Preoperative Frailty Assessment, Operative Severity Score, and Early Postoperative Loss of Independence in Surgical Patients Age 65 Years or Older

J Am Coll Surg. 2021 Apr;232(4):387-395. doi: 10.1016/j.jamcollsurg.2020.11.026. Epub 2020 Dec 29.


Background: Preoperative discussions around postoperative discharge planning have been amplified by the COVID pandemic. We wished to determine whether our preoperative frailty screen would predict postoperative loss of independence (LOI).

Study design: This single-institutional study included demographic, procedural, and outcomes data from patients 65 years or older who underwent frailty screening before a surgical procedure. Frailty was assessed using the Edmonton Frail Scale. The Operative Severity Score was used to categorize procedures. The Hierarchical Condition Category risk-adjustment score, as calculated by the Centers for Medicare and Medicaid Services, was included. LOI was defined as an increase in support outside of the home after discharge. Univariable, multivariable logistic regressions, and adjusted postestimation analyses for predictive probabilities of best fit were performed.

Results: Five hundred and thirty-five patients met inclusion criteria and LOI was seen in 38 patients (7%). Patients with LOI were older, had a lower BMI, a higher Edmonton Frail Scale score (7 vs 3.0; p < 0.001), and a higher Hierarchical Condition Category score than patients without LOI. Being frail and undergoing a procedure with an Operative Severity Score of 3 or higher was independently associated with an increased risk of LOI. In addition, social dependency, depression, and limited mobility were associated with an increased risk for LOI. On multivariable modeling, frailty status, undergoing an operation with an Operative Severity Score of 3 or higher, and having a Hierarchical Condition Category score ≥1 were the most predictive of LOI (odds ratio 12.72; 95% CI, 12.04 to 13.44; p < 0.001). In addition, self-reported depression, weight loss, and limited mobility were associated with a nearly 11-fold increased risk of postoperative LOI.

Conclusions: This study was novel, as it identified clear, generalizable risk factors for LOI. In addition, our findings support the implementation of preoperative assessments to aid in care coordination and provide specific targets for intervention.

MeSH terms

  • Age Factors
  • Aged
  • Aged, 80 and over
  • Elective Surgical Procedures / adverse effects*
  • Female
  • Frailty / diagnosis
  • Frailty / epidemiology*
  • Functional Status*
  • Geriatric Assessment / statistics & numerical data*
  • Hospital Mortality
  • Humans
  • Length of Stay
  • Male
  • Patient Discharge / statistics & numerical data
  • Postoperative Period
  • Preoperative Care / methods*
  • Risk Assessment / methods
  • Risk Factors