Interventions to improve the outcomes of frail people having surgery

18 Pages·2017·2.45 MB·English

RESEARCHARTICLE
Interventions to improve the outcomes of frail
people having surgery: A systematic review
DanielI.McIsaac1,2,3☯*,TimJen1‡,NikhileMookerji4‡,AbhilashaPatel4‡,Manoj
M.Lalu1,2,3☯
1 DepartmentofAnesthesiologyandPainMedicine,UniversityofOttawa,Ottawa,Ontario,Canada,
2 DepartmentofAnesthesiologyandPainMedicine,TheOttawaHospital,Ottawa,Ontario,Canada,
3 ClinicalEpidemiologyProgram,OttawaHospitalResearchInstitute,Ottawa,Ontario,Canada,4 Facultyof
Medicine,UniversityofOttawa,Ottawa,Ontario,Canada
☯Theseauthorscontributedequallytothiswork.
‡Theseauthorsalsocontributedequallytothiswork.
*[email protected]
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Abstract
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a1111111111 Background
Frailtyisanimportantprognosticfactorforadverseoutcomesandincreasedresourceuse
inthegrowingpopulationofoldersurgicalpatients.Weidentifiedandappraisedstudiesthat
testedinterventionsinpopulationsoffrailsurgicalpatientstoimproveperioperative
OPENACCESS outcomes.
Citation:McIsaacDI,JenT,MookerjiN,PatelA,
LaluMM(2017)Interventionstoimprovethe Methods
outcomesoffrailpeoplehavingsurgery:A
systematicreview.PLoSONE12(12):e0190071. WesystematicallysearchedCochrane,CINAHL,EMBASEandMedlinetoidentifystudies
https://doi.org/10.1371/journal.pone.0190071 thattestedinterventionsinpopulationsoffrailpatientshavingsurgery.Allphasesofstudy
Editor:TerenceJQuinn,UniversityofGlasgow, selection,dataextraction,andriskofbiasassessmentweredoneinduplicate.Resultswere
UNITEDKINGDOM synthesizedqualitativelyperaprespecifiedprotocol(CRD42016039909).
Received:March31,2017
Results
Accepted:December7,2017
Weidentified2593titles;11wereincludedforfinalanalysis,representing1668participants
Published:December29,2017
inorthopedic,general,cardiac,andmixedsurgicalpopulations.Onlyonestudywasmulti-
Copyright:©2017McIsaacetal.Thisisanopen
centerandriskofbiaswasmoderatetohighinallstudies.Interventionswereappliedpre-
accessarticledistributedunderthetermsofthe
CreativeCommonsAttributionLicense,which andpostoperatively,andincludedexercisetherapy(n=4),multicomponentgeriatriccare
permitsunrestricteduse,distribution,and protocols(n=5),andbloodtransfusiontriggers(n=1);nospecificsurgicaltechniqueswere
reproductioninanymedium,providedtheoriginal
compared.Exercisetherapy,appliedpre-,orpost-operatively,wasassociatedwithsignifi-
authorandsourcearecredited.
cantimprovementsinfunctionaloutcomesandimprovedqualityoflife.Multicomponentpro-
DataAvailabilityStatement:Allrelevantdataare
tocolssufferedfrompoorcomplianceanddifficultiesinimplementation.Transfusiontriggers
withinthepaperanditsSupportingInformation
hadnosignificantimpactonmortalityorotheroutcomes.
files.
Funding:Theauthorsreceivednospecificfunding
Conclusions
forthiswork.
Despiteagrowingliteraturethatdemonstratesstrongindependentassociationsbetween
Competinginterests:Theauthorshavedeclared
thatnocompetinginterestsexist. frailtyandadverseoutcomes,fewinterventionshavebeentestedtoimprovetheoutcomes
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Interventionsforfrailsurgicalpatients
offrailsurgicalpatients,andmostavailablestudiesareatsubstantialriskofbias.Multicen-
ter,lowriskofbias,studiesofperioperativeexerciseareneeded,whilesubstantialefforts
arerequiredtodevelopandtestotherinterventionstoimprovetheoutcomesoffrailpeople
havingsurgery.
