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. 2023 Jun 15;4(3):e00044.
doi: 10.1227/neuprac.0000000000000044. eCollection 2023 Sep.

The Risk Analysis Index Has Superior Discrimination Compared With the Modified Frailty Index-5 in Predicting Worse Postoperative Outcomes for the Octogenarian Neurosurgical Patient

Alyssa G Yocky  1 , Oluwafemi P Owodunni  2 , Evan N Courville  2 , Syed Faraz Kazim  2 , Meic H Schmidt  2 , Susan L Gearhart  3 , Diana L Greene-Chandos  4   5 , Naomi George  6   5 , Christian A Bowers  2
Affiliations

The Risk Analysis Index Has Superior Discrimination Compared With the Modified Frailty Index-5 in Predicting Worse Postoperative Outcomes for the Octogenarian Neurosurgical Patient

Alyssa G Yocky et al. Neurosurg Pract. .

Abstract

Background and importance: Healthcare systems continuously strive to improve quality and value of care. Advances in surgical technologies, enhanced perioperative surgical planning, and multidisciplinary care strategies are increasing the number of elective procedures in the geriatric population. However, frail older adults are still more likely to have poor postoperative outcomes. We examined the impact of frailty on postoperative outcomes, we compared the discriminative thresholds for the Risk Analysis Index (RAI), modified Frailty Index-5 (mFI-5), and increasing patient age.

Clinical presentation: Octogenarian patients undergoing spine, cranial, and other procedures captured in the American College of Surgeons National Surgical Quality Improvement Program between 2012 and 2020 were included. We used receiver operating characteristic curve to examine discriminative thresholds of RAI, mFI-5, and increasing patient age. Multivariable analyses were performed. Our primary outcomes were 30-day mortality, extended length of stay (eLOS [≥75th percentile]), and continued inpatient care >30 days (pLOS). Secondary outcomes were skilled care facility (skilled nursing facility [SNF]) discharges and readmissions.

Discussion: In total, 20 710 octogenarians were included, with a mean age of 83 years (SD, 2.5) and a men (52.7%) and White (79.8%) majority. The RAI had higher predictive discriminative thresholds for 30-day mortality (C-statistic of 0.743), eLOS (C-statistic: 0.692), and pLOS (C-statistic: 0.697) compared with the mFI-5 (C-statistic: 0.574, 0.556, and 0.550, respectively), and increasing patient age (C-statistic: 0.577, 0.546, and 0.504, respectively), P < .001. On multivariable analyses, RAI showed a larger effect size with adverse postoperative outcomes by increasing frailty strata than mFI-5 and increasing patient age. Nonetheless RAI showed decreased risk for SNF discharges.

Conclusion: We found that RAI was a more accurate predictor than mFI-5 and increasing patient age for 30-day mortality, eLOS, and pLOS in octogenarian neurosurgery patients. More research is needed on RAI's performance in different specialized neurosurgical populations. Moreover, it is increasingly clear that comprehensive risk assessment strategies tailored to optimize perioperative care should be prioritized to potentially improve outcomes for this at-risk population.

Keywords: 30-day mortality; Frailty; Geriatrics; Length of stay; Modified frailty index; Postoperative outcomes; Risk analysis index.

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Conflict of interest statement

