Expert Q&A

Frailty and Mortality Following Surgery

Frailty is associated with mortality risk in patients undergoing emergency general surgery (EGS), with greater associations shown in patients undergoing low-risk EGS procedures, according to a recent study.

The researchers conducted a cross-sectional study using data from 882,929 Medicare inpatient claims. Overall, 12.6% of the patients were considered frail, and frailty was shown to be significantly associated with mortality. Following stratification, high-risk procedures were associated with an odds ratio of 1.53 (95% CI, 1.49-1.58) and low-risk procedures were associated with an odds ratio of 2.05 (95% CI, 1.94-2.17).

Consultant360 spoke with study author Manuel Castillo-Angeles, MD, MPH, postdoctoral research fellow at the Center for Surgery and Public Health, Brigham and Women’s Hospital, for more information.

Consultant360: In your study, you examined whether procedural risk influenced the relationship between frailty and morbidity and mortality in older adults undergoing emergency surgery. How did this research question come about?

Dr Castillo-Angeles: The effect of frailty in morbidity and mortality in older adults undergoing emergency general surgery (EGS) has been established. However, the recent standardized definition of EGS encompasses 7 different procedures that represent 80% of the national operative burden. Moreover, prior work from our group evaluated if the increased burden of morbidity and mortality of EGS was constant across all procedure types by comparing them with their non-EGS counterparts. They found that it was different, and the procedures were classified into high (laparotomy, colectomy, small bowel resection, peptic ulcer repair and lysis of adhesions) and low (appendectomy and cholecystectomy) risk. Therefore, we wanted to evaluate if the association between frailty and mortality varied on the level of procedural risk (high vs. low).

C360: Overall, you found that the relationship was more pronounced in patients undergoing low-risk emergency surgery than in those undergoing high-risk procedures. Why was this result surprising, and what factors could explain it?

Dr Castillo-Angeles: Within low-risk procedures, the overall mortality was 2.01%, so it was surprising that frail patients undergoing those low-risk procedures had a mortality as high as 5.89%. So basically, frail patients undergoing a low-risk procedure had about the same risk as the non-frail people undergoing a high-risk procedure (for which mortality was 5.87%), which effectively suggests that in a frail patient even appendectomy and cholecystectomy are high-risk. One of the factors that could explain this is that these procedures are well known to have lower morbidity and mortality, therefore being frail doesn’t really have decisive weight in the decision to proceed with the operation. Therefore, being frail did not necessarily influence the surgical team’s willingness to perform a low-risk less complex procedure in a patient with a high baseline risk.

C360: How do your findings contribute to the existing literature about this topic?

Dr Castillo-Angeles: Our results suggest that frailty screening should be applied universally because even low risk procedures may be high risk among patients who are frail. In these situations, some interventions can be helpful. First, frailty associated risks should be discussed with patients in a robust process of shared decision making. If electing to pursue surgical intervention, patient optimization could be targeted if possible. Also, geriatric co-management would be one strategy to reduce post op complications like delirium. Moreover, geriatric nursing protocols can improve mobility and reduce functional decline in these patients.

C360: What should future research focus on as next steps within this area of study?

Dr Castillo-Angeles: Future research should focus on identifying areas of improvement to provide better care for older frail adults undergoing EGS. Studies should evaluate the implementation of tailored interventions such as patient optimization before surgery, geriatric co-management and nursing protocols, and its impact in morbidity and mortality in these frail EGS patients.


Castillo-Angeles M, Cooper Z, Jarman MP, Sturgeon D, Salim A, Havens JM. Association of frailty with morbidity and mortality in emergency general surgery by procedural risk level. JAMA Surg. 2021;156(1):68-74. doi:10.1001/jamasurg.2020.5397