Informatics approaches to assessing patient frailty in surgical care

摘要 手术并发症很常见、昂贵且致命。老年患者手术不良的风险很高 结果，尤其是当他们表现出脆弱时。虚弱是一种生理储备减少和丧失能力的状态 适应压力源的能力。在过去的十年中，虽然衰弱已越来越被认为是一种 手术结果不佳的重要风险因素，将标准化衰弱指标纳入临床护理已 没有实现。一个主要障碍是现有的衰弱评估不够标准化、客观或广泛 可用，限制了它们在外科决策中的常规应用。以改善的长期目标 对于老年人的手术护理，我们将评估两个“电子衰弱”指标，这些指标可以自动导出 作为常规临床护理的一部分已经收集的电子或数字数据。这些电子脆弱性指标 首先，包括电子健康记录 (EHR) 数据的详细患者档案（基于索赔数据的风险评分） 或根据生理和实验室值），第二，根据手术前计算得出的肌肉损失评估 断层扫描 (CT) 扫描（骨骼肌质量低，称为肌肉减少症，以及脂肪浸润肌肉 表明身体功能下降，称为肌脂肪变性）。在目标 1 中，我们将计算这两个电子脆弱性 超过 41,000 名腹部手术患者的不同人群的指标；表征重叠 根据两个电子衰弱指标指定为衰弱的患者之间；并评估他们与 30 天的关联 再入院和其他不良手术结果（30 天和 1 年死亡率、并发症、非家庭 出院，且住院时间 >7 天）。在目标 2 中，我们将比较电子脆弱性指标的性能 根据标准风险分层工具预测 30 天再入院和其他不良手术结果 （急性和慢性疾病严重程度指标）现已通过交叉验证和 超过 14,000 例近期腹部手术的独立验证数据集。在目标 3 中，我们将检查 电子衰弱指标是否会改变患者从实现术后目标中获得的益处，包括 早期和持续的活动——这是美国最大的加速康复外科 (ERAS) 计划之一 国家。我们将研究电子衰弱指标作为生物年龄的显着指标，用于预测发病率和 死亡率。总之，电子衰弱指标在识别外科领域的高危患者方面显示出巨大的前景， 但它们需要集成到临床工作流程中才能实现可扩展和可持续。该提案将 计算从 EHR 数据自动得出的标准化电子衰弱指标并提供新信息 关于这些电子衰弱指标对于改善老年人手术护理的潜在价值。这项研究 还将为未来将电子衰弱指标纳入临床护理的前瞻性干预措施奠定基础 改善考虑手术的患者的风险分层和咨询，并加强围手术期护理 体弱的手术患者。

ABSTRACT Surgical complications are common, costly, and deadly. Older patients are at high risk of adverse surgical outcomes, especially when they exhibit frailty. Frailty is a state of decreased physiologic reserve and loss of capacity to adapt to stressors. Over the past decade, while frailty has been increasingly recognized as an important risk factor for poor surgical outcomes, integration of a standardized frailty metric into clinical care has not been achieved. A key barrier is that existing frailty assessments are not standardized, objective, or widely available, limiting their routine application in surgical decision-making. With the long-term goal of improving surgical care for older adults, we will evaluate two “e-frailty” metrics that can be automatically derived from electronic or digital data that are already collected as part of routine clinical care. These e-frailty metrics include, first, granular patient profiles of electronic health record (EHR) data (risk scores based on claims data or on physiologic and laboratory values), and second, muscle loss assessed from pre-surgical computed tomography (CT) scans (low skeletal muscle mass, known as sarcopenia, and fatty infiltration into muscle indicative of reduced physical function, known as myosteatosis). In Aim 1, we will calculate these two e-frailty metrics among a diverse population of over 41,000 abdominal surgical patients; characterize the overlap between patients designated as frail by the two e-frailty metrics; and evaluate their associations with 30-day readmission and other adverse surgical outcomes (30-day and 1-year mortality, complications, non-home discharge, and length of stay >7 days). In Aim 2, we will compare the performance of e-frailty metrics for predicting 30-day readmission and other adverse surgical outcomes to that of standard risk stratification tools (acute and chronic illness severity metrics) already embedded in EHRs today using cross-validation and an independent validation dataset of over 14,000 more recent abdominal surgeries. In Aim 3, we will examine whether e-frailty metrics modify the benefits that patients derive from achieving postoperative targets -including early and sustained mobilization- in one of the largest Enhanced Recovery After Surgery (ERAS) programs in the nation. We will examine e-frailty metrics as salient indicators of biologic age for predicting morbidity and mortality. In sum, e-frailty metrics show great promise for identifying high-risk patients in the surgical domain, but they need to be integrated within clinical workflows to be scalable and sustainable. This proposal will compute standardized e-frailty metrics automatically derived from EHR data and provide new information regarding the potential value of these e-frailty metrics for improving surgical care for older adults. This study will also lay the groundwork for future prospective interventions integrating e-frailty metrics into clinical care to improve risk stratification and counseling of patients considering surgery and enhance perioperative care for frail surgical patients.