring it.
The criteria used to define frailty with the calculator developed at Johns Hopkins University include:
- Unintentional weight loss
- Low energy expenditure
- Low grip strength
- Slowed walking speed
The study at UCH, which began in 2014, uses a Frailty Assessment Calculator developed at Johns Hopkins University that requires little more than low-tech tools such as tape measures, stopwatches and scales to gauge a patient’s physical reserves. The American College of Surgeons used the Hopkins creation in a 2013 study of elderly surgical patients. It concluded that the frailer the patient, the more likely he or she was to suffer a post-surgical complication.
The UCH study aims to enroll 600 neurosurgery patients by the time it closes enrollment in 2018. To date, 256 brain tumor patients at UCH have received the assessment before surgery, said Tessa Harland, a third-year medical student at the University of Colorado School of Medicine. Harland was the initial clinical coordinator for the study and continues to assist in compiling and analyzing data from it.
Strength for surgery
The tool ranks frailty on a scale of 0-to-5, Harland said. Patients scoring 0 to 2 are considered “robust,” while those scoring 3 to 5 are classified as intermediately to extremely frail. Thus far, the number of extremely frail patients is small, Harland said, making it difficult to draw comparisons with the robust group. But even in the intermediate group, some significant differences have emerged.
For example, patients who were not frail stayed in the hospital an average of 4.1 days after surgery, compared with 6.0 days for those in the intermediate category. Just under 98 percent of the non-frail were discharged to their homes rather than an institution like a nursing home after surgery; the percentage was only 83 percent for intermediately frail patients.
Patients who participate in the UCH study take the frailty assessment prior to going into surgery, a decision made to avoid testing patients who consider but then decide not to pursue surgery. Depending on the results, though, the frailty assessment might be made in the clinic before neurosurgery as part of the standard of care. That would follow the direction of the American Society of Anesthesiologists Physical Status Classification System, which is now regularly used to assess patients before surgery.
The overall goal is to determine if frailty can widen the lens of both patients and providers in surveying the surgical risk picture and making treatment decisions, Ormond said.
“In general, the number of complications is higher among frail patients,” he said. “The risks of surgery may outweigh the benefits.” In some cases, for example, radiation or targeted drug therapies might be better options than surgery for a frail patient. A debilitated patient might choose to delay surgery until he or she can regather strength – if his or her disease allows it. Palliative care might be a consideration.
Ormond’s study could also have broader implications. For example, the more accurately providers predict surgical risk and post-surgical outcomes, the better the health care system might allocate its resources.
“When a person starts weaker, they have a more difficult time recovering,” Ormond said. He noted that frailty decreases mobility, which in turn can lengthen hospital and rehabilitation stays. That means a tougher time for the patient, higher costs, and greater financial and operational demands for hospitals and long-term care facilities.
Frailty is one factor among many that patients and providers must consider before neurosurgery or any procedure. But as Harland put it, “The study is trying to articulate a way to measure risk and help to decide on the best choice of treatment for brain tumor patients.”