Frailty Is Associated with Worse Short-Term Outcomes in Patients undergoing Transsphenoidal Resection of Pituitary Tumors

Background Frailty, distinct from old age, has been shown to significantly impact outcome after surgery and thus may have potential value in preoperative risk assessment. Despite being well studied in most other surgeries, there is currently no study that has examined the impact of frailty on the outcome of patients undergoing transsphenoidal pituitary surgery. Here, employing a national database, we examine the impact of frailty on patient outcome after transsphenoidal surgery.

Methods Data from the 2001–2010 Nationwide Inpatient Sample was studied. Consecutive patients admitted with a diagnosis of pituitary tumor and who underwent transsphenoidal surgery were identified using appropriate ICD-9-CM codes and included for study. Standard descriptive techniques and matched propensity score analyses adjusted for multiple confounders were used to explore the odds ratios (OR) of postoperative complications and discharge dispositions.

Results A total of 72,905 transsphenoidal surgery cases were included. Frailty was present in 1.31%. The mean age for frail versus nonfrail patients was 58.72 years (SD ± 16.38) versus 51.52 years (SD ± 15.91, p < 0.001). A greater proportion of frail compared with nonfrail patients were ≥ 65 years old (42.36 vs. 23.27%, p < 0.001). Frail patients compared with nonfrail were more likely to be black (20.50 vs. 12.31%, p < 0.001), possess Medicare insurance (40.69 vs. 23.64%, p < 0.001), belong to lower median income groups (p < 0.001), and more likely to present with single and/or multiple comorbidities (p < 0.001). There were no significant differences in long-term use of aspirin (0.51 vs. 1.29, p = 0.34) or anticoagulant (0.55 vs. 0.73, p = 0.78) therapy between frail and nonfrail patients. Results of propensity score matched and adjusted multivariate regression revealed that frail patients were significantly more likely for complications of fluid and electrolyte disorders (OR = 2.65; 95% CI =1.85–3.80; p < 0.001), including hyperosmolality/hypernatremia (OR = 3.61; 95% CI = 1.52–8.59; p < 0.001); hemorrhagic complications (OR = 2.14; 95% CI = 1.10–4.17; p = 0.03), including hemorrhage/hematoma (OR = 3.94; 95% CI = 1.11–13.94; p = 0.03) and iatrogenic cerebrovascular hemorrhage (OR = 2.92; 95% CI = 1.69–12.39; p = 0.04); and altered mental status (OR = 9.73; 95% CI = 8.11–66.68; p = 0.03). Frail patients were also more likely for medical complications including pulmonary insufficiency (OR = 2.98; 95% CI = 1.01–8.74; p = 0.04) in the propensity score matched models. Overall mortality was 0.41% and was higher among frail versus nonfrail cases (1.67 vs. 0.40%, p = 0.01). Frail patients were more likely for nonroutine discharges (p < 0.001). The overall mean total charge associated with transsphenoidal surgery was $45,209.10 (95% CI: $44,403.52–$46,014.69). Total charges were significantly higher among frail versus nonfrail patients ($107,476.90 [95% CI: $85,383.96–$129,569.80] vs. $44,381.31 [95% CI: $43,629.93–$45,132.69], p < 0.001). Overall total length of hospitalization was 4.66 days (95% CI: 4.56–4.75) and was significantly prolonged among frail patients (11.75 days [95% CI: 9.38–14.12] vs. 4.56 days [95% CI: 4.47–4.66], p < 0.001). On the whole, patients with one or more postoperative complications demonstrated higher charges and longer hospital stays compared with patients without complications.

Conclusion We have implemented a critical evaluation of frailty and its impact on short-term outcome among patients undergoing transsphenoidal surgery for resection of pituitary tumors. Our study demonstrates that frailty is associated with worse postoperative outcomes and greater financial burden, indicative of a potentially valuable role of a routine preoperative frailty assessment for risk stratification. These findings would warrant further validation in a prospective cohort.