Association of Frailty with Outcomes After Low-Risk and High-Risk Head and Neck Cancer Surgery

Presentation: AHNS-QS-102
Topic: Value / Quality
Type: Quickshot
Date: Thursday, May 2, 2019
Session: 5:30 PM - 6:00 PM
Authors: Alexander N Goel, BA, Govind Raghavan, BA, Jennifer L Long, MD, PhD
Institution(s): University of California- Los Angeles

IMPORTANCE: Frailty is a measure of decreased physiologic reserve that is associated with morbidity and mortality after major surgery. However, the association of frailty with outcomes after relatively lower risk inpatient head and neck procedures has yet to be established.

OBJECTIVE: To assess the association of frailty with short-term outcomes in patients undergoing high- and low-risk ablative head and neck cancer surgery

DESIGN: Cross-sectional analysis, 2010-2014

SETTING: Nationwide Readmissions Database

PARTICIPANTS:  Patients undergoing ablative surgery for a malignant oral cavity, oropharyngeal, laryngeal, or hypopharyngeal neoplasm

MAIN OUTCOMES AND MEASURES: Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator. Procedures were categorized as low mortality risk (≤1%) or high mortality risk (>1%). High-risk procedures included total laryngectomy, total glossectomy, maxillectomy, mandibulectomy, pharyngectomy, and esophagectomy. Low-risk procedures included partial glossectomy, partial laryngectomy, tonsillectomy, and other oral cavity/oropharyngeal excision. Multivariate regression was used to analyze the association of frailty with postoperative outcomes including in-hospital mortality, Clavien-Dindo IV complications, 30-day readmissions, nonhome discharge, length of stay, and hospital costs. Length of stay and hospital costs were considered elevated if they were in the highest quartile for the given risk group.  

RESULTS: Of 76,625 included patients, 42,121 (55%) underwent low-risk and 34,504 (45%) underwent high-risk surgery. Frailty was more common in patients undergoing high-risk (18%) compared to low-risk procedures (9%). After low-risk surgery, the rate of major complications in frail patients was 30%, compared to 8% for non-frail patients (+22%; 95% CI, 19%-25%). After high-risk surgery, these rates were 35% and 14% for frail and non-frail patients, respectively (+21%; 95% CI, 18%-23%). Frail patients experienced higher rates of in-hospital mortality after both low-risk (2% vs. 0.4%; +D1.6%; 95% CI, 1%-3%) and high-risk surgery (3% vs. 1%; +D2%; 95% CI, 1%-3%). Similarly, rates of 30-day readmission were higher among frail patients after low-risk (17% vs. 10%; +D7%; 95% CI, 5%-11%) and high-risk (21% vs. 17%; +D3%; 95% CI, 1%-6%) operations. Frail patients undergoing low-risk surgery had increased odds of nonhome discharge (adjusted odds ratio (aOR), 3.81; 95% confidence interval (CI), 3.14-4.64), prolonged hospital stay (aOR, 5.60; 95% CI, 4.83-6.51) and elevated hospital costs (aOR, 6.14; 95% CI, 5.28-7.13). After high-risk surgery, the corresponding aORs were elevated to a lesser degree: nonhome discharge: aOR, 2.07; 95% CI, 1.81-2.38; prolonged hospital stay: aOR, 2.85; 95% CI 2.51-3.23; elevated hospital costs: aOR, 2.90; 95% CI, 2.59-3.27.

CONCLUSIONS AND RELEVANCE: Frailty has a strong independent relationship with poor short-term outcomes and increased resource utilization, which is apparent after low-risk and high-risk head and neck cancer surgery. Preoperative screening of patients to identify frailty may aid risk-stratification and improve patient counseling and selection.