Impact of Frailty on Risk of Long-Term Functional Decline Following Vascular Surgery

Abstract

Objectives:

Frailty is a clinical syndrome associated with slow recovery after vascular surgery. However, the degree and length of functional impairment frail patients experience after surgery is unclear. The objective of this study was to prospectively measure changes in functional status among frail and non-frail patients undergoing a spectrum of different vascular surgery procedures.

Methods:

Patients consented to undergo elective minor and major vascular surgery procedures at an academic medical center between May 2018 and March 2019 were prospectively identified. Prior to surgery, all patients underwent provider assessment of frailty using the validated Clinical Frailty Scale (CFS), as well as baseline assessment of functional status using the Katz Activities of Daily Living (ADL) index and the Lawton Instrumental Activities of Daily Living (iADL) index. These same instruments were used to evaluate each patient’s functional status at 2-week, 1-month, 1-year, and 2-year time points following surgery. Changes in iADL and ADL scores among frail (CFS≥5) and non-frail patients were compared using paired Wilcoxon signed-rank tests and logistic regression models.

Results:

A total of 126 patients were assessed before and after minor (55%) and major (45%) vascular procedures, of which 43 (34%) patients were determined to be frail prior to surgery. Frail patients were older and more likely than non-frail subjects to have medical comorbidities including chronic kidney disease, COPD, or diabetes (all p<0.05). When compared to the non-frail cohort, frail patients had significantly lower ADL and iADL scores before surgery and experienced a greater decline in ability to independently complete ADL and iADL activities after surgery that was sustained at 2-years (P<0.05 and P<0.001, respectively). After risk-adjustment, frailty was associated with an increased likelihood of decline in ADLs (OR:5.4;95%CI:1.9–15.4; P<.05) and iADLs (OR:6.3; 95%CI:2.6–15.1; P<0.001) at 2-years following surgery.

Conclusions:

Frail patients experience a significant decline in ability to perform ADL and iADLs that persists 2-years following vascular surgery. These data highlight the degree of functional decline occurring immediately following surgery, as well as risk for long-term, sustained impairment that should be shared with frail patients before undergoing a procedure.

TABLE OF CONTENTS SUMMARY:

In this single-center prospective observational study, frail patients were found to be at significant risk for long-term loss of functional independence after surgery with inability to perform a majority of activities of daily living (ADLs) persisting 2-years after their procedure. These findings can be used to counsel frail patients and their caregivers on the nature, extent and duration of functional decline expected following vascular surgery procedures.

INTRODUCTION

Frailty is an aging-related syndrome of physiological decline that is found in up to 60% of the vascular surgery patient population.(1) Frail patients are characterized by weakness and fatigue, medical complexity, and marked vulnerability to surgical stress such as vascular interventions. Further, frail patients have been shown to have worse outcomes following vascular surgery including higher rate of perioperative complications, mortality, and non-home discharge.(2, 3) This increased need for post-acute care represents at least a short-term loss in functional independence in response to surgical stress

A patient’s functional status represents the ability to perform normal activities of daily living (ADLs) required to meet basic needs, fulfill usual roles, and maintain health and well being.(4) While it is established that frail patients experience short-term decline in their functional status after vascular surgery, it is unclear whether they return to baseline and/or regain their functional independence over time. A recent systematic review of the literature found limited evidence to establish the trajectory of functional outcomes among frail patients undergoing vascular procedures for peripheral arterial disease.(5) Of note, the assessment of functional status and dependency of ADLs in these studies was either limited to the hospital discharge period, or only extended to 6 months after surgery.(6–8) As such, it is still unknown whether patients regain functional independence at long-term follow-up after vascular surgery. It is important to determine the extent and duration that frail patients experience functional impairment after vascular procedures. The objective of this study was to prospectively measure generalizable changes in functional status over a 2-year time period among frail and non-frail patients after undergoing a broad spectrum of major and minor vascular surgery procedures. We hypothesized that the majority of frail patients would not regain ADLs that were lost after undergoing a vascular procedure.

