Original Article: Preoperative Evaluation and Frailty Assessment in Older Patients [Lown Right Care]

Issue Date: December 15, 2020

See additional reader comments at: https://www.aafp.org/afp/2020/1215/p753.html

To the Editor: We appreciate Dr. Lindsay and colleagues' efforts to address this topic. Primary care physicians often make the decision to refer patients to surgeons, and considering frailty is important. However, the statement, “Patients who are frail and very frail who had lower-stress procedures, such as cystourethroscopy or hydrocele surgery, were shown to have higher 30-day mortality rates than those who had the high-stress procedures, such as lung resection or liver transplant,” warrants clarification.

The study referenced by the authors found that patients who are frail and very frail had high postoperative mortality rates regardless of the level of stress of the operative procedure.¹ Although the mortality rate was slightly higher in patients undergoing higher-risk procedures, the authors did not conclude that this was because these procedures are less risky for patients who are frail and very frail. Instead, the authors concluded that surgeons and others in the care team recognized that patients who were frail and very frail needed extra pre- and perioperative attention for the highest-risk procedures. Therefore, the outcomes were not as bad. Another possibility is that surgeons only offered procedures considered to be riskier to patients who were frail and had some other resilience factor that the Risk Analysis Index did not measure.

All patients who undergo any low- or high-stress surgical procedure should be screened for frailty because all surgical procedures are high-risk for a patient who is frail. Another study showed that patients who are frail have worse outcomes even with ambulatory procedures, such as hernia, breast, thyroid, or parathyroid procedures.² A subsequent study found that with both low- and high-risk procedures, the level of frailty is directly associated with failure to rescue (i.e., death after potentially preventable complications).³ Therefore, the primary care team should recognize this risk when deciding to refer patients for any surgical procedure and determine how to optimize the peri- and postoperative outcomes or whether to forgo the procedure.

In Reply: I thank Drs. Tamesis and Spencer for emphasizing the importance of screening all patients for frailty who will undergo any surgical procedure. However, I would like to emphasize that screening with the Risk Analysis Index (https://bit.ly/2Mo6ECe) helps physicians make appropriate clinical decisions and mitigate operative risks proactively and is vital for shared decision-making so patients and their families can make informed decisions about the benefits and risks of procedures.¹ Helen Haskell and John James, patient partners for the Lown Right Care series, also suggested that clinicians discuss surgical risk with patients rather than use the term “frailty,” which may be a source of distress.