Introduction
Westernpopulationsareagingrapidly.[1,2]Olderpeoplehavesurgeryatovertwotimesthe
rateofyoungerindividuals,[3]andadvancedageisawell-establishedriskfactorforadverse
postoperativeoutcomes.[4,5]However,amongsttheoldersurgicalpopulation,outcomesvary
substantially.[6]Frailty,astateofincreasedvulnerabilitytostressorsduetoage-,anddisease-
relateddeficitsthataccumulateacrossmultipledomains,isakeyfactorinexplainingthe
increasedratesofcomplications,healthcareresourceuse,lossofindependence,andmortality
experiencedbyoldersurgicalpatients[7–11]
Theprevalenceoffrailtyincreasesexponentiallywithage.[12]Therefore,asourpopulation
ages,anincreasingnumberoffrailpatientsareexpectedtopresentforsurgery.Infact,con-
temporarystudiesestimatethat25–40%ofolderpatientshavingmajorsurgeryarefrailorpre-
frail.[13–15]Basedonaconservativeestimatethatfrailtyisassociatedwitha2-to3-fold
increaseintherelativeriskofadversepostoperativeevents,[8]weestimatethattheproportion
ofadverseeventsattributable[16]tofrailtyis25–50%.However,despitethestrongand
increasinglywell-recognizedassociationoffrailtywithadversepostoperativeeventsand
increasedresourceuseacrosssurgicalspecialties,[8,9,17]andthemultitudeofinstruments
thathavebeenusedtodiagnosefrailty,[18]interventionsspecificallytailoredtofrailsurgical
patientsarenotcommonlydescribedintheliterature,andhavenotbeensystematically
reviewed.Knowledgegeneratedfromsuchasynthesisisneededtoinformcurrentcareand
futureresearch.Therefore,weundertookasystematicreviewtoidentifyinterventionsthat
havebeentestedinpopulationsoffrailsurgicalpopulationstoimprovehealthoutcomes,
patientexperienceorcostsofcare.[19]
Materialsandmethods
ThissystematicreviewwasperformedinaccordancewithguidelinesfromtheCochraneCol-
laboration,[20]andisreportedaccordingtothePreferredReportingItemsforSystematic
ReviewsandMeta-Analysesguidelines(seechecklistinS1File).[21]Thestudyprotocolwas
registeredwiththeInternationalProspectiveRegisterofSystematicReviews(2016:
CRD42016039909).
Searchstrategy
Asystematicsearchstrategywasdesignedinconsultationwithaninformationspecialist,and
thenreviewedandfinalizedusingthepeerreviewofelectronicsearchstrategychecklist.[22]
ThesearchstrategyisprovidedinTableAinS2File.Weemployedabroadstrategyusing
keywordsandcontrolledvocabularytoidentifyfrailtyandsurgicalprocedures.Thesearchdid
notplacelimitationsonoutcomesorstudydesigns.Nolanguagerestrictionswereapplied,and
alldatabases(Cochrane,Medline,CumulativeIndexofNursingandAlliedHealthLiterature,
andtheExcerptaMedicaDatabase)weresearchedfrominceptiontoFebruary14,2016.Grey
literaturewassearchedandconsidered,includingconferenceproceedings(2010–2016)from
theAmericanCollegeofSurgeons,AmericanGeriatricsSociety,AmericanSocietyof
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Interventionsforfrailsurgicalpatients
Anesthesiology,BritishGeriatricsSociety,andtheEuropeanGeriatricsSociety,aswellascon-
ferenceabstractsidentifiedthroughourdatabasesearches.WealsosearchedClinicalTrials.gov
toidentifyplanned,in-progressorcompletedstudiesthathadnotyetbeenreported.