METHODS

Study Design, Setting, and Patient Population

Prospective enrollment into the study occurred from May 2018 to March 2019 among all patients presenting to the outpatient vascular surgery clinic at the University of Utah Cardiovascular Center for evaluation of any type of vascular disease condition. All patients included in the study cohort had consented to undergo a minor or major elective vascular surgery procedure, and were over 18 years of age. Minor surgery was defined as procedures that involved hospital stays < 24 hours such as vein ligation or AV fistula creation. Major surgery was defined as a procedure requiring hospital admission > 24 hours, and included non-urgent amputations to treat ischemia and/or wounds that were not amenable to revascularization therapy. Patients were excluded from enrollment in the study if they were undergoing urgent or emergent surgery, had progressive neurologic disease (e.g., dementia), were on hospice care, or if they did not speak English. The University of Utah Institutional Review Board granted approval to conduct the study. In addition, we used the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines when designing the study and preparing the manuscript.(9)

Frailty Assessment

A vascular surgeon evaluated the level of patient frailty in the outpatient clinic using the validated Clinical Frailty Scale (CFS) as shown in Table 1. The CFS is a simplified frailty assessment tool that was developed and validated using the Comprehensive Geriatric Assessment(10) and scored on a 9-point scale (1-very fit, to 9-terminally ill), requiring the clinician to inquire about the level of physical activity, the ability to complete activities of daily living, and overall level of independence (Table 1). CFS scores are independently collected by both medical assistants and surgical providers on all patients who present to the University of Utah Cardiovascular Center as part of routine clinical practice, and have been previously shown to have high-inter reliability (Kappa: 0.79) for frailty assessment.(11) Frail patients were defined using the CFS criterion as those assigned a score of ≥ 5, whereas non-frail patients received a CFS score < 5. This specific score cutoff is defined by the CFS, and has been further validated and used in prior studies to define vascular surgery patient frailty.(3, 10, 11)

Table 1.

Clinical Frailty Scale^*

Descriptor	Definition	Numerical Score
Very Fit	People who are robust, active, energetic, and motivated. These people commonly exercise regularly. They are among the fittest for their age.	1
Well	People who have no intense disease symptoms but are less fit than category 1. Often, they exercise or are very active occasionally, e.g., seasonally.	2
Managing Well	People whose medical problems are well controlled, but are not regularly active beyond routine walking.	3
Vulnerable	While not dependent on others for daily help, often symptoms limit activities. A common complaint is being “slowed-up” and being tired during the day.	4
Mildly Frail	People often have more evident slowing, and need help with finances, transportation, heavy housework, and medications. Typically, mild frailty progressively impairs shopping and walking outside alone, meal preparation and housework.	5
Moderately Frail	People need help with all outside activities and with keeping house. Inside, they often have problems with stairs and need help with bathing and might need minimal assistance (stand-by) with dressing.	6
Severely Frail	Completely dependent on personal care from whatever cause (physical or cognitive). Even so, they seem stable and not at high risk of dying (within six months).	7
Very Severely Frail	These patients are completely dependent, approaching the end of life. Typically, they could not recover even from minor illnesses.	8
Terminally ill	Approaching the end of life. This category applies to people with a life expectancy of under 6 months, which are not otherwise evidently frail.	9

^*Adapted with permission from Dalhousie University (Rockwood K, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173(5):489–495)

Outcome Measure – Change in ADL and iADL

The primary outcome was whether patients suffered a decline in functional status following any vascular surgery procedure. This was determined by measuring the change in Katz Activities of Daily Living Index (ADLs) and the Lawton-Brody Instrumental Activities of Daily Living (iADLs) Index scores at various timepoints (2-weeks, 1-month, 1-year, and 2-years) following surgery and comparing to baseline scores. The Katz Index is a validated 6-item instrument that measures a patient’s independence in performing main activities of daily living, including bathing, dressing, toileting, transferring, continence, and feeding. Patients were scored using the Katz Index on a scale from 0 (low function, dependent) to 6 (high function, independent). The Lawton-Brody Index is a validated 8-item instrument that measures a patient’s ability to use a telephone, shop, prepare food, perform housekeeping chores, perform laundry, travel independently, manage medications, and handle finances. Patients were scored using the Lawton-Brody Index on a scale from 0 (low function, dependent) to 8 (high function, independent). Data was collected from both of these instruments during scheduled in-person clinic visits, if possible, but responses were also collected over the phone at designated timepoints if patients were not scheduled for a clinic visit. A secondary outcome was all-cause mortality at the 2-year follow-up after surgery.

