To evaluate the independent effect of frailty, as measured by the Risk Analysis Index-Administrative (RAI-A) for postoperative complications and discharge outcomes following brain tumor resection (BTR) in a large multi-center analysis.Patients undergoing BTR were queried from the National Surgical Quality Improvement Program (NSIQP) for the years 2015 to 2019. Multivariable logistic regression was performed to evaluate the independent associations between frailty tools (age, 5-factor modified frailty score [mFI-5], and RAI-A) on postoperative complications and discharge outcomes.We identified 30,951 patients who underwent craniotomy for BTR; the median age of our study sample was 59 (IQR 47-68) years old and 47.8% of patients were male. Overall, increasing RAI-A score, in an overall stepwise fashion, was associated with increasing risk of adverse outcomes including in-hospital mortality, non-routine discharge, major complications, Clavien-Dindo Grade IV complication, and extended length of stay. Multivariable regression analysis (adjusting for age, sex, BMI, non-elective surgery status, race, and ethnicity) demonstrated that RAI-A was an independent predictor for worse BTR outcomes. The RAI-A tiers 41-45 (1.2% cohort) and > 45 (0.3% cohort) were ~ 4 (Odds Ratio [OR]: 4.3, 95% CI: 2.1-8.9) and ~ 9 (OR: 9.5, 95% CI: 3.9-22.9) times more likely to have in-hospital mortality compared to RAI-A 0-20 (34% cohort).Increasing preoperative frailty as measured by the RAI-A score is independently associated with increased risk of complications and adverse discharge outcomes after BTR. The RAI-A may help providers present better preoperative risk assessment for patients and families weighing the risks and benefits of potential BTR. 

/pdf/preoperative-frailty-measured-by-risk-analysis-index-1tg5plxe.pdf

Preoperative frailty measured by risk analysis index predicts complications and poor discharge outcomes after Brain Tumor Resection in a large multi-center analysis

BACKGROUND AND IMPORTANCE: Healthcare systems continuously strive to improve quality and value of care. Advances in surgical technologies, enhanced perioperative surgical planning, and multidisciplinary care strategies are increasing the number of elective procedures in the geriatric population. However, frail older adults are still more likely to have poor postoperative outcomes. We examined the impact of frailty on postoperative outcomes, we compared the discriminative thresholds for the Risk Analysis Index (RAI), modified Frailty Index-5 (mFI-5), and increasing patient age. CLINICAL PRESENTATION: Octogenarian patients undergoing spine, cranial, and other procedures captured in the American College of Surgeons National Surgical Quality Improvement Program between 2012 and 2020 were included. We used receiver operating characteristic curve to examine discriminative thresholds of RAI, mFI-5, and increasing patient age. Multivariable analyses were performed. Our primary outcomes were 30-day mortality, extended length of stay (eLOS [≥75th percentile]), and continued inpatient care &gt;30 days (pLOS). Secondary outcomes were skilled care facility (skilled nursing facility [SNF]) discharges and readmissions. DISCUSSION: In total, 20 710 octogenarians were included, with a mean age of 83 years (SD, 2.5) and a men (52.7%) and White (79.8%) majority. The RAI had higher predictive discriminative thresholds for 30-day mortality (C-statistic of 0.743), eLOS (C-statistic: 0.692), and pLOS (C-statistic: 0.697) compared with the mFI-5 (C-statistic: 0.574, 0.556, and 0.550, respectively), and increasing patient age (C-statistic: 0.577, 0.546, and 0.504, respectively), P &lt; .001. On multivariable analyses, RAI showed a larger effect size with adverse postoperative outcomes by increasing frailty strata than mFI-5 and increasing patient age. Nonetheless RAI showed decreased risk for SNF discharges. CONCLUSION: We found that RAI was a more accurate predictor than mFI-5 and increasing patient age for 30-day mortality, eLOS, and pLOS in octogenarian neurosurgery patients. More research is needed on RAI's performance in different specialized neurosurgical populations. Moreover, it is increasingly clear that comprehensive risk assessment strategies tailored to optimize perioperative care should be prioritized to potentially improve outcomes for this at-risk population. 

The Risk Analysis Index Has Superior Discrimination Compared With the Modified Frailty Index-5 in Predicting Worse Postoperative Outcomes for the Octogenarian Neurosurgical Patient