Inclusionandexclusioncriteria
Randomizedandnon-randomized(e.g.,cohort,controlledbeforeafter,interruptedtime
series,otherquasi-randomizeddesigns)studieswereeligibleforinclusion,however,non-
experimentalstudies(suchascasereportsorcaseseries)wereexcluded.Tobeincluded,stud-
ieshadtoevaluateapopulationoffrailindividualshavingsurgery(endovascularcardiacvalve
procedures,endoscopicprocedures,andcataractsurgerywerenotincludedasperioperative
processesandtrajectorieswerefelttodiffersubstantiallyfromprototypicalsurgicalproce-
dures),orhaveaspecificsubgroupoffrailpatientswherefrailty-specificinterventionandout-
comedatacouldbeextracted.Inthecaseofamixedpopulation(i.e.,surgicalandmedical),
surgicalpatientshadtorepresentthemajorityofincludedparticipants.Includedstudieshad
tostatethespecificmethodusedtodefineindividualsasfrail,however,weplacednolimita-
tionsonwhatfrailtydefinitionswereacceptable.Studiescouldtestanyintervention,solongas
itwasappliedintheperioperativeperiodandwasrelatedtothefactthatpatientswerehaving,
orhadsurgery.Wedidnotlimitinclusiontospecificoutcometypes,however,wedidcatego-
rizeoutcomesinoneofthethreedomainsoftheIHITripleAimoutcomeframework(health,
cost,experience).[19]
Selectionofincludedstudiesanddataextraction
Allidentifiedtitlesandabstracts,andconferenceproceedingswerescreenedinduplicateby
twoindependentreviewers.Whenadherencetoinclusion/exclusioncriteriawasunclear,stud-
iesweremovedforwardforfulltextreview.Fulltextreviewwasalsoperformedinduplicate,
anddisagreementatanystagewasresolvedindiscussionwiththeprimaryinvestigator(DM).
Thereferencelistsofallincludedarticlesweresearchedtoidentifyanyotherstudiesthatmay
havebeenmissedbyoursearchstrategy.
Fordatacollection,aformdesignedspecificallyforthisreviewwasfirstpilotedonsixstud-
ies,andthenappliedtoallstudies.Datawasextractedinduplicate,andreviewedinatriadthat
includedbothreviewersandtheprimaryinvestigator.Publicationcharacteristics,patientand
surgicalfactors,detailsoftheintervention,andstudyoutcomeswereextractedforallincluded
studies.Allcitationscreening,fulltextreview,anddatacollectionwasperformedusingDistil-
lerSR1(EvidencePartners,Ottawa,Canada).
Riskofbiasassessment
Riskofbiasassessmentswereconductedforallstudies.Non-randomizedstudieswereassessed
usingtheRiskofBiasinNon-randomizedstudiesofInterventions(ROBINS-I);[23]random-
izedcontrolledtrials(RCTs)wereassessedwiththeCochraneRiskofBiasToolforrandom-
izedtrials.[20]Thescalesforeachriskofbiastoolweremodifiedtoprovideconsistentscoring
acrossstudydesigns.Allriskofbiasassessmentsweredoneinduplicatebytheprimaryinvesti-
gatorandasecondteammember;disagreementswereresolvedbyconsensus.
Analysisanddatasynthesis
Wesummarizedthestudydesigns,frailtyinstruments,surgeries,patientcharacteristics,inter-
ventioncharacteristicsandoutcomesreported.Wedidnotanticipateidentifyingadequately
homogenousdatatosupportformalmeta-analysis,andwethereforepre-specifiedaqualitative
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Interventionsforfrailsurgicalpatients
approachtodatasynthesis.Weorganizedourqualitativesynthesisfirstaroundthetypeof
intervention,thenbysurgicalpopulation,andfinallybephaseoftheperioperativeperiod
whereinterventionwasemployed.Wealsosynthesizedthetypesofoutcomesthatwerestud-
iedwithinthesegroupings.
Results
Followingremovalofduplicaterecords,weidentified2593uniquetitleandabstractsto
review,andasdescribedinFig1,included11studiesforfinalanalysis(1studygenerated3
uniquecitationstheresultofwhichwereconsideredtogetherasasinglestudy).Theonecon-
ferenceabstractidentifiedwasnotincludedinourformalsynthesis,asfrailtydefinitionsused
werenotdescribed,andbecauseinadequateinformationwasavailabletoassessriskofbias.
