For the most part today, doctors determine if a patient can withstand the stress of surgery based on the "eyeball test," a loose and variable judgment based on "a look-over or a glance," says Martin A. Makary, MD, associate professor of surgery at Johns Hopkins School of Medicine.
"We as doctors communicate among ourselves by saying, ‘She looks 60 going on 90' or, ‘He doesn't look very strong.'" These assessments and communications aren't scientific ways to determine if someone can endure an operation, Makary says.
That's why he and his colleagues derived the first test of its kind, a simple, 10-minute "frailty" evaluation tool, for doctors to use in their offices to much more accurately gauge whether elective surgery is more likely to help or harm a patient.
The measure, described in the June issue of the Journal of the American College of Surgeons, uses an objective five-point scale to score the chance that a patient will develop post-operative complications such as develop infections or blood clots, suffer a fall, die, have a longer than usual length of stay, require readmission, or need discharge to a nursing home or assisted living facility.
"Now with this data, we have an ethical duty to tell patients that out of the past 100 patients in your situation that have been studied, a large portion required a nursing home after this surgery," Makary says. "It's our duty to tell them what it means to be frail, and to not tell them, I think, would not be forthright."
Patients then can make their own decisions whether to forward with surgery.
Use of such a measure across the country may go a long way to reduce regional variation in the number of costly surgeries that do not make patients better, he says.
Currently, for example, some surgeons and physicians test a patient's ability to withstand chest surgery on whether they can walk up one flight of stairs, says Paul Speckart, MD, a San Diego internist. "To a thoughtful physician who knows the patient, that's usually a pretty good test," he says. But for a referring doctor who doesn't know the patient, it may not be.
"It's important to incorporate an objective standardized way to measure frailty that's the same in every part of the country in every hospital," Makary says. "Every surgeon has seen someone too frail being operated on and every surgeon has seen a non-frail patient being denied an operation because of the risks."
"We can't forget the fact that there's a strong financial incentive for surgeons to operate based on current fee for service system," he says.
The scale, developed at Johns Hopkins, scores patients based on answers to these five questions:
- Has the patient unintentionally lost 10 pounds or more within the past year?
- What is the strength of the patient's grip, based on a squeeze of a hand-held dynamometer, adjusted for body mass index and gender?
- How quickly does the patient become exhausted and how much is the patient motivated?
- What physical activities does the patient perform during leisure time?
- How fast can the patient walk 15 feet?
Makary and colleagues used this scoring system in 594 patients over age 65. They found that patients who were considered frail were 2.5 times as likely as those who were not frail to spend more time in the hospital. And, frail patients were 20 times as likely to be discharged to a nursing home or assisted living facility 30 days after surgery when previously they lived at home.
"We found that this scoring system was highly predictive," he says. And it's critically important that such an evaluation tool be standardized for older people because half of all operations in the U.S. are performed in patients older than 65.
Makary and colleagues wrote that use of a frailty tool "might help explain why some older patients recover better than expected and others fare worse than expected."
They wrote: "A fundamental tenet of geriatric medicine is that standard indications for medical interventions might not be generalizable to older patients because physiologic changes from aging, potentially exacerbated by multiple morbidities, can alter the risk-to-benefit analysis."
Additionally, patients who are judged too frail for the risks of surgery may have options. Some "can benefit from interventions to reduce risk, such as preoperative conditioning, nutrition or even pharmacological therapy," the authors wrote.
Makary pointed out that today physicians may use other scoring systems that rank "reserve thresholds" for various organs. For example, they might say that a person has a strong or a weak kidney reserve, heart strength reserve, muscle mass reserve or, for people with dementia, a "psychological" reserve.
"We think they are all related, and when one system fails it affects the others and starts a vicious cycle," says Makary. The frailty scoring system he and his colleagues developed, takes all of those reserve systems into account.
The frailty test, the researchers wrote, "strengthened the predictive ability of other commonly used" tests that attempt to determine morbidity risk of surgical candidates.
Makary's study has several shortcomings. The trial only looked at 30-day outcomes and did not look at quality of life. The participants were patients at an academic medical center, where results of trials don't always translate to community practice.
The study received financial support from the National Institutes of Health, and several nonprofit foundations and organizations.