Statistical Analysis

We first compared patient demographics, comorbidities, and the degree of surgical stress experienced during vascular procedures based on CFS frailty stratification using bivariate analyses. Surgical stress was calculated as previously described using the Vascular Physiologic and Operative Severity Score for the enumeration of Mortality and Morbidity (V-POSSUM) score, which has been found to correlate with post-operative complications and mortality among frail patients.(12, 13) An unpaired t-test or Wilcoxon rank sum test was used for continuous variables, depending on the normality of distribution. Categorical variable analyses were completed with a chi-squared or a Fisher’s exact test, depending on factor level combinations more or less than five, respectively. Subsequently, variables found to reach statistical significance at P≤0.1 in these bivariate analyses were considered for the multivariate logistic regression model if there was overlap between frail and non-frail patients. To prevent overfitting, a parsimonious regression model was constructed to assess the association between frailty and the risk of decline in functional status over time that adjusted for three potential confounders including age, sex, and surgical stress (i.e. V-POSSUM scores). All analyses were performed to assess the change in functional status following surgery relative to baseline ADL and iADL scores before surgery. We also performed a sensitivity analysis with amputation and vein ligation cases removed. Robust standard errors were used for determination of p-values and confidence intervals. Significance was set to <0.05 for all statistical tests. All analyses were performed using Stata 14.0 (StataCorp, College Station, TX).

RESULTS

A total of 126 patients were enrolled in the study cohort that underwent baseline frailty assessment with the CFS [median CFS: 4 (IQR:3–5)] and functional status determination with Katz and Lawton-Brody Indices before elective vascular surgery, including 43 (34%) patients diagnosed as frail [median CFS: 5 (IQR:5–6)] and 83 (66%) patients categorized as non-frail [median CFS: 3 (IQR:3–4)]. This cohort represented approximately an 18% sample of elective operations at our institution during the study time period. Patients were followed for 2 years after their surgical procedure and functional status was assessed at predetermined time points. There were no in-hospital deaths among the study cohort but a total of 24 patients had died by the 2-year follow-up, including 13 (30%) frail patients and 11 (13%) non-frail patients (P=0.021). In addition, there were 3 frail patients unable to be contacted at the 2-year follow-up time point, constituting a 97% follow-up rate. Among the entire study cohort, 60.3% were male (n=76) and 81.7% were Caucasian (n=103) with a mean (SD) age of 61.5 (17.2) years. Additional demographic characteristics, stratified by frailty status, are presented in Table 2. Based on a score ≥ 5 on the CFS instrument, 43 (34%) patients were considered frail and 83 (66%) were deemed non-frail. While most comorbidities were similar among both comparison groups, patients stratified into the frail group were more likely to be female, older, have chronic kidney disease, chronic obstructive pulmonary disease, and be diagnosed with type 1 or type 2 diabetes (Table 2).

Table 2.

Characteristics of patients in the study cohort, stratified by whether they were determined to be frail or non-frail using the Clinical Frailty Scale instrument before surgery.