SeventrialswereidentifiedthroughClinicalTrials.gov(November23rd,2016);onehadcom-
pletedrecruitment(anemailtotheinvestigatorsrequestingdatawasnotreturned),fourwere
currentlyrecruiting,andtwowerenotyetopenforrecruitment.Theconferenceabstractand
summariesofClincalTrials.govprotocolsareprovidedinTableBinS2File.
Studyandpopulationcharacteristics
SixoftheincludedstudieswereRCTs,andfivewereobservational(fourcontrolledbefore
after,andonewhosedesignwasunclearbutwhichappearedtobemostconsistentwithapro-
spectivenon-randomizedtrial;[24]Table1).Samplesizesrangedfrom21to386participants
(1668total).Meanparticipantagewasolderthan70yearsinallstudies.Surgerytypes
includedgeneralsurgery(threestudies),cardiac(twostudies),orthopedic(fourstudies),solid
tumor(onestudy)andmixed(onestudy).Surgicalurgencyincludedelective(sixstudies),
Fig1.Flowdiagramoutliningselectionofstudies.
https://doi.org/10.1371/journal.pone.0190071.g001
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Interventionsforfrailsurgicalpatients
Table1. Characteristicsofincludedstudies.
Source Study Surgery FrailtyInstrument Control Intervention Mean Intervention
Type (n) (n) age
Bakkeretal,201427 CBA Mixed Geriatricexamination 191 195 77 Enhancedcare
protocol
Binderetal,200433 RCT HipFracture mPPTscoreandADLs 44 46 80 Post-operative
exercise
Chenetal,201426 CBA General Fried’sfrailtyphenotype 52 52 73 Enhancedcare
protocol
Goreliketal,201524 Unclear General Geriatricexamination 35 36 82 Enhancedcare
protocol
Gregersenetal, RCT HipFracture ComprehensiveGeriatric 140 144 86 Bloodtransfusion
201535−37 Assessment trigger
Hempeniusetal, RCT Solidtumor GroningenFrailtyIndicator 149 148 77 Enhancedcare
201329 protocol
Hoogeboometal, RCT Hip ClinicalFrailtyScale 11 10 77 Pre-operative
201030 replacement exercise
Indrakusumaetal, CBA General ISAR 50 50 81 Enhancedcare
201425 protocol
Molino-Lovaetal, RCT Cardiac SPPBscore 48 51 75 Post-operative
201134 exercise
Oostingetal,201231 RCT Hip ISAR 15 15 77 Pre-operative
replacement exercise
Opasichetal,201032 CBA Cardiac BPOMA 74 150 75 Post-operative
exercise
BPOMA:BalancePerformanceOrientedMobilityAssessment;CBA:controlledbeforeafter;ISAR:IdentificationofSeniorsAtRisk;mPPT:modifiedversion
ofthePhysicalPerformanceTest;RCT:randomizedcontrolledstudy;SPPB:ShortPhysicalPerformanceBatteryscore
https://doi.org/10.1371/journal.pone.0190071.t001
emergency(twostudies),mixed(onestudy),andnotreported(twostudies).Otherdetailsare
providedinTable1.Frailtywasdefinedbygeriatricassessmentinthreestudies,theIdentifica-
tionofSeniorsatRiskquestionnaireintwostudies,Fried’sFrailtyPhenotypeinonestudy,
GroningenFrailtyIndicator(GFI)foronestudy,ClinicalFrailtyScaleforonestudy,andphys-
icalperformancemeasuresinthreestudies.
Interventioncharacteristics
Interventionswereappliedinthepre-andpostoperativeperiod;however,nospecificintrao-
perativeinterventionswereidentified.Threecategoriesofinterventionswereidentified:multi-
componentgeriatriccareprotocols(n=5),exerciseinterventions(n=5),andtransfusion
triggers(n=1).SpecificdetailsforeachinterventionareprovidedinTable2,whiletrendsin
outcomeeffectsacrossinterventiontypesandsurgicalpopulationsaredescribedinFig2.
