A seven-year study of patients at the VA Medical Center in Omaha showed that screening patients before an operation to determine how frail they are can save lives after surgery.
The screening test is so simple and the results so profound that the procedure is beginning to be implemented in other places, said Dr. Jason Johanning, who was chief of surgery at the Omaha VA when the study was done. Johanning remains affiliated with the VA and is a cardiac surgeon at the Nebraska Medical Center.
The study, reported Nov. 30 in the medical journal JAMA Surgery, showed that overall mortality among post-surgical patients dropped by more than half, from 1.6 percent to .7 percent, when measured 30 days after surgery.
Death rates among patients found to be the most frail dropped even more, by about two-thirds, and the difference continued up to a year. Mortality dropped from 12 percent to 4 percent after 30 days, 24 percent to 8 percent after 180 days, and from 35 percent to 12 percent after 365 days.
Johanning came up with the idea after seeing frail and elderly patients suffer higher rates of complications and death after surgery in his military and civilian practice.
So he proposed asking patients coming in for elective surgery a handful of screening questions about their health and lifestyle, such as: Do you walk with a cane? Do you live in a nursing home? Have you had kidney failure? Do you have congestive heart failure?
The questions, called the Risk Analysis Index, are a screening tool for determining who among the elderly are most frail, and therefore most at risk. The tool is approved by the American College of Surgeons and the American Geriatric Society but is rarely used by doctors.
"Literally, you can complete this tool in a minute and a half or two minutes," Johanning said in an interview last week. "It gives you a framework to think through."
So doctors at the Omaha VA hospital began screening all patients who had major, elective, non-cardiac surgeries using the tool. Ultimately, the study included more than 9,000 patients treated between Oct. 1, 2007, and July 1, 2014.
In most cases, the patients who were found to be frail still received surgery, Johanning said, but they also received additional care or attention. Doctors were made aware so they could anticipate complications.
"It also allowed us to bring family into the picture," he said.
After gathering the data, Johanning and several VA colleagues submitted it to Dr. Daniel Hall, a general surgeon at the VA Medical Center in Pittsburgh, for objective analysis. Hall and two other researchers authored the article for JAMA Surgery.
Johanning said the screening remains part of the pre-surgery protocol at the Omaha VA hospital and has been adopted at several other VA facilities as well. He is using it in his practice at Nebraska Medicine, too, and has received queries from numerous other doctors around the country. He has made presentations about the findings at several medical conferences.
"The research is so clear that frail patients don’t do well with surgery," Johanning said. "We’ve got to do something."