Characteristic	Total (n=126)	Frail (n=43)	Non-Frail (n=83)	P-value
Mean Age (SD)	60.7 (15.9)	65.7 (11.9)	58.7 (16.5)	0.033
Male, n (%)	76 (60)	20 (46)	56 (67)	0.023
Race, n (%)
White	103 (81)	36 (83)	67 (81)	0.680
Black / African American	3 (2)	2 (5)	(1)	0.229
Asian	2 (2)	0 (0)	(2)	0.305
American Indian	2 (2)	2 (5)	0 (0)	0.048
Pacific Islander/Alaska Native	6 (5)	0 (0)	(7)	0.071
Other	10 (8)	3 (7)	(8)	0.774
Ethnicity, n (%)
Hispanic or Latino	13 (10)	5 (12)	8 (10)	0.728
Not Hispanic or Latino	113 (90)	38 (88)	75 (90)	0.728
Atrial Fibrillation, n (%)	13 (10)	5 (12)	8 (10)	0.728
History of Cancer, n (%)	19 (15)	6 (14)	13 (16)	0.978
Prostate	3 (2)	0 (0)	3 (4)	0.207
GI/GU	7 (5)	4 (9)	3 (4)	0.186
Sarcoma	2 (2)	0 (0)	2 (2)	0.305
Lymphoma/leukemia	3 (2)	2 (5)	1 (1)	0.229
Other	4 (3)	0 (0)	4 (5)	0.143
Chronic Kidney Disease, n (%)	61 (48)	27 (63)	34 (41)	0.020
COPD, n (%)	13 (10)	8 (19)	5 (6)	0.028
Coronary Artery Disease, n (%)	31 (25)	14 (33)	17 (20)	0.136
Depression, n (%)	22 (17)	11 (26)	11 (13)	0.084
Diabetes, n (%)	52 (41)	27 (63)	25 (30)	0.000
CHF, n (%)	8 (6)	5 (12)	3 (36)	0.080
Hyperlipidemia, n (%)	45 (36)	18 (42)	27 (33)	0.300
Hypertension, n (%)	79 (63)	28 (65)	51 (61)	0.686
Osteoporosis, n (%)	5 (4)	2 (5)	3 (4)	0.777
Stroke, n (%)	14 (11)	6 (14)	8 (10)	0.465
Ischemic Heart Disease, n (%)	5 (4)	2 (5)	3 (4)	0.777
V-POSSUM Surgical Stress, mean (SD)	1.56 (1.62)	1.84 (2.0)	1.41 (1.36)	0.162

Abbreviations: SD, standard deviation; GI/GU, gastrointestinal genitourinary; COPD, Chronic Obstructive Pulmonary Disease; CHF, Congestive Heart Failure.

Patients in the study cohort were found to represent a generalizable sample of individuals who present to an academic vascular surgery practice for evaluation, and subsequently underwent a wide variety of vascular surgery procedures as displayed in Table 3. Most types of vascular surgery procedures were equally represented among both patient groups, including a broad range of endovascular and open peripheral interventions as well as both endovascular and open abdominal aortic aneurysm repairs. In addition, the surgical stress associated with these procedures as determined by V-POSSUM scores was not found to be significantly different between frail and non-frail patients. However, frail patients were significantly more likely to undergo a supra-inguinal bypass or lower extremity amputation than non-frail controls, and vein ligations were only undertaken in non-frail patients (Table 3).

Table 3.

Vascular surgery procedures undertaken among patients determined to be frail versus non-frail using the CSF instrument before surgery.

Surgical Intervention	Total (n=126)	Frail (n=43)	Non-Frail (n=83)	P-value
CEA, n (%)	9 (7)	1 (2)	8 (10)	0.131
AAA, n (%)	2 (2)	0 (0)	2 (2)	0.305
Hemodialysis, n (%)	58 (46)	21 (49)	37 (45)	0.649
EVAR, n (%)	16 (13)	5 (12)	11 (13)	0.795
PVI, n (%)	9 (7)	2 (5)	7 (8)	0.434
Infrainguinal Bypass, n (%)	12 (10)	5 (12)	7 (8)	0.795
Suprainguinal Bypass, n (%)	6 (5)	5 (12)	1 (1)	0.009
Major Amputation, n (%)	4 (3)	4 (9)	0 (0)	0.005
Vein Ligation*, n (%)	10 (8)	0 (0)	10 (12)	0.018

^*Vein ligation was performed for symptomatic lower extremity varicose vein indications in all cases

Abbreviation: CEA, carotid endarterectomy; AAA, abdominal aortic aneurysm; EVAR, endovascular aneurysm repair; and PVI, peripheral vascular intervention.

When compared to the non-frail cohort, frail patients had lower baseline mean (±SD) ADL scores before surgery [frail 4.95 (±1.5) vs. non-frail 5.77 (±0.5); P<0.001] and experienced greater declines in ability to independently complete ADL activities after surgery (Figure 1). Decreases in ADLs after surgery based on change in Katz Index scores from baseline demonstrated that the largest decline in the ability to complete ADL activities occurred 2-weeks after surgery among frail patients [frail −0.56 (±1.3) vs. non-frail −0.05 (±0.9); P<0.05]. While frail patients steadily improved their ADL scores up to 1-year after surgery, they never returned to baseline and continued to have a significant decline in functional status at 2-years [frail −0.49 (±1.4) vs. non-frail −0.18 (±0.9); P<0.05] following surgery relative to preoperative baseline scores (Figure 1). In comparison, non-frail counterparts did not demonstrate a significant decline in ADL scores after surgery and were back at their baseline at 1-month.

