Interventions to improve the outcomes of frail people having surgery PDF
Preview Interventions to improve the outcomes of frail people having surgery
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] a1111111111 Abstract a1111111111 a1111111111 a1111111111 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 PLOSONE|https://doi.org/10.1371/journal.pone.0190071 December29,2017 1/18 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 PLOSONE|https://doi.org/10.1371/journal.pone.0190071 December29,2017 2/18 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 PLOSONE|https://doi.org/10.1371/journal.pone.0190071 December29,2017 3/18 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 PLOSONE|https://doi.org/10.1371/journal.pone.0190071 December29,2017 4/18 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. PLOSONE|https://doi.org/10.1371/journal.pone.0190071 December29,2017 5/18 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) PLOSONE|https://doi.org/10.1371/journal.pone.0190071 December29,2017 6/18 Interventionsforfrailsurgicalpatients 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) PLOSONE|https://doi.org/10.1371/journal.pone.0190071 December29,2017 7/18 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) PLOSONE|https://doi.org/10.1371/journal.pone.0190071 December29,2017 8/18 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] PLOSONE|https://doi.org/10.1371/journal.pone.0190071 December29,2017 9/18 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 PLOSONE|https://doi.org/10.1371/journal.pone.0190071 December29,2017 10/18
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