In this prospective observational study of patients aged 65 or older undergoing elective surgery we established the prevalence of frailty to be 17.0% using the Reported Edmonton Frail scale. Frail patients were more likely to present with modifiable pre-operative co-morbidities, require carers, and were less likely to be discharged to their own homes following surgery. All of these are relevant factors in the planning of personalised perioperative care.
To our knowledge, this is the first study to assess the prevalence of frailty in patients undergoing solely elective surgery in the UK. The prevalence of frailty in the surgical population varies widely in the literature and is influenced by both the tool being used and the population being assessed. The largest study to date of frailty in patients undergoing elective and emergency surgery (over 430,000 American veterans) found 8.5% patients to be frail(14) whereas a recent meta-analysis of over 2000 general surgical patients (elective and emergency) estimated the prevalence to be higher, at between 10 and 37%.(15) Few studies have been undertaken in the UK and all are a mix of elective and emergency patients, for example a study of emergency and elective vascular patients in a UK setting found 52% of patients aged over 60 were frail, using the Edmonton Frail Scale.(16)
One of the key findings of our study was that many frail patients had reached the day of planned surgery with medical problems which, had they been identified earlier, could have been corrected or optimised in advance. For example, nearly two thirds of frail patients were found to be anaemic compared to only a third of non-frail patients. Identifying and treating these frail patients, who appear to have a significantly higher risk of anaemia, could reduce associated post-operative complications(15). There was also a trend towards frail patients having a higher rate of diabetes, another important perioperative risk factor. The use of a frailty screening tool such as the REFS could highlight these patients earlier in the perioperative pathway, allowing time for pre-operative optimisation and a reduction in post-operative complications(17, 18). The Royal College of Anaesthetists emphasises that frailty requires a cross-specialty approach to enable optimisation of medicines and improved management of non-surgical comorbidities. A challenge is that to achieve this requires both time and resources, especially when considering the impact of COVID-19 on elective surgery(19). Whilst the REFS was easily implemented on the morning of surgery, clearly screening would be best performed earlier in the perioperative pathway to allow time for intervention, for example at time of referral from primary care. A practical alternative could be to integrate the REFS (or other frailty assessment tool) into the routine pre-operative assessment questionnaires already performed by hospital pre-admission teams.
Knowledge of the presence and severity of frailty can help with assessing surgical risk (20) and, thus, help inform shared decision-making discussions and ensure validity of consent(21). Having been informed of their higher-risk status, some patients may choose to proceed with planned surgery, whilst others may elect for an alternative procedure or choose not to have surgery at all(22). Advanced knowledge of frailty can help ensure appropriate personnel and equipment are available in theatres on the day of surgery. For example, frail patients may be given a longer time-slot for induction of anaesthesia, or be cared for by a more senior anaesthetist. There may be adjustments that need to be made to the anaesthetic technique; such as additional monitoring or selection of regional blockade in place of general anaesthesia. Discussion of these interventions in advance of surgery will also allow patient expectations to be managed.
From the point-of-view of post-operative care and discharge planning, an awareness of frailty pre-operatively can also ensure adequate planning and resource allocation. For example frail patients could be identified in advance of surgery so that physiotherapists, dietitians and a clinician with an interest in perioperative medicine for the elderly could be involved in planning their post-operative care. Not only could this improve quality of care but may also optimise hospital efficiency through reduced length-of-stay and cancellations. Although our study did not demonstrate significant differences in length-of-stay we did show that 99% of non-frail patients were discharged to their own home, compared to only 83% of frail patients. This again may suggest a benefit for discharge planning in identifying these patients early on in their surgical journey.
One of the main strengths of this study was that it recruited participants from a wide geographical area incorporating a mixture of small and large hospitals serving a mixture of inner city, semi-rural and rural communities. In practice we found the REFS questionnaire to be quick to perform; taking only five minutes or less to complete. It was also found to be acceptable to patients. The junior doctors administering the questionnaire, predominantly anaesthetic trainees, did not require any additional training which suggests that the REFS would be quick and cost-effective to introduce into routine clinical practice. The delivery of a multi-centre study by doctors in training is another strength.
However, this study has limitations. The participants were recruited from a heterogeneous group of surgical specialties and it is likely that different specialties will have differing rates of frailty. Furthermore, the COVID-19 pandemic impacted on elective surgery to an extent still difficult to ascertain. While this study was conducted during a period of relatively increased operating activity, it is likely that patients listed for surgery were selected because they were from a less vulnerable patient group or not shielding. The pandemic also led to a shortage of high dependency and intensive care beds, meaning fewer high-risk elective procedures were performed(1). A further factor affecting the study’s generalisability was that patient’s without capacity were excluded. Some of the most severely frail patients presenting for surgery, for example with advanced dementia, will therefore not have been approached.