Automated Frailty Screening At-Scale for Pre-Operative Risk Stratification Using the Electronic Frailty Index

J Am Geriatr Soc. 2021 May;69(5):1357-1362. doi: 10.1111/jgs.17027. Epub 2021 Jan 19.


Background: Frailty is associated with numerous post-operative adverse outcomes in older adults. Current pre-operative frailty screening tools require additional data collection or objective assessments, adding expense and limiting large-scale implementation.

Objective: To evaluate the association of an automated measure of frailty integrated within the Electronic Health Record (EHR) with post-operative outcomes for nonemergency surgeries.

Design: Retrospective cohort study.

Setting: Academic Medical Center.

Participants: Patients 65 years or older that underwent nonemergency surgery with an inpatient stay 24 hours or more between October 8th, 2017 and June 1st, 2019.

Exposures: Frailty as measured by a 54-item electronic frailty index (eFI).

Outcomes and measurements: Inpatient length of stay, requirements for post-acute care, 30-day readmission, and 6-month all-cause mortality.

Results: Of 4,831 unique patients (2,281 females (47.3%); mean (SD) age, 73.2 (5.9) years), 4,143 (85.7%) had sufficient EHR data to calculate the eFI, with 15.1% categorized as frail (eFI > 0.21) and 50.9% pre-frail (0.10 < eFI ≤ 0.21). For all outcomes, there was a generally a gradation of risk with higher eFI scores. For example, adjusting for age, sex, race/ethnicity, and American Society of Anesthesiologists class, and accounting for variability by service line, patients identified as frail based on the eFI, compared to fit patients, had greater needs for post-acute care (odds ratio (OR) = 1.68; 95% confidence interval (CI) = 1.36-2.08), higher rates of 30-day readmission (hazard ratio (HR) = 2.46; 95%CI = 1.72-3.52) and higher all-cause mortality (HR = 2.86; 95%CI = 1.84-4.44) over 6 months' follow-up.

Conclusions: The eFI, an automated digital marker for frailty integrated within the EHR, can facilitate pre-operative frailty screening at scale.

Keywords: frailty; healthcare utilization; preoperative assessment.

Publication types

  • Evaluation Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Electronic Health Records / statistics & numerical data*
  • Female
  • Frail Elderly / statistics & numerical data*
  • Frailty / diagnosis*
  • Frailty / mortality
  • Geriatric Assessment / statistics & numerical data
  • Health Status Indicators*
  • Hospitalization / statistics & numerical data
  • Humans
  • Male
  • Mass Screening / methods
  • Mass Screening / statistics & numerical data
  • Patient Acceptance of Health Care / statistics & numerical data
  • Patient Readmission / statistics & numerical data
  • Postoperative Period
  • Preoperative Period
  • Proportional Hazards Models
  • Retrospective Studies
  • Risk Assessment / methods*
  • Risk Factors
  • Systems Integration