Frailty Is Associated With Decreased Survival in Adult Patients With Nonoperative and Operative Traumatic Subdural Hemorrhage: A Retrospective Cohort Study of 381,754 Patients

Evan N Courville; Oluwafemi P Owodunni; Jordyn T Courville; Syed F Kazim; Alexander J Kassicieh; Allyson M Hynes; Meic H Schmidt; Christian A Bowers

doi:10.1097/AS9.0000000000000348

Frailty Is Associated With Decreased Survival in Adult Patients With Nonoperative and Operative Traumatic Subdural Hemorrhage: A Retrospective Cohort Study of 381,754 Patients

Ann Surg Open. 2023 Nov 7;4(4):e348. doi: 10.1097/AS9.0000000000000348. eCollection 2023 Dec.

Authors

Evan N Courville^{1

2}, Oluwafemi P Owodunni^{2

3}, Jordyn T Courville⁴, Syed F Kazim^{1

2}, Alexander J Kassicieh^{2

4}, Allyson M Hynes^{3

5}, Meic H Schmidt^{1

2}, Christian A Bowers²

Affiliations

¹ From the Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, NM.
² Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM.
³ Department of Emergency Medicine, University of New Mexico Hospital, Albuquerque, NM.
⁴ Louisiana State University Health and Sciences Center School of Medicine, Shreveport, Louisiana, US; University of New Mexico School of Medicine, Albuquerque, NM.
⁵ Division of Critical Care, Department of Surgery, University of New Mexico Hospital, Albuquerque, NM.

Abstract

Objective: We investigated frailty's impact on traumatic subdural hematoma (tSDH), examining its relationship with major complications, length of hospital stay (LOS), mortality, high level of care discharges, and survival probabilities following nonoperative and operative management.

Background: Despite its frequency as a neurosurgical emergency, frailty's impact on tSDH remains underexplored. Frailty characterized by multisystem impairments significantly predicts poor outcomes, necessitating further investigation.

Methods: A retrospective study examining tSDH patients ≥18 years and assigned an abbreviated injury scale score ≥3, and entered into ACS-TQIP between 2007 and 2020. We employed multivariable analyses for risk-adjusted associations of frailty and our outcomes, and Kaplan-Meier plots for survival probability.

Results: Overall, 381,754 tSDH patients were identified by mFI-5 as robust-39.8%, normal-32.5%, frail-20.5%, and very frail-7.2%. There were 340,096 nonoperative and 41,658 operative patients. The median age was 70.0 (54.0-81.0) nonoperative, and 71.0 (57.0-80.0) operative cohorts. Cohorts were predominately male and White. Multivariable analyses showed a stepwise relationship with all outcomes P < 0.001; 7.1% nonoperative and 14.9% operative patients had an 20% to 46% increased risk of mortality, that is, nonoperative: very frail (HR: 1.20 [95% CI: 1.13-1.26]), and operative: very frail (HR: 1.46 [95% CI: 1.38-1.55]). There were precipitous reductions in survival probability across mFI-5 strata.

Conclusion: Frailty was associated with major complications, LOS, mortality, and high level care discharges in a nationwide population of 381,754 patients. While timely surgery may be required for patients with tSDH, rapid deployment of point-of-care risk assessment for frailty creates an opportunity to equip physicians in allocating resources more precisely, possibly leading to better outcomes.

Keywords: frailty; modified frailty index-5; mortality; risk assessment; traumatic subdural hemorrhage.