Daniel McIsaac, MD, MPH, FRCPC Ottawa Hospital ......2018/01/10 · Welcome • Q&A session • Please submit your Qs online during presentation • We will answer as many Qs as time

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Identifying older patients at high risk of poor outcomes after joint replacement surgery

Webinar SeriesJanuary 10, 2018

Daniel McIsaac, MD, MPH, FRCPCOttawa Hospital Research Institute

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2018-01-10

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• Wednesday, January 31, 2018 at 12 noon ET (Tentative)Reducing post-discharge potentially inappropriate medications amongst the elderly: a multi-centre electronic deprescribing intervention – CFN-funded Catalyst Grant Program – Todd Campbell Lee and Emily McDonald, McGill University Health Centre

• Wednesday, February 14, 2018 at 12 noon ETAn ounce of prevention: intensive resistance training to optimize health in pre-frail older adults – CFN-funded Catalyst Grant Program – Ada Tang and Christina Nowak, McMaster University

• Wednesday, February 28, 2018 at 12 noon ETThe eDosette Study: Optimizing medication use and safety in community dwelling seniors – CFN-funded Catalyst Grant Program – Henry Siu, McMaster University

2018-01-10

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2018 Catalyst Grant Competition

• Based on the findings of the CFN-funded Canadian Frailty Priority Setting Partnership study

• Intent to Apply is due Monday, January 15, 2018 by 5 p.m. ET

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2018-01-10

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2018-01-10

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Presenter

• Associate Scientist at the Ottawa Hospital Research Institute

• Assistant Professor in the Departments of Anesthesiology & Pain Medicine, and Epidemiology and Public Health at the University of Ottawa

• Adjunct Scientist at the Institute for Clinical Evaluative Sciences (ICES) and an Anesthesiologist at The Ottawa Hospital

• On the Board of Directors for the Society for Geriatric Anesthesia

2018-01-10

Identifying older patients at high risk of poor outcomes after joint replacement surgery

Daniel McIsaac,MD, MPH, FRCPC

Affiliated with • Affilié à 1

IDENTIFYING HIGH RISK OLDER PEOPLE BEFORE SURGERY:

COMPARATIVE ASSESSMENT OF TWO FRAILTY INSTRUMENTS TO PREDICT PATIENT-REPORTED

DISABILITY AFTER SURGERY

Daniel I McIsaac MD, MPH, FRCPC

on behalf of the Ottawa Perioperative Frailty Research Group

▶ No conflicts of interest

▶ Program funding:

• Canadian Frailty Network

• University of Ottawa Department of Anesthesiology

• TOHAMO

• Canadian Anesthesiologists’ Society

• International Anesthesia Research Society

▶ Collaborators

2

• Paul Beaule• Gregory Bryson• Alan Forster• Sylvain Gagne• Allen Huang• John Joanisse• Claire Kendall• Manoj Lalu• Sylvain Boet

• Luke Lavalee• Colin McCartney• Hussein Moloo• Julie Nantel• Janet Squires• Dawn Stacey• Monica Taljaard• Carl van

Walraven

▶ Review

• Epidemiology and outcomes of older people with frailty having surgery

• Current recommendations for frailty assessment before surgery

• Comparative accuracy of the Clinical Frailty Scale vs the modified Fried Index in predicting new patient-reported disability after surgery

3

OUTLINE


OUR AGEING POPULATION:IMPACT ON PERIOPERATIVE CARE

Affiliated with • Affilié à 5Etzioni, Ann Surg, 2001



>50% of major surgery in people >65 y.o.

