From the Centre for Perioperative Medicine, University College London, London, United Kingdom (S.D.A., D.W.) the Department of Anesthesiology and Pain Medicine, (S.D.A., M.H., R.S., D.I.M.) the School of Epidemiology and Public Health (J.S., D.I.M.), University of Ottawa, Ottawa, Canada the Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Canada (S.D.A., D.I.M.) the Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, Washington (I.B.) the Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Canada (D.I.M.).
Anesthesiology. 2020 Jul;133(1):78-95. doi: 10.1097/ALN.0000000000003257.
A barrier to routine preoperative frailty assessment is the large number of frailty instruments described. Previous systematic reviews estimate the association of frailty with outcomes, but none have evaluated outcomes at the individual instrument level or specific to clinical assessment of frailty, which must combine accuracy with feasibility to support clinical practice.
The authors conducted a preregistered systematic review (CRD42019107551) of studies prospectively applying a frailty instrument in a clinical setting before surgery. Medline, Excerpta Medica Database, Cochrane Library and the Comprehensive Index to Nursing and Allied Health Literature, and Cochrane databases were searched using a peer-reviewed strategy. All stages of the review were completed in duplicate. The primary outcome was mortality and secondary outcomes reflected routinely collected and patient-centered measures; feasibility measures were also collected. Effect estimates were pooled using random-effects models or narratively synthesized. Risk of bias was assessed.
Seventy studies were included; 45 contributed to meta-analyses. Frailty was defined using 35 different instruments; five were meta-analyzed, with the Fried Phenotype having the largest number of studies. Most strongly associated with: mortality and nonfavorable discharge was the Clinical Frailty Scale (odds ratio, 4.89; 95% CI, 1.83 to 13.05 and odds ratio, 6.31; 95% CI, 4.00 to 9.94, respectively); complications was associated with the Edmonton Frail Scale (odds ratio, 2.93; 95% CI, 1.52 to 5.65); and delirium was associated with the Frailty Phenotype (odds ratio, 3.79; 95% CI, 1.75 to 8.22). The Clinical Frailty Scale had the highest reported measures of feasibility.
Clinicians should consider accuracy and feasibility when choosing a frailty instrument. Strong evidence in both domains support the Clinical Frailty Scale, while the Fried Phenotype may require a trade-off of accuracy with lower feasibility.
常规术前虚弱评估的一个障碍是描述了大量的虚弱工具。以前的系统评价估计了虚弱与结果的相关性，但没有一个评价过个体工具水平或特定于虚弱临床评估的结果，这必须结合准确性和可行性来支持临床实践。
作者进行了一项预先注册的系统评价（CRD42019107551），前瞻性地在手术前使用临床环境中的虚弱工具。使用同行评审策略在 Medline、Excerpta Medica Database、Cochrane Library 和 Comprehensive Index to Nursing and Allied Health Literature 以及 Cochrane 数据库中进行了检索。所有阶段的审查都是重复完成的。主要结果是死亡率，次要结果反映了常规收集和以患者为中心的措施；还收集了可行性措施。使用随机效应模型或叙述性综合方法汇总效应估计值。评估了偏倚风险。
纳入了 70 项研究；其中 45 项有助于荟萃分析。虚弱使用 35 种不同的工具进行定义；有 5 种工具进行了荟萃分析，其中 Fried 表型的研究数量最多。与死亡率和非有利出院最相关的是临床虚弱量表（优势比，4.89；95%置信区间，1.83 至 13.05 和优势比，6.31；95%置信区间，4.00 至 9.94）；并发症与埃德蒙顿虚弱量表相关（优势比，2.93；95%置信区间，1.52 至 5.65）；而谵妄与虚弱表型相关（优势比，3.79；95%置信区间，1.75 至 8.22）。临床虚弱量表报告的可行性测量最高。
临床医生在选择虚弱工具时应考虑准确性和可行性。在这两个领域都有强有力的证据支持临床虚弱量表，而 Fried 表型可能需要在准确性和较低的可行性之间进行权衡。