To the Editor, Occam’s Razor insinuates that the premise with the fewest assumptions, or the most straightforward explanation, should be selected when presented with competing hypotheses.1 While this principle has frequently proven helpful in numerous disparate fields,1 it is essential to exercise caution when applying it to healthcare-related decisions (e.g., preoperative frailty risk assessment). Frailty risk assessment plays a pivotal role in perioperative management, as it empowers clinicians to identify high-risk patients who would benefit from preoperative optimization and multidisciplinary planning.2,3 Nonetheless, inaccurate frailty risk assessments can lead to inappropriate care plans, increased expenditures, and potentially adverse patient outcomes through erroneously understating the actual risk.4 Two prevalent frailty screening tools frequently utilized in neurosurgical practices are the Risk Analysis Index (RAI)2,5 and the 5-factor Modified Frailty Index (mFI-5) (Fig. 1).3 We aim to draw the neurosurgery workforce’s attention to the potential pitfalls of exclusively relying on Occam’s Razor when implementing frailty interventions. Additionally, we emphasize the importance of a thorough assessment method, as there are instances when Hickam’s Dictum takes precedence over parsimony. The mFI-5 evaluates patients based on 5 specific parameters: diabetes, hypertension, functional dependence, chronic obstructive pulmonary disease, and congestive heart failure.3 The mFI-5 is advantageous due to its simplicity and ease of implementation.3 However, it also has certain drawbacks, such as its potential to overlook other critical aspects of frailty and oversimplification of complex cases, consequently leading to suboptimal care plans.3,5 Despite this the mFI-11, an extended, comorbidity-based frailty measure version of the mFI5, is the most commonly reported frailty index, garnering considerable attention in the neurosurgery spine literature.6 RAI is an alternative screening tool that evaluates a patient’s overall health status based on various factors, including age, functional dependence, and comorbidities.5,7 RAI offers several advantages, such as its ease of use and integration into clinical workflows.7-10 Studies in the neurosurgery literature, encompassing a wide range of routinely Neurospine

/pdf/the-fine-line-between-simplicity-and-oversimplification-285665t8.pdf

The Fine Line Between Simplicity and Oversimplification: Comparing the Risk Analysis Index and 5-Factor Modified Frailty Index as Frailty Assessment Tools

The awake craniotomy (AC) procedure allows for safe and maximal resection of brain tumors from highly eloquent regions. However, geriatric patients are often viewed as poor candidates for AC due to age and medical comorbidities. Frailty assessments gauge physiological reserve for surgery and are valuable tools for preoperative decision-making. Here, we present a novel case illustrating how frailty scoring enabled an elderly but otherwise healthy female to undergo successful AC for tumor resection.A 92-year-old right-handed female with history of hypertension and basal cell skin cancer presented with a 1-month history of progressive aphasia and was found to have a ring-enhancing left frontoparietal mass abutting the rolandic cortex concerning for malignant neoplasm. Frailty scoring with the recalibrated risk analysis index (RAI-C) tool revealed a score of 30 (of 81) indicating low surgical risk. The patient and family were counseled appropriately that, despite advanced chronological age, a low frailty score predicts favorable surgical outcomes. The patient underwent left-sided AC for resection of tumor and experienced immediate improvement of speech intraoperatively. After surgery, the patient was neurologically intact and had an unremarkable postoperative course with significant improvements from preoperatively baseline at follow-up.To the best of our knowledge, this case represents the oldest patient to undergo successful AC for brain tumor resection. Nonfrail patients over 90 years of age with the proper indications may tolerate cranial surgery. Frailty scoring is a powerful tool for preoperative risk assessment in the geriatric neurosurgery population. 

/pdf/advanced-frailty-assessment-tool-predicts-successful-awake-2zmlovqo.pdf

Advanced frailty assessment tool predicts successful awake craniotomy in a 92-year-old patient: A case report

Background: The awake craniotomy (AC) procedure allows for safe and maximal resection of brain tumors from highly eloquent regions. However, geriatric patients are often viewed as poor candidates for AC due to age and medical comorbidities. Frailty assessments gauge physiological reserve for surgery and are valuable tools for preoperative decision-making. Here, we present a novel case illustrating how frailty scoring enabled an elderly but otherwise healthy female to undergo successful AC for tumor resection. Case Description: A 92-year-old right-handed female with history of hypertension and basal cell skin cancer presented with a 1-month history of progressive aphasia and was found to have a ring-enhancing left frontoparietal mass abutting the rolandic cortex concerning for malignant neoplasm. Frailty scoring with the recalibrated risk analysis index (RAI-C) tool revealed a score of 30 (of 81) indicating low surgical risk. The patient and family were counseled appropriately that, despite advanced chronological age, a low frailty score predicts favorable surgical outcomes. The patient underwent left-sided AC for resection of tumor and experienced immediate improvement of speech intraoperatively. After surgery, the patient was neurologically intact and had an unremarkable postoperative course with significant improvements from preoperatively baseline at follow-up. Conclusion: To the best of our knowledge, this case represents the oldest patient to undergo successful AC for brain tumor resection. Nonfrail patients over 90 years of age with the proper indications may tolerate cranial surgery. Frailty scoring is a powerful tool for preoperative risk assessment in the geriatric neurosurgery population.

https://surgicalneurologyint.com/wp-content/uploads/2022/09/11862/SNI-13-404.pdf

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Preoperative frailty risk in deep brain stimulation patients: Risk analysis index predicts Clavien-Dindo IV complications

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Worse Pituitary Adenoma Surgical Outcomes Predicted by Increasing Frailty, Not Age.

Preoperative frailty risk in deep brain stimulation patients: Risk analysis index predicts Clavien-Dindo IV complications

Advanced frailty assessment tool predicts successful awake craniotomy in a 92-year-old patient: A case report