Impact of frailty on risk of long-term functional decline following vascular surgery.

OBJECTIVE: Frailty is a clinical syndrome associated with slow recovery after vascular surgery. However, the degree and length of functional impairment frail patients experience after surgery is unclear. The objective of this study was to prospectively measure changes in functional status among frail and non-frail patients undergoing a spectrum of different vascular surgery procedures. METHODS: Patients consented to undergo elective minor and major vascular surgery procedures at an academic medical center between May 2018 and March 2019 were prospectively identified. Prior to surgery, all patients underwent provider assessment of frailty using the validated Clinical Frailty Scale (CFS), as well as baseline assessment of functional status using the Katz Activities of Daily Living (ADL) index and the Lawton Instrumental Activities of Daily Living (iADL) index. These same instruments were used to evaluate each patient's functional status at 2-weeks, 1-month, 1-year, and 2-year time points following surgery. Changes in iADL and ADL scores among frail (CFS ≥5) and non-frail patients were compared using paired Wilcoxon signed-rank tests and logistic regression models. RESULTS: A total of 126 patients were assessed before and after minor (55%) and major (45%) vascular procedures, of which 43 patients (34%) were determined to be frail prior to surgery. Frail patients were older and more likely than non-frail patients to have medical comorbidities including chronic kidney disease, chronic obstructive pulmonary disease, or diabetes (all P < .05). When compared with the non-frail cohort, frail patients had significantly lower ADL and iADL scores before surgery and experienced a greater decline in ability to independently complete ADL and iADL activities after surgery that was sustained at 2 years (P < .05 and P < .001, respectively). After risk-adjustment, frailty was associated with an increased likelihood of decline in ADLs (odds ratio, 5.4; 95% confidence interval, 1.9-15.4; P < .05) and iADLs (odds ratio, 6.3; 95% confidence interval, 2.6-15.1; P < .001) at 2 years following surgery. CONCLUSIONS: Frail patients experience a significant decline in ability to perform ADL and iADLs that persists 2 years following vascular surgery. These data highlight the degree of functional decline occurring immediately following surgery, as well as risk for long-term, sustained impairment that should be shared with frail patients before undergoing a procedure.

Characterizing the volume of surgery and post-operative complications during the COVID-19 pandemic.

PURPOSE: The COVID-19 pandemic led to unprecedented changes in volume and quality of surgery. Utilizing the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, the current study assesses the impact of COVID-19 on surgical volume during each quarter of 2020 in comparison to 2019. Quality of surgical care during 2020 was also investigated by assessing postoperative complications, readmissions, and reoperations during 2020 in comparison to the previous 5 years. MATERIALS AND METHODS: The NSQIP database was queried from 2015 to 2020. Descriptive statistics and a chi-squared test were utilized to compare demographic variables. A seasonal autoregressive integrated moving average time-series model was fit to assess the trend and seasonality of complications from 2015 to 2019 and was used to forecast the proportion of complications in the year 2020 and compared the forecast with the actual proportions graphically. RESULTS: There were fewer patients operated on in 2020 compared to 2019, with the most dramatic drop in Q2 with a nearly 27% decrease. Patients with ASA class 3 or greater were operated on at a greater proportion in every quarter of 2020. Q2 of 2020 represented the highest proportion of any operative complications since 2015 at ~13%. Q4 of 2020 demonstrated a return to 2020 Q1 complication proportions. CONCLUSION: Surgical volume was heavily affected in 2020, particularly in Q2. Patients during Q2 of 2020 were generally of a higher ASA class and had increased operative complications. Operative volume and overall surgical complication rate normalized over the next two quarters.

Long-Term Functional Decline Following Vascular Surgery Among Vulnerable Adults.

BACKGROUND: Identification of high-risk patients that may experience functional decline following surgery poses a challenge to healthcare providers. The Vulnerable Elders Survey (VES-13) is a patient-reported tool designed to identify risk for health deterioration based on age, self-rated health, physical function, and functional disabilities. This study was designed to determine whether VES-13 could predict long-term functional decline among patients undergoing vascular surgery procedures. METHODS: Vascular surgery patients at an academic hospital were administered VES-13 between May 2018 and March 2019, and those scoring ≥3-points were classified as vulnerable. Each patient's functional status was assessed using the Katz Activities of Daily Living (ADL) and the Lawton-Brody Instrumental Activities of Daily Living (iADL) indices preoperatively and at 2-week, 1-month, and 1-year postoperative time points. Logistic regression models were used to identify independent predictors of functional decline. RESULTS: 126 patients (59% male) were assessed before and after minor (56%) and major (44%) vascular procedures, with 55 (43%) meeting criteria for vulnerability. Vulnerable patients were older, had lower baseline functional status, and were more likely than non-vulnerable patients to experience declines in ADLs and iADLs at all time-points (P < 0.05 for all time points). These findings were confirmed in risk-adjusted regression models where vulnerability was associated with an increased likelihood of decline in ADLs (OR:3.3; 95%CI:1.0-10.6; P < 0.05) and iADLs (OR:2.6; 95%CI:1.0-6.6; P = 0.05) at 1-year following surgery. CONCLUSION: The patient-reported VES-13 survey identifies vulnerable patients who are at risk for long-term functional decline following vascular surgery. This quick preoperative screening tool can allow surgeons to prepare older patients and caretakers for postoperative functional limitations.