The modified Frailty Index does not significantly help with Esophagectomy Risk Prediction Modelling
Hayley Reddington , *Samih Shafique MS, *Kevin Dickson , *Allison Crawford MS, Mark W. Maxfield MD, Karl F. Uy MD, *Isabel Cristina M. Emmerick , Feiran Lou MD
Surgery, University of Massachusetts, Worcester, MA
Background:
Frailty is defined as a progressive loss of vigor with or without coexisting conditions or diseases, along with physical and cognitive decline. The modified frailty index (mFI-5) is a comorbidity-based index containing five components: diabetes (DM), hypertension requiring medication (HTN), congestive heart failure (CHF), functional status (partially or totally dependent), and chronic obstructive pulmonary disease (COPD). This study investigates the mFI-5 score or the included 4 comorbid conditions correlated to post-esophagectomy outcomes.
Study design:
Patients who underwent esophagectomy for malignancy were identified using the National Surgical Quality Improvement Program (NSQIP) targeted database from 2016-2022. Primary outcome was major complication (presence of at least one post-operatively: re-intubation, prolonged ventilation, pneumonia, esophageal leak requiring treatment, renal failure, re-operation) or 30-day mortality (M/M). Descriptive analysis, univariable and multivariable logistic regression models correlated mFI-5 and other pre-operative characteristics with the outcomes of interest.
Results:
A total of 5657 patients met inclusion criteria. Only a small percentage of these patients had CHF (1.1%) or partially/totally dependent functional status (0.6%). Most patients had a mFI-5 <2 (81%). In the univariable regression the mFI-5 score was significantly associated with major morbidity and mortality (p<0.0001). In the multi-variable model with the mFI-5 score, a score of >2 was again strongly correlated with postoperative major complications and mortality (p=0.0002). The relationship was maintained whether mFI-5 score >2 or each of the individual components were used in the models(c-statistic 0.616 and 0.621, respectively). When the individual components of the mFI-5 score were represented separately in the model, all were statistically significant except for dependent status.
Conclusion(s):
In this large cohort of esophagectomy patients, an association between mFI-5 and adverse outcomes was identified. However, when each component of mFI-5 were assessed, all except dependent status were predictive of M/M. In the case of esophagectomies, the association of mFI-5 is mainly driven by comorbid conditions like HTN, CHF, COPD, and DM, . Future studies on frailty should focus on assessing the impact of frailty phenotype as the mFI-5 may be a surrogate for comorbid conditions.
Multivariable logistic regressions for predicting post-operative major morbidity or 30-day mortality in NSQIP 2016 to 2022, n=5266
Model fit with all mFI-5 components as predictors | |||||
Variable | % N | OR | 95% CI | p-value | |
Hx COPD | 6.9 | 1.55 | 1.24 | 1.94 | 0.0001 |
Hx CHF | 1.1 | 1.74 | 1.02 | 2.98 | 0.042 |
Partially or totally dependent | 0.6 | 1.37 | 0.68 | 2.79 | 0.38 |
HTN requiring medication | 49.7 | 1.23 | 1.08 | 1.40 | 0.002 |
Hx Diabetes | 19.5 | 1.17 | 1.003 | 1.37 | 0.046 |
Age, per 10-year increase | 1.12 | 1.05 | 1.20 | 0.001 | |
Preop creatinine, per 0.1 unit increase | 1.03 | 1.01 | 1.05 | 0.006 | |
Preop WBC, per 1 unit increase | 1.05 | 1.02 | 1.08 | 0.0006 | |
BMI (versus 18.5 to <25, n = 1641/5266) | 0.005 | ||||
Under 18.5 | 3.4 | 1.65 | 1.19 | 2.29 | 0.003 |
25 to <30 | 36.3 | 1.01 | 0.87 | 1.17 | 0.93 |
30 to <35 | 19.0 | 1.20 | 0.999 | 1.43 | 0.051 |
35 to <40 | 6.7 | 1.30 | 1.003 | 1.67 | 0.047 |
40 or higher | 3.6 | 1.34 | 0.96 | 1.88 | 0.09 |
Thoracic anastomosis location (versus Ivor-Lewis, n=3319/5266) | <0.0001 | ||||
Transhiatal | 15.0 | 1.07 | 0.90 | 1.27 | 0.44 |
McKeown | 15.9 | 1.43 | 1.22 | 1.68 | <0.0001 |
Thoraco-abdominal | 6.0 | 0.80 | 0.61 | 1.05 | 0.11 |
Neoadjuvant therapy | 72.8 | 0.81 | 0.71 | 0.93 | 0.002 |
Positive margins | 7.7 | 1.29 | 1.03 | 1.60 | 0.024 |
Current smoker | 23.3 | 1.52 | 1.32 | 1.76 | <0.0001 |
Bleeding disorder | 3.6 | 1.52 | 1.12 | 2.07 | 0.007 |
C-statistic = 0.621
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