Exerciseinterventions. Twostudiesevaluatedtheimpactofpreoperativeexercisepro-
gramsforelectivetotalhiparthroplastypatients.[25,26]Participantsinbothtrialsweresatis-
fiedwiththeinterventions,andbothstudiesfoundpositiveimpactsofexerciseonfunctional
outcomes.Noimprovementsinpostoperativefunctionwerenoted.[25]Threestudiesevalu-
atedpostoperativeexerciseinterventions,twoincardiacsurgeryandoneafterhipfracture
surgery.[27–29]Allthreestudiesfoundpositiveimpactsoftheexerciseinterventiononfunc-
tionaloutcomes,whileinthelowestriskofbiasstudy,theexerciseinterventionsignificantly
improvedqualityoflifeoutcomes.(28)Detaileddescriptionoftheexerciseinterventionsis
providedintheTableCinS2File,whileasummaryofevidenceusingtheGRADEFramework
[30]isprovidedinTable3.
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Interventionsforfrailsurgicalpatients
Table2. Descriptionofinterventionsandoutcomes.
Source Intervention Intervention ControlGroup Outcome(s) Outcome Result
Timing Intervention Window
Bakker,201427 Pre&Post CareProtocol: Standardcare Hospital-acquired In-hospital Nodifference
delirium
Orientation Cognitivedecline In-hospital Nodifference
Mobilization Physicaldecline Atdischarge Worsewith
interventiongroup
Dayprogram ADL Atdischarge Worsewith
activities intervention
Physiotherapy ADL Atdischarge Nodifference
consult
Dietitianconsult ADL 3monthspost- Betterwith
discharge intervention
Discharge Readmission 30dayspost- Nodifference
planning discharge
Medicationreview Unplannedreadmission 30dayspost- Nodifference
discharge
CGAby Caregiverburden 3monthspost- Nodifference
geriatrician discharge
Binder,200433 Post Exercise Non-personalized ModifiedPhysical 6monthsafter Betterwith
exercisewithout PerformanceTest surgery intervention
weighttraining
FunctionalStatus 6monthsafter Betterwith
Questionnaire surgery intervention
BasicADL 6monthsafter Nodifference
surgery
InstrumentalADL 6monthsafter Nodifference
surgery
Assistivedevicesuse 6monthsafter Lessusewith
surgery intervention
Kneeextensionstrength 6monthsafter Betterwith
surgery intervention
Walkingspeed 6monthsafter Betterwith
surgery intervention
Singlelimbstancetime 6monthsafter Betterwith
surgery intervention
Bergbalancescore 6monthsafter Betterwith
surgery intervention
Totalfat-freemass 6monthsafter Nodifference
surgery
Bonemineraldensity 6monthsafter Nodifference
surgery
SF-36score 6monthsafter Betterhealth,
surgery physicialandsocial
functionwith
intervention
HipRatingQuestionnaire 6monthsafter Betterwith
surgery intervention
Chen,201426 Post CareProtocol: Standardcare *Frailtyrate Atdischarge Betterwith
intervention
3monthspost- Nodifference
discharge
Earlymobilization Transitionsbetweenfrailty Fromadmission Betterwith
states todischarge intervention
Oraland
nutritional
assistance
Orientating Fromadmission Nodifference
communication to3-monthspost-
discharge
(Continued)
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Table2. (Continued)
Source Intervention Intervention ControlGroup Outcome(s) Outcome Result
Timing Intervention Window
Gorelik,201524 Post CareProtocol: Standardcare *Stability 6monthsafter Betterwith
surgery intervention
Walking 6monthsafter Betterwith
surgery intervention
Rehabilitation Malnutrition 6monthsafter Betterwith
surgery intervention
Nutritionsupport Cognitivedisorders 6monthsafter Betterwith
surgery intervention
Psychotherapy Moralstatus 6monthsafter Betterwith
surgery intervention
Homecarefor Independence 6monthsafter Betterwith
some surgery intervention
Gregersen, Post Restrictiveblood Liberalblood ModifiedBarthelIndex 10daysafter Nodifference
201535−37 transfusion transfusion surgery
