Frailty Assessment Prior to Total Joint Arthroplasties Predicts Length of Hospitalization and Postoperative Discharge: A Prospective Cohort Study

Abstract

Abstract Background: Individuals age 65 and older account for 59% of total hip (THA) and total knee (TKA) arthroplasties. It is understood that this patient demographic is more frequently found to be frail, predisposing them to significantly poorer health outcomes. We developed a brief preoperative assessment tool to determine whether preoperative frailty predicts patients’ health care utilization following total joint arthroplasty (TJA). Methods: In a prospective cohort study, we conducted preoperative in-person frailty assessment for all orthopedic patients aged 65 years or older undergoing THA or TKA at a large academic center between April 2017 and September 2019. Frailty was defined based on the validated Fried Phenotype, examining patients across five domains: Shrinkage, Weakness, Exhaustion, Physical Activity and Slowness. We then examined risks of extended hospital stay and discharge to a facility amongst frail, pre-frail, and non-frail patients. Results: Of 1,373 TJA patients, 63 (4.6%) were frail, 402 (29.3%) were pre-frail, and 908 (66.1%) were non-frail. In univariate analysis, frail and pre-frail patients were found to have significantly higher resource utilization than their non-frail counterparts. Patients who underwent a revision procedure were more likely to have a facility discharge and an extended stay than those undergoing a primary procedure. THA patients had a higher risk of an extended stay than TKA patients but a similar risk for being discharge to a facility. Age was positively associated with discharge to a facility for age 71-75 years, as well as with an extended stay vs. 65-70 years. Adjusting for age, procedure type, and primary vs. revision surgery, the relative risk of being discharged to a facility (vs. home) was greater than two-fold for pre-frail patients, and nearly four-fold for frail patients compared to non-frail patients. Pre-frailty also increased patients’ risk of extended stay by 43%, while frailty doubled the risk compared to non-frail status. Conclusion: Frailty status clearly demonstrates an increased risk of resource utilization and represents a hidden risk in most orthopedic programs. Our preoperative frailty assessment tool proved to be useful for optimizing TJA patients, improving efficiency and optimizing care for our patients.