Affiliated with • Affilié à

▶ Advanced age is associated with 2-4 fold increase in

• Morbidity

• Mortality

• Costs

AGE AND PERIOPERATIVE RISK

81. Hamel et al. JAGS 2005; 2. Turrentine et al. JACS 2006


▶ Significant outcome variation amongst older surgical population

• Not explained by age and comorbidity burden

OUTCOME VARIATION IN OLDER PEOPLE

9Oresanya, JAMA, 2014


▶ Preoperative frailty predicts

• Mortality

• Morbidity

• ICU admission

• Length of stay

• Institutional discharge

FRAILTY AND SURGICAL OUTCOMES

101. Beggs CJA 2015; 2. Marcantonio, AIM, 2017


▶ Preoperative frailty predicts

• Mortality

• Morbidity

• ICU admission

• Length of stay

• Institutional discharge

▶ Estimated 35-45% prevalence

FRAILTY AND SURGICAL OUTCOMES

111. Beggs CJA 2015; 2. Marcantonio, AIM, 2017


▶ Morbidity & mortality

• 25-40% attributable risk

FRAILTY ATTRIBUTABLE RISK

12


PERIOPERATIVE CARE

13

0

5

10

15

20

25

30

35

0 10 20 30 40 50 60 70 80 90

Ad

just

ed

HR

Post-operative day

HR 95%CI

Impact of frailty on mortality by post-operative day

McIsaac et al. JAMA Surgery 2016


▶ 3-5 fold increase

• 30-50% absolute incidence

LOSS OF INDEPENDENCE

141. McIsaac et al. BJJ 2016; 2. McIsaac et al. Anes Analg 2017


▶ Older people commonly have surgery

▶ Frailty prevalence >35%

▶ Significant increase in risk of adverse outcomes

▶ Consistent across surgical specialties and frailty instruments

SUMMARY

15


PERIOPERATIVE HEALTHCARE SYSTEM AND FRAILTY

PERIOPERATIVE CARE

17

IntraoperativePreoperative Postoperative

PERIOPERATIVE CARE

18


• Evaluation• Decision making• Care planning• Optimization

• Anesthesia• Surgery• Pain management • Acute monitoring

• Pain management• Recovery/rehabilitation• Transition to community

TARGETS FOR IMPROVING CARE

19


• Evaluation• Decision making• Care planning• Optimization

• Anesthesia• Surgery• Pain management • Acute monitoring

• Pain management• Recovery/rehabilitation• Transition to community


20


• Evaluation

▶ What instrument?

▶ What outcome?

▶ How to implement?


21


• Evaluation

▶ What instrument?

▶ What outcome?

▶ How to implement?

CHALLENGES

▶ 100’s of frailty instruments

▶ Literature to date limited to non-patient reported outcomes

▶ Time and resource limited clinical areas

22


WHAT TOOL?

WHAT TOOL?

24Chow et al, JACS, 2012

WHAT TOOL?

▶ Modified Fried Index

25Chow et al, JACS, 2012

-low activity-weight loss-falls-grip strength-gait speed

WHAT COMPARATOR TOOL?

26

WHAT TOOL?

▶ Clinical Frailty Scale

27

WHAT TOOL?

▶ Clinical Frailty Scale

• Well-validated in acute care

• Good inter-rater reliability

• Similar prognostic accuracy vs 30+ item indices

28

WHAT OUTCOME?

29

WHAT OUTCOME?

▶ Mortality, morbidity, LOS, etc. well-reported

▶ Patient-reported and functional outcomes rarely reported

30

WHAT OUTCOME?

▶ Patient reported new disability

• World Health Organization Disability Assessment Schedule 2.0

31

WHAT OUTCOME?



- 100 point scale

- 8 point MICD

- 25 point cut off for disability, or 8 points higher than baseline

32

WHAT OUTCOME?



- Standing

- Household responsibilities

- Learning a new task

- Community activities

- Emotional impact

- Concentration

- Walking

- Getting dressed

- Dealing with new people

- Friendships

- Day to day tasks or work

33

WHAT OUTCOME?



• Validated in surgery and many other acute/chronic conditions

34Shulman, Anes, 2014


RESEARCH QUESTION

RESEARCH QUESTION

▶ Population: People >65 years having major elective non-cardiac surgery

▶ Exposure: Preoperative frailty

▶ Comparators: CFS vs. mFI

▶ Outcomes:

• Primary: Patient-reported new disability 90 days after surgery

36

RESEARCH QUESTION

▶ Population: People >65 years having major elective non-cardiac surgery

▶ Exposure: Preoperative frailty

▶ Comparators: CFS vs. mFI

▶ Outcomes:

• Primary: Patient-reported new disability 90 days after surgery

• Secondary:

- Feasibility

- Acceptability

- Complications, LOS, discharge disposition, survival

37


DESIGN

DESIGN

▶ Multicenter prospective cohort study

39


4040

• Frailty-CFS/mFI• Co-morbidities• Mood/Anxiety• Substance use• Cognitive screen• Baseline disability


4141

• Frailty-CFS/mFI• Co-morbidities• Mood/Anxiety• Substance use• Cognitive screen• Baseline disability


4242

• LOS• Complications• Discharge disposition


4343

• Mortality• Disability• Anxiety/Depression


4444

• Mortality• Disability• Anxiety/Depression• Decisional regret


4545

• Mortality• Disability• Anxiety/Depression• Health resource use


ANALYSIS

ANALYSIS

▶ Primary:

• Relative true positive rate (rTPR; ratio of sensitivities)

• Relative false positive rate (rFPR; ratio of 1-specificity)

47Alonzo, Stat Med, 2002

ANALYSIS

▶ Primary:



▶ Sample size

• Expected rate new disability 18%

• Sensitivity mFI 60%

• 648 participants

- 80% power, alpha 5% for rTPR 1.3


ANALYSIS

▶ Primary:



▶ Sample size






n=700 allows 15% attrition

ANALYSIS

▶ Primary:



▶ Sample size






n=700 allows 15% attrition

Dichotomization:CFS->4mFI>3

ANALYSIS

▶ Effect sizes (ORs, RRs, ARDs)

▶ ROC analyses

51


RESULTS

RESULTS

53

96%

93%

RESULTS

▶ Mean age

• 73 (SD 6) years

▶ Female

• 49%

▶ Comorbidity score

• 2 (IQR 1-3)

54

RESULTS

▶ Mean age

• 73 (SD 6) years

▶ Female

• 49%

▶ Comorbidity score

• 2 (IQR 1-3)

▶ Surgical Specialty

•

55

0 10 20 30 40 50 60

Other

Neuro

Gynecology

Urology

General

Thoracics

Vascular

Orthopedics

Percent of cohort

FRAILTY STATUS

▶ CFS > 4

• 42%

▶ mFI > 3

• 37%

56

FRAILTY STATUS

▶ CFS > 4

• 42%

▶ mFI > 3

• 37%

▶ Agreement

• Kappa=0.51

57

DISABILITY

▶ 90-day

• 10 patients deceased (1.5%)

• 11.1% experienced death or new disability

58

FRAILTY STATUS AND NEW DISABILITY

▶ CFS

59

0 10 20 30 40 50

Without frailty

With frailty 15.5%

7.9%

0 10 20 30 40 50

Without frailty

With frailty

FRAILTY STATUS AND NEW DISABILITY

▶ CFS

▶ mFI

60

0 10 20 30 40 50

Without frailty

With frailty

16.7%

7.8%

15.5%

7.9%

CFS VS MFI

▶ CFS

• Sensitivity – 60%

• Specificity – 59%

61

CFS VS MFI

▶ CFS



62

▶ mFI



CFS VS MFI

▶ CFS



63

▶ mFI



Relative True Positive Rate

1.07 (0.86-1.29)

CFS VS MFI

▶ CFS



64

▶ mFI



Relative True Positive Rate

1.07 (0.86-1.29)Relative False Positive Rate

0.90 (0.80-1.01)

EFFECT SIZES

▶ Died or new disability

• CFS >4:

- OR-2.15 (95%CI 1.30-3.54)

• mFI >3:

- OR-2.36 (95%CI 1.44-3.88)

65

DISCRIMINATION-AREA UNDER THE ROC (AUC)

66


CFS: AUC=0.59mFI: AUC=0.61


CFS: AUC=0.59mFI: AUC=0.61

P=0.75


DISABILITY TRAJECTORY


DISABILITY TRAJECTORY

DECREASING DISABILITY

▶ Repeated measures analysis

• Significantly greater decrease in disability for people with frailty

- -8.1 (95%CI -9.1 to -7.1); P<0.0001

71

FEASIBILITY

72

FEASIBILITY

▶ Time to administer

• CFS

- 42 seconds (IQR 20-50)

• mFI

- 300 seconds (IQR 240-360)

73

FEASIBILITY

▶ Time to administer

• CFS

- 42 seconds (IQR 20-50)