The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

Figures

None
Graphical abstract
FIGURE 1.
FIGURE 1.
Assessing the predictive thresholds of frailty screening tools and age for all octogenarian neurosurgery patients (N = 20, 710) using receiver operating characteristics analysis outlined by A, 30-day mortality, B, extended length of hospital stay, and C, LOS >30 days. A, 30-day mortality C-statistics (95% CI): RAI 0.743 (0.726-0.760) vs mFI-5 0.574 (0.556-0.591) vs age 0.577 (0.558-0.596). Delong P-value: RAI vs mFI-5 vs age <0.001; RAI vs mFI-5 < 0.001; RAI vs age <0.001; mFI-5 vs age = 0.99. B, Extended LOS C-statistics (95% CI): RAI 0.692 (0.683-0.700) vs mFI-5 0.556 (0.548-0.564) vs age 0.546 (0.537-0.555). Delong P-value: RAI vs mFI-5 vs age <0.001; RAI vs mFI-5 < 0.001; RAI vs age <0.001; mFI-5 vs age = 0.01. C, LOS >30 days C-statistics (95% CI): RAI 0.697 (0.660-0.733) vs mFI-5 0.550 (0.509-0.590) vs age 0.504 (0.464-0.544). Delong P-value: RAI vs mFI-5 vs age <0.001; RAI vs mFI-5 < 0.001; RAI vs age <0.001; mFI-5 vs age = 0.14. LOS, length of hospital stay; mFI-5, modified Frailty Index-5; RAI, Risk Analysis Index.
FIGURE 2.
FIGURE 2.
Assessing the predictive thresholds of frailty screening tools and age for elective octogenarian neurosurgery patients (N = 15, 339) using receiver operating characteristics analysis outlined by A, 30-day mortality, B, extended LOS, and C, LOS >30 days. A, 30-day mortality C-statistics (95% CI): RAI 0.777 (0.743-0.812) vs mFI-5 0.598 (0.560-0.635) vs age 0.581 (0.543-0.619). Delong P-value: RAI vs mFI-5 vs age <0.001; RAI vs mFI-5 < 0.001; RAI vs age <0.001; mFI-5 vs age = 0.52. B, Extended LOS C-statistics (95% CI): RAI 0.640 (0.625-0.654) vs mFI-5 0.559 (0.545-0.572) vs age 0.527 (0.513-0.541). Delong P-value: RAI vs mFI-5 vs age <0.001; RAI vs mFI-5 < 0.001; RAI vs age <0.001; mFI-5 vs age = 0.001. C, LOS >30 days C-statistics (95% CI): RAI 0.681 (0.603-0.760) vs mFI-5 0.600 (0.514-0.685) vs age 0.522 (0.435-0.610). Delong P-value: RAI vs mFI-5 vs age = 0.01; RAI vs mFI-5 = 0.12; RAI vs age = 0.001; mFI-5 vs age = 0.20. LOS, length of hospital stay; mFI-5, modified Frailty Index-5; RAI, Risk Analysis Index.
FIGURE 3.
FIGURE 3.
Assessing the predictive thresholds of frailty screening tools and age for emergency octogenarian neurosurgery patients (N = 5, 371) using receiver operating characteristics analysis outlined by A, 30-day mortality, B, extended LOS, and C, LOS >30 days. A, 30-day mortality C-statistics (95% CI): RAI 0.597 (0.575-0.620) vs mFI-5 0.540 (0.518-0.562) vs age 0.534 (0.513-0.559). Delong P-value: RAI vs mFI-5 vs age <0.001; RAI vs mFI-5 < 0.001; RAI vs age <0.001; mFI-5 vs age = 0.79. B, Extended LOS C-statistics (95% CI): RAI 0.588 (0.572-0.604) vs mFI-5 0.538 (0.523-0.553) vs age 0.508 (0.492-0.524). Delong P-value: RAI vs mFI-5 vs age <0.001; RAI vs mFI-5 < 0.001; RAI vs age <0.001; mFI-5 vs age = 0.01. C, LOS >30 days C-statistics (95% CI): RAI 0.570 (0.525-0.615) vs mFI-5 0.502 (0.457-0.547) vs age 0.457 (0.412-0.502). Delong P-value: RAI vs mFI-5 vs age = 0.002; RAI vs mFI-5 = 0.02; RAI vs age = 0.001; mFI-5 vs age = 0.20. LOS, length of hospital stay; mFI-5, modified Frailty Index-5; RAI, Risk Analysis Index.