NewMobilityScore 10daysafter Nodifference
surgery
Ambulationscore 10daysafter Nodifference
surgery
Transferindependence 10daysafter Nodifference
surgery
Walkingindependence 10daysafter Nodifference
surgery
Mortality,perprotocol 30-day Worsewithrestrictive
Mortality 90-day Nodifference
Leukocytecounts 30dayspost- Nodifference
operatively
CRPconcentration 30dayspost- Nodifference
operatively
Infection 10dayspost- Nodifference
operatively
Complications 10dayspost- Nodifference
operatively
ModifiedBarthelIndex Day30to1year Betterwithliberal
post-operatively
Depression Day30post- Nodifference
operatively
1yearpost- Nodifference
operatively
Hempenius, Pre&Post Standardcare Postoperativedelirium 10daysafter Nodifference
201329 surgery
CareProtocol: Severityofdelirium 10daysafter Nodifference
surgery
Complications,>1 10daysafter Nodifference
surgery
Individualized Mortality In-hospital Nodifference
geriatriccareplan SF-36score Discharge Nodifference
Caredependency Assessedat Nodifference
discharge
Returntoanindependent Assessedat Worsewith
livingsituation discharge intervention
Additionalcareathome Assessedat Nodifference
discharge
Lengthofstay In-hospital Nodifference
(Continued)
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Interventionsforfrailsurgicalpatients
Table2. (Continued)
Source Intervention Intervention ControlGroup Outcome(s) Outcome Result
Timing Intervention Window
Hoogeboom, Pre Exercise Standardcare OsteoarthritisOutcome Weekbefore Nodifference
201030 Score surgery
LongitudinalAgingStudy Weekbefore Nodifference
AmsterdamPhysical surgery
ActivityQuestionnaire
PhysicalWorkingCapacity Weekbefore Nodifference
surgery
6-MWT Weekbefore Nodifference
surgery
TimedUp&GoTest Weekbefore Nodifference
surgery
ChairRiseTime Weekbefore Nodifference
surgery
GripStrength Weekbefore Nodifference
surgery
Timeneededtofunctional In-hospital Nodifference
independence
Patient-Specific Weekbefore Nodifference
ComplaintsQuestionnaire surgery
Lengthofstay In-hospital Nodifference
Indrakusuma, Pre CareProtocol: Standardcare Mortality 30dayspost- Nodifference
201425 operatively
Nutrition Postoperativedelirium Notreported Nodifference
supplements
Cardiologyconsult Postoperative Notreported Nodifference
complications
Bloodtransfusion Lengthofstay In-hospital Nodifference
Haloperidol
prophylaxis
Molino-Lova, Post Exercise Usualaerobic ShortPhysical 1year Betterwith
201134 exercise PerformanceBattery intervention
Oostingetal, Pre Exercise Standardcare TimedUp&GoTest 6weekspost- Nodifference
201231 discharge
6-MWT 6weekspost- Betterwith
discharge intervention
ChairRiseTime 6weekspost- Betterwithintervetion
discharge
Hipdisabilityand 6weekspost- Nodifference
OsteoarthritisOutcome discharge
Score
LongitudinalAgingStudy 6weekspost- Nodifference
AmsterdamPhysical discharge
ActivityQuestionnaire
Pain 6weekspost- Nodifference
discharge
PatientSpecific 6weekspost- Nodifference
ComplaintsQuestionnaire discharge
(Continued)
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Interventionsforfrailsurgicalpatients
Table2. (Continued)
Source Intervention Intervention ControlGroup Outcome(s) Outcome Result
Timing Intervention Window
Opasichetal, Post Exercise Traditional *Nursingneeds Atdischarge Betterwith
201032 physiotherapy intervention
program
BalancePerformance Atdischarge Betterwith
OrientedMobility intervention
Assessment
TimedUp&GoTest Atdischarge Betterwith
intervention
ArmCurl Atdischarge Betterwith
intervention
ChairStand Atdischarge Betterwith
intervention
6-MWT Atdischarge Nodifference
Healthrelatedqualityoflife Atdischarge Nodifference
LengthofStay In-hospital Shorterwith
intervention
