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A Call for Frailty Screening in the Preoperative Setting.

Frailty is associated with an increased risk of undesirable postoperative outcomes across surgical subspecialties, including complications, length of stay, discharge to a skilled or assisted-living facility, 1–3 and morbidity. 4 With the rapidly increasing older population, frailty assessment in the preoperative setting is becoming an increasingly important, yet rarely performed, screening tool that is recommended by both the American College of Surgeons and the American Geriatric Society. 5 In this issue of JAMA Surgery, Hall et al 6 share their experience with the implementation of the Frailty Screening Initiative at a Veterans Affairs medical center. They used the Risk Analysis Index, which is a deficit accumulation model of frailty, to identify frail individuals to undergo further review before their anticipated operation. Compared with a historical control of patients in the same medical center before implementation of the Frailty Screening Initiative, patients who underwent frailty screening had a decrease in overall mortality from 1.6% to 0.7%. However, this decrease was most pronounced among frail individuals, who had decreases from 12.2% to 3.8% for 30-day mortality, 23.9% to 7.7% for 180-day mortality, and 34.5% to 11.7% for 365-day mortality. As noted by the authors, this study likely benefitted from the Hawthorne effect, whereby patients received more scrutinized preoperative care, potentially leading to a positive selection bias by excluding poor operative candidates from undergoing surgery. Although this finding may suggest more appropriate use of surgery, there are certainly situations (ie, palliative surgery) when alleviation of symptoms and pain, not improved 1-year mortality, is the most important outcome. Excluding patients with limited life expectancy from surgical interventions that may improve symptom management out of fear of poor mortality statistics is a real concern. The authors also note that their use of preoperative palliative