FIGURE 4.
FIGURE 4.
Assessing the predictive thresholds of frailty screening tools and age for spine octogenarian neurosurgery patients (N = 15, 915) using receiver operating characteristics analysis outlined by A, 30-day mortality, B, extended LOS, and C, LOS >30 days. A, 30-day mortality C-statistics (95% CI): RAI 0.760 (0.728-0.791) vs mFI-5 0.603 (0.571-0.634) vs age 0.565 (0.531-0.599). Delong P-value: RAI vs mFI-5 vs age <0.001; RAI vs mFI-5 < 0.001; RAI vs age <0.001; mFI-5 vs age = 0.10. B, Extended LOS C-statistics (95% CI): RAI 0.657 (0.646-0.669) vs mFI-5 0.567 (0.557-0.577) vs age 0.545 (0.533-0.556). Delong P-value: RAI vs mFI-5 vs age <0.001; RAI vs mFI-5 < 0.001; RAI vs age <0.001; mFI-5 vs age = 0.001. C) LOS >30 days C-statistics (95% CI): RAI 0.712 (0.663-0.760) vs mFI-5 0.582 (0.530-0.635) vs age 0.497 (0.441-0.553). Delong P-value: RAI vs mFI-5 vs age <0.001; RAI vs mFI-5 < 0.001; RAI vs age <0.001; mFI-5 vs age = 0.05. LOS, length of hospital stay; mFI-5, modified Frailty Index-5; RAI, Risk Analysis Index.
FIGURE 5.
FIGURE 5.
Assessing the predictive thresholds of frailty screening tools and age for cranial octogenarian neurosurgery patients (N = 4, 247) using receiver operating characteristics analysis outlined by A, 30-day mortality, B, extended LOS, and C, LOS >30 days. A, 30-day mortality C-statistics (95% CI): RAI 0.556 (0.531-0.580) vs mFI-5 0.567 (0.546-0.589) vs age 0.569 (0.545-0.594). Delong P-value: RAI vs mFI-5 vs age = 0.44; RAI vs mFI-5 = 0.21; RAI vs age = 0.44; mFI-5 vs age = 0.77. B, Extended LOS C-statistics (95% CI): RAI 0.603 (0.586-0.619) vs mFI-5 0.550 (0.535-0.565) vs age 0.535 (0.518-0.552). Delong P-value: RAI vs mFI-5 vs age <0.001; RAI vs mFI-5 < 0.001; RAI vs age <0.001; mFI-5 vs age = 0.02. C, LOS >30 days C-statistics (95% CI): RAI 0.567 (0.506-0.628) vs mFI-5 0.510 (0.446-0.574) vs age 0.491 (0.429-0.553). Delong P-value: RAI vs mFI-5 vs age = 0.16; RAI vs mFI-5 = 0.14; RAI vs age = 0.08; mFI-5 vs age = 0.67. LOS, length of hospital stay; mFI-5, modified Frailty Index-5; RAI, Risk Analysis Index.
FIGURE 6.
FIGURE 6.
Assessing the predictive thresholds of frailty screening tools and age for other octogenarian neurosurgery patients (N = 548) using receiver operating characteristics analysis outlined by A, 30-day mortality, B, extended LOS, and C, LOS >30 days. A, 30-day mortality C-statistics (95% CI): RAI 0.698 (0.548-0.848) vs mFI-5 0.414 (0.292-0.535) vs age 0.486 (0.292-0.680). Delong P-value: RAI vs mFI-5 vs age = 0.01; RAI vs mFI-5 = 0.005; RAI vs age = 0.07; mFI-5 vs age = 0.59. B, Extended LOS C-statistics (95% CI): RAI 0.661 (0.603-0.719) vs mFI-5 0.542 (0.490-0595) vs age 0.542 (0.487-0.597). Delong P-value: RAI vs mFI-5 vs age <0.001; RAI vs mFI-5 = 0.003; RAI vs age = 0.001; mFI-5 vs age = 0.81. C, LOS >30 days C-statistics (95% CI): RAI 0.700 (0.492-0.908) vs mFI-5 0.582 (0.349-0.815) vs age 0.587 (0.430-0.745). Delong P-value: RAI vs mFI-5 vs age = 0.51; RAI vs mFI-5 = 0.41; RAI vs age = 0.29; mFI-5 vs age = 0.97. LOS, length of hospital stay; mFI-5, modified Frailty Index-5; RAI, Risk Analysis Index.
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