Evidence For Preoperative Risk Stratification Of Surgically Managed Pressure Injuries Using The 5-factor Modified Frailty Index
Allyson R. Alfonso, B.S., B.A., Gustave K. Diep, M.D., Jasmine Lee, B.A., Rami S. Kantar, M.D., M.P.H., Zoe P. Berman, M.D., Elie P. Ramly, M.D., David A. Daar, M.D., M.B.A., Jamie P. Levine, M.D., Daniel J. Ceradini, M.D..
NYU Langone Health, New York, NY, USA.
PURPOSE: Non-healing pressure injuries can require surgical intervention in medically complex patients. Due to the risk of recurrence and complication rates, decisions to pursue surgical intervention can benefit from clinically-relevant preoperative risk stratification. We therefore evaluated the 5-factor modified frailty index (mFI-5) as a predictor of postoperative complications in patients undergoing surgical management of pressure injuries.
METHODS: Retrospective review of the ACS-NSQIP database identified patients undergoing surgical management of pressure injuries (2010-2015). The mFI-5 score accounts for history of diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease and dependent functional status. In accordance with previous studies, mFI-5 was analyzed as a categorical variable with a cutoff of 2. Primary outcomes included wound and overall complications. Secondary outcomes included hospital length of stay (LOS) and operative time. Multivariate regression analysis assessed independent predictors of complications. The model controlled for age, BMI, sex, smoking, ASA class, surgical team specialty, and wound classification as potential confounders.
RESULTS: A total of 1,372 patients (69.5% mFI-5 score ≥ 2) met inclusion criteria. Rate of wound and overall complications was 5% and 44%, respectively. There were significantly higher rates of overall complications (46.2% vs. 39.1%; p= 0.02) and shorter operative times (40.2 ± 34.7 vs. 50.8 ± 53.5; p< 0.001) in patients with an mFI-5 score ≥ 2. Multivariate regression analysis showed that an mFI-5 score ≥ 2 was an independent predictor of overall complications (OR= 1.27; 95% CI: 1.01 - 1.62; p= 0.04), meanwhile wound classification, surgical team specialty, age, BMI, ASA class, sex, and smoking status were not associated with overall complications.
CONCLUSION: Wide variability in reported complication rates following surgical management of pressure injuries highlights the need for better preoperative risk stratification. This study demonstrates that the mFI-5 predicts higher rates of overall complications in patients. The mFI-5 therefore has the potential to become a clinically useful tool for preoperative risk assessment.
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