Fig. 1.

Katz activities of daily living (ADLs) scores among frail and non-frail patients at 2-weeks, 1-month, 1-year, and 2-years following vascular surgery. Data represent mean ADL scores (± standard deviation) from each follow-up time point relative to baseline scores. * Denotes P<0.05 for comparisons.

Similar findings were observed when evaluating changes in ability to complete iADLs after surgery (Figure 2). Frail patients had a significant lower iADL at baseline [frail 5.81 (±2.1) vs. non-frail 7.69 (±0.9); P<0.001] and experienced the greatest decline in ability to independently complete iADL activities at 2-weeks [frail −0.50 (±0.5) vs. non-frail −0.16 (±0.4); P<0.001] after surgery (Figure 2). Functional status continued to deteriorate at 1-month and there was a sustained lower functional status 2-years [frail −1.5 (±2.2) vs. non-frail −0.44 (±1.6); P=0.002] following surgery when compared to preoperative baseline scores (Figure 2). Although non-frail counterparts did demonstrate some decline in iADL scores at 2 weeks, the effect was markedly less pronounced.

Fig. 2.

Lawton-Brody instrumental activities of daily living (iADLs) scores among frail and non-frail patients at 2-weeks, 1-month, 1-year, and 2-years following vascular surgery. Data represent mean ADL scores (± standard deviation) from each follow-up time point relative to baseline scores. * Denotes P<.05 and ** Denotes P<.001 for comparisons.

Long-term functional decline at the 2-year post-operative time point was further examined by separating Katz ADL and Lawton-Brody iADL survey responses into their individual components (Table 5). Stratifying the Katz survey into specific activities demonstrated that frail patients sustained the most decline in independently feeding and toileting after surgery. In comparison, non-frail patients did not sustain significant decline in any specific ADL skill. Analysis of components of the Lawton-Brody survey revealed that frail patients sustained significant declines in every iADL skill, except for the ability to use the telephone. In contrast, non-frail patients only demonstrated a decline after surgery in shopping, food preparation, and transportation.

Table 5.

Association between preoperative frailty status and decline in ability to complete individual activities of daily living at 2-years following vascular surgery procedures

Activity	Frail (n=27)	Non-Frail (n=72)	P-value*
Decline in ADL skills at 2-years following vascular surgery
Bathing, n (%)	6 (22.0)	1 (1.4)	0.058
Dressing, n (%)	1 (3.7)	3 (4.2)	0.654
Toileting, n (%)	5 (18.5)	1 (1.4)	0.025
Transferring, n (%)	1 (3.7)	1 (1.4)	0.706
Continence, n (%)	3 (11.1)	3 (4.2)	0.366
Feeding, n (%)	4 (14.8)	2 (2.8)	0.046
Decline in iADL skills at 2-years following vascular surgery
Telephone, n (%)	1 (3.7)	1 (1.4)	0.317
Shopping, n (%)	8 (29.6)	9 (12.5)	0.033
Food Preparation, n (%)	14 (51.9)	9 (12.5)	0.002
Housework, n (%)	8 (29.6)	3 (4.2)	0.001
Laundry, n (%)	8 (29.6)	5 (6.9)	0.021
Transportation, n (%)	8 (29.6)	7 (9.7)	0.021
Medications, n (%)	9 (33.3)	5 (6.9)	0.003
Finances, n (%)	7 (25.9)	2 (2.8)	0.008

