• Daniel I McIsaac, Gregory L Bryson, and Carl van Walraven.
• University of Ottawa, Ottawa, Ontario, Canada2Institute for Clinical Evaluative Sciences, Ottawa, Ontario, Canada3Department of Anesthesiology, The Ottawa Hospital, Ottawa, Ontario, Canada4Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
• JAMA Surg. 2016 Jun 1; 151 (6): 538-45.

ImportanceSingle-center studies identify frailty as a risk factor for 30-day postoperative mortality. The long-term and population-level effect of frailty on postoperative mortality is, to our knowledge, poorly described, as are the interactions of frailty with important predictors of mortality.ObjectiveTo measure the population-level effect of patient frailty on, and its association with, 1-year postoperative mortality.Design, Setting, And ParticipantsPopulation-based retrospective cohort study in Ontario, Canada, with data collected between April 1, 2002 and March 31, 2012. Analysis was performed from December 2014 to March 2015. All patients were community-dwelling individuals aged 65 years or older on the day of elective, major noncardiac surgery.ExposureFrailty, as defined by the Johns Hopkins Adjusted Clinical Groups (ACG) frailty-defining diagnoses indicator. The ACG frailty-defining diagnoses indicator is a binary variable that uses 12 clusters of frailty-defining diagnoses.Main Outcomes And MeasuresOne-year all-cause postoperative mortality.ResultsOf 202 811 patients, 6289 (3.1%) were frail (mean [SD] age, 77 [7] years). Within 1 year, 13.6% (n = 855) of frail and 4.8% (n = 9433) of nonfrail patients died. Adjustment for sociodemographic and surgical confounders resulted in a hazard ratio of 2.23 (95% CI, 2.08-2.40). The interaction between frailty and postoperative time demonstrated an increased relative hazard for death in frail patients (hazard ratio, 35.58; 95% CI, 29.78-40.19) on postoperative day 3. The association between frailty and increased risk of death decreased with patient age (HR, 2.66; 95% CI, 2.28-3.10 at age 65; HR, 1.63; 95% CI, 1.36-1.95 at age 90). Significant variations in the increased risk for death in frail patients existed between different surgery types and was strongest after total joint arthroplasty (HR, 3.79; 95% CI, 3.21-4.47 for hip replacement; HR, 2.68; 95% CI, 2.10-3.42 for knee replacement).Conclusions And RelevanceAt a population level, preoperative frailty-defining diagnoses were associated with a significantly increased risk of 1-year mortality that was particularly notable in the early postoperative period, in younger patients, and after joint arthroplasty.

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