*Primaryoutcomenotspecifiedinstudy.6-MWT:6minutewalktest;ADL:activitiesofdailyliving;CRP:c-reactiveprotein;SF:shortform
Boldedandunderlinedtext=Primaryoutcomes
Boldedoutcomesreachedstatisticalsignificance
https://doi.org/10.1371/journal.pone.0190071.t002
Multicomponentgeriatriccareprotocols. Priortoelectivecolorectalsurgery,geriatric
assessmenttoguideperioperativecareplanningwasassociatedwithdecreasedlengthofhospi-
talstay,howevernodifferencesinprimaryorotheroutcomeswereidentified.[31]
Geriatric-specificmulticomponentinterventionsweretestedinthreeobservationalstudies,
twoofwhichincludedgeneralsurgerypatients,[24,32]andthethirdwhichincludedamixof
surgicalspecialties.[33]Followingelectivegeneralsurgery,institutionofamodifiedhospital
elderlifeprogram(aformalevidence-basedprogramtooptimizecareofolderpatientsinhos-
pital[34])wasassociatedwithalowerrateoffrailtyathospitaldischarge.[32]Followinginstitu-
tionofateam-basedcomplexgeriatricinterventionforamixedsurgicalpopulation,therewas
nosignificantdifferenceinprimaryormostsecondaryoutcomes.[33]Astructuredgeriatric
rehabilitationprogramafterlaparoscopiccholecystectomywasassociatedwithimprovements
infunctional,nutritionalandcognitiveoutcomes.[24]
AsingleRCTevaluatedageriatriccareprotocolwithpre-andpostoperativecomponents
inelectivecancersurgery.[35]Theauthorsfoundthattheindividualsintheinterventiongroup,
whounderwentpreoperativegeriatricassessment,individualizeddeliriumpreventionplans,
dailygeriatricnurseliaisonwhileinhospitalandconsultativetreatmentadviceexperienced
similarratesofdeliriumandotheroutcomescomparedtothosewhoreceivedstandardcare.
Poorprotocoladherencewasnotedintwooffivemulticomponentstudies,[31,33]while
anothermulticomponentstudyreporteddifficultieswiththecomplexityofapplyingandmea-
suringadherencetothestudy’sspecificprotocolcomponents.[35]Detailsofeachmulticompo-
nentinterventionandcontrolgroupcareareprovidedintheTableDinS2File.
Transfusiontrigger. Followinghipfracturesurgery,onestudyofarestrictivevs.liberal
redbloodcelltransfusionstrategyfoundnodifferencesinmortality,qualityoflife,functional
outcomes,orinfectiouscomplicationsbetweenarms.Theauthorsdidreportanincreasein
30-daymortalityintherestrictivearmpertheirsecondaryperprotocolanalysis,however,
therewereanequalnumberofprotocolviolationsinbothstudyarms,andat90daysthere
wasnodifferenceinmortality,evenwhenanalyzedperprotocol.[36–38]
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Interventionsforfrailsurgicalpatients
Fig2.Summaryofstudyoutcomesbyinterventiontypeandsurgicalpopulation.Thesizeofeachcircleisproportionaltothenumberofparticipantsin
eachgrouping.
https://doi.org/10.1371/journal.pone.0190071.g002
Riskofbias
TwoRCTswereassessedasmoderateriskofbias;allotherswereathighriskofbias.Perfor-
mancebiasrelatedtoblindingofparticipants,andselectiveoutcomereportingwerethe
domainsmostoftenratedasmoderatetohighriskofbias.Allobservationalstudieswereat
highriskofbias,andinparticularsufferedfromconfoundingbias(Fig3).
Outcomes
BasedontheTripleAimFramework,allstudiesreportedatleastonehealthoutcome,eight
studiesreportedapatientexperienceoutcome,andcostoutcomeswerereportedinfourstud-
ies.Sevenstudiesspecifiedaprimaryoutcome,whilefourstudiesreportedonmultipleout-
comeswithoutspecifyingaprimaryoutcomeofinterest.Aformalmeta-analysiswasnot
possibleduetotheheterogeneityofstudydesigns,interventionsandoutcomes.
Discussion
Asubstantialproportionofpostoperativeadverseeventsinoldersurgicalpatientsareattri-
butabletothepresenceoffrailty.However,despiteamarkedincreaseintheepidemiological
literaturedescribingassociationsbetweenfrailtyandadversepostoperativeoutcomes,we
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