^*P-values calculated using Wilcoxon rank-sum test

Lastly, the association between CFS-defined frailty and functional decline was examined after risk-adjustment in multivariable regression analyses that included all patients in the cohort (Table 4). After controlling for patient age, gender, and surgical stress, frailty was associated with a 12.1 increased odds ratio for ADL decline at 1 month (95%CI: 3.0–48.5; P<0.001) and 5.37 increased likelihood of decline in ADLs at 2-years (95%CI:1.1–12.6; P<0.01). Further, there was a 5.36 increased likelihood of iADL decline at 1-month (95%CI: 2.0–14.2; P=0.001) and a 6.27 increased likelihood of decline at 2-years (95%CI:2.6–15.1; P<0.001) following surgery. Finally, the odds ratio for decline in ADLs (OR:4.17; 95%CI:1.28–13.5; P<0.05) and iADLs (OR:5.68; 95%CI:2.25–14.3; P<0.001) at 2-years was similar when amputation and vein ligation cases were removed in sensitivity analyses.

Table 4.

Risk-adjusted association between preoperative frailty status and decline in ability to complete activities of daily living at 2-years following vascular surgery procedures

Variable	Odds Ratio	95% Confidence Interval	P-value
Decline in ADLs (Katz Index) at 2-years following vascular surgery
Frail (CFS ≥ 5)	5.37	1.87 – 15.42	0.002
Age	1.03	0.99 – 1.07	0.151
Female Sex	0.44	0.14 – 1.34	0.146
Surgical Stress (V-POSSUM Score)	1.12	0.86 – 1.46	0.386
Decline in iADLs (Lawton Index) at 2-years following vascular surgery
Frail (CFS ≥ 5)	6.27	2.60 – 15.09	<0.001
Age	1.04	1.00 – 1.08	0.029
Female Sex	1.37	0.55 – 3.38	0.496
Surgical Stress (V-POSSUM Score)	1.09	0.85 – 1.41	0.485

Abbreviation: CFS, clinical frailty scale; V-POSSUM, Vascular Physiologic and Operative Severity Score for the enumeration of Mortality and Morbidity.

DISCUSSION

Frailty is a syndrome of physiological decline characterized by vulnerability to adverse outcomes and loss of functional independence after vascular surgery procedures. However, the severity and length of functional impairment experienced by frail patients during long term follow-up after surgery has not been clear. The results of the present study show that frail patients are at significant risk for losing their capacity to independently perform a spectrum of activities of daily living after vascular surgery. These functional deficits include a third of ADL and nearly all iADLs at 2-weeks that often persisted at 2-years following their procedure. In comparison, non-frail patients did not manifest any specific ADL deficits and demonstrated only a short-term decline in half of the iADL tasks. These findings help illustrate the trajectory of postoperative recovery and can be used to counsel frail patients and their caregivers on the nature, extent and duration of loss of independence expected following vascular surgery procedures.

The demographics of patients referred to vascular surgery providers continues to change, with an increasing number of older patients with multiple medical comorbidities that are diagnosed as being frail being evaluated for surgery in outpatient clinics.(14, 15) While many patients choose to undergo an elective vascular procedure with an intent to improve their quality of life, a frail phenotype has been shown to predict the trajectory of decreasing quality-of-life (QOL) scores with continued deterioration of QOL scores over time as frailty persists.(16–18) These findings underscore the value of tools to help identify frail patients as well as subsequently predict the extent and duration of potential long-term functional decline. While prior retrospective studies have examined patient frailty and post-operative functional decline after vascular interventions, they have limited the scope of outcome analysis to within 6-months after discharge.(5–8) In comparison, the present study prospectively followed a large cohort of patients for 2-years after surgery in order to determine whether loss of independence incurred as a result of vascular surgery stress persists over long term follow-up. Importantly, we found that frail patients suffered a much greater immediate decline in ability to independently perform ADLs after vascular surgery than non-frail patients, and these patients often do not return to their baseline level of function. These findings suggest that vascular surgery may have a long-term impact on care needs and quality of life among frail patients.