• mFI

- 300 seconds (IQR 240-360)

74

▶ Missing data

• CFS

- 0%

• mFI

- 17%

ACCEPTABILITY

Very or extremely CFS mFI Difference

Easy to use 90%

Useful in practice 70%

Beneficial to care 46%

Easy logistically 94%

75Brehaut, Med Dec Making, 2010

ACCEPTABILITY


Easy to use 90% 47% 43%

Useful in practice 70% 47% 23%

Beneficial to care 46% 44% 2%

Easy logistically 94% 47% 47%

76

ACCEPTABILITY


Easy to use 90% 47% 43%

Useful in practice 70% 47% 23%

Beneficial to care 46% 44% 2%

Easy logistically 94% 47% 47%

77

▶ 71% of patients willing or extremely willing to participate in preoperative frailty assessment

• Only 0.5% unwilling

SUMMARY

▶ CFS vs mFI

• No significant difference in

- Sensitivity

- False positive rates

- Discrimination

• CFS was superior based on

- Less missing data

- Faster time for administration

- Higher acceptability score

78

SUMMARY

▶ CFS vs mFI

• No significant difference in

- Sensitivity

- False positive rates

- Discrimination

• CFS was superior based on

- Less missing data

- Faster time for administration

- Higher acceptability scores

▶ Disability trajectory and preoperative frailty

• People with frailty before surgery have a greater decrease in disability after surgery

79


FUTURE DIRECTIONS

IMPLEMENTATION OF PREOP FRAILTY ASSESSMENT

▶ Qualitative theory based interviews

• Theoretical Domains Framework

- Anesthesiologists, surgeons, preoperative nurses

81

IMPLEMENTATION OF PREOP FRAILTY ASSESSMENT

▶ Qualitative theory based interviews

• Theoretical Domains Framework

▶ Preliminary results – Barriers and Facilitators

82

BARRIERS AND FACILITATORS

▶ Knowledge

• Familiar with concept, unable to define

• Understand large impact on outcomes

▶ Professional role

• Appropriate to screen for frailty before surgery

▶ Beliefs

• Easy to perform

▶ Goals

• Assessing for frailty is important

83

INTERVENTIONS TO IMPROVE OUTCOMES

84


85


▶ Only 11 studies identified

• All moderate to high risk of bias

- 6 RCTs

86


▶ Only 11 studies identified

• Exercise (pre- and post-op) promising

- Well-powered low risk of bias studies needed

87

88

▶ 200 patient, parallel arm RCT

• P->65, frail per CFS

• I-home-based exercise >3 weeks preop

• C-standard care

• O-Six minute walk test at first postop followup visit

89

▶ 200 patient, parallel arm RCT

• P->65, frail per CFS

• I-home-based exercise >3 weeks preop

• C-standard care

• O-Six minute walk test at first postop followup visit

90

Already largest trial of preoperative exercise in people with frailty!

FINAL SUMMARY

▶ Frailty is:

• prevalent before major surgery

• associated with increased rates of new disability

91

FINAL SUMMARY

▶ Frailty is:



▶ The Clinical Frailty Scale is:

• prognostically equivalent to the mFI

• more feasible and acceptable than the mFI for preop use

92

FINAL SUMMARY

▶ Frailty is:






▶ Older people with frailty before surgery:

• Experience a greater overall decrease in disability after surgery

93

FINAL SUMMARY

▶ Frailty is:






▶ Older people with frailty before surgery:

• Experience a greater overall decrease in disability after surgery

▶ Interventions specifically designed for people with frailty having surgery are urgently needed

94

THANK YOU

▶ Periop frailty team

95Erin Beasley

Chelsey Saunders

Kristin Dorrance

Emily Hladkowicz

Coralie Wong

96

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Reducing post-discharge potentially inappropriate medications amongst the elderly: a multi-centre electronic deprescribing intervention – CFN-funded Catalyst Grant Program – Todd Campbell Lee and Emily McDonald, McGill University Health Centre

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Daniel McIsaac, MD, MPH, FRCPC Ottawa Hospital ......2018/01/10 · Welcome • Q&A session • Please submit your Qs online during presentation • We will answer as many Qs as time