Prior work suggests that a patient’s capacity to recover after vascular surgery depends on the degree of surgical stress they experience and available physiological reserves, as well as the presence of any minor or major complications that may occur during the perioperative period.(12) But the trajectory of recovery after vascular surgery has not been well-described. Recovery after surgical procedures has been described as being comprised of five separate domains, including 1) energy-requiring processes; 2) a return to a state of normality and wholeness defined by comparative standards; 3) regaining control over physical, psychologic, social, and habitual functions; 4) returning to preoperative levels of independency/dependency in ADLs; and 5) regaining an optimum level of well-being.(19) While successful recovery from surgery involves a return to function across all these relevant domains spanning physical, psychological, and social aspects of health, it’s clear that many patients never reach this goal.(20) Our data demonstrates that being frail significantly impacts the ability and time to recover from vascular surgery, and that the overall process can take at least one year or more for frail vulnerable patients. Further, we show that frail patients may be dependent on caregivers for ADL and iADL support that requires substantial time and resources. For example, frail patients may need a family member to take over paying their bills, or doing weekly shopping. Caregivers and family should anticipate the potential need to pick up these types of duties in the post-operative period.

The ability to predict the need for this support as well as the trajectory of the postoperative recovery process is valuable to providers and their patients when discussing the risks and benefits of elective vascular surgery procedures. In particular, the preoperative identification of frail patients provides an opportunity discuss anticipatory short-and-long-term post-operative functional decline. The longitudinal findings from this study can be referenced to help inform multiple aspects of care for patients and their caregivers. This includes 1) helping guide goals-of-care discussions and deciding if surgery meets these goals; 2) allowing the care team to make appropriate arrangements for post-acute-care and employ strategies to mitigate loss of independence; and 3) anticipating the duration of time that patients may need to stay in a skilled nursing facility as well as require caregiver support once they return home. These factors may influence the decision to undergo an elective vascular surgical procedure as well as set realistic expectations for long-term outcomes.

There are several limitations of the study to discuss. First, there was the potential for survey response bias when study patients completed the Katz Activities of Daily Living Index and the Lawton-Brody Instrumental Activities of Daily Living Index at each time point during the study. This includes the potential for social desirability bias in patient responses to individual questions. However, we do not suspect that these types of bias differentially impacted frail versus non-frail patients in the study. Second, the assessment of a patient’s ability to complete ADL and iADLs in this study did not account for the degree of support being provided by caregivers or family members. While frail patients would be expected to have a greater need for daily ADL and iADL support, the specific types of services used or resources they had access to were not assessed during follow-up. Third, this study did not specifically assess the cognitive status of enrolled patients at baseline or during follow-up. However, frailty assessment using the CFS evaluates specific domains that include cognition as well as comorbidities and physical function. Fourth, our analysis combined a heterogeneous group of vascular surgery procedures together including vein ligations and amputations, and there was insufficient number of frail and non-frail patients in separate VQI registry procedure groups in order to perform a comparison between treatment modalities for specific vascular conditions. However, this was intended to increase external validity of study results and we were able to control for the degree of surgical stress patients experienced in our regression analysis. Given that a large proportion of procedures in our cohort involved dialysis access creation that are typically associated with low surgical stress, we are likely underestimating the degree of loss of independence that can occur after vascular surgery. Fifth, a patient’s functional status at 2-years after surgery may be more likely due to their overall physiological condition (i.e. degree of frailty), and less related to the vascular procedure itself. While the current study does not contain a control group of frail patients who did not undergo surgery, we have previously shown that frail patients with vascular conditions who undergo non-operative management have similarly poor outcomes as those who undergo vascular procedures. Finally, frailty status in this study was dichotomized based on a CFS score of 5 but does not account for patients with a pre-frail diagnosis or those with even a more severe frail phenotype.

CONCLUSIONS

This study illustrates the extent and duration of functional decline that frail patients experience after undergoing an elective vascular surgery procedure. Our data shows that patients will lose the ability to perform many activities of daily living that allow them to live independently, which is most pronounced at 2-weeks but can persist for up to 2-years after surgery. We believe the frail patients and their caregivers should be informed of these expected deficits and understand the duration support they will likely need before consenting to undergo an elective vascular procedure.

ARTICLE HIGHLIGHTS:

Type of Research:

Single-center retrospective analysis of prospectively collected data.

Key Findings:

The results of this study show that frail patients experience a significant risk for decline in ability to perform ADL and iADLs that persists at 2-years following a spectrum of minor and major vascular surgery procedures.

Take-Home Message:

Frail patients and their caregivers should be counselled on the extent and duration of loss of functional independence expected following vascular surgery procedures.