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Clinical Research

Multiplicative effect of frailty and obesity on postoperative mortality following spine surgery: a deep dive into the frailty, obesity, and Clavien-Dindo dynamic

International Journal of Obesity volume 48, pages 360–369 (2024)Cite this article

Subjects

Abstract

Background/objectives

Obesity is a global health challenge that affects a large proportion of adults worldwide. Obesity and frailty pose considerable health risks due to their potential to interact and amplify one another’s negative effects. Therefore, we sought to compare the discriminatory thresholds of the risk analysis index (RAI), 5-factor modified frailty index (m-FI-5) and patient age for the primary endpoint of postoperative mortality.

Subjects/methods

We included spine surgery patients ≥18 years old, from the American College of Surgeons National Quality Improvement program database from 2012-2020, that were classified as obese. We performed receiver operating characteristic curve analysis to compare the discrimination threshold of RAI, mFI-5, and patient age for postoperative mortality. Proportional hazards risk-adjusted regressions were performed, and Hazard ratios and corresponding 95% Confidence intervals (CI) are reported.

Results

Overall, there were 149 163 patients evaluated, and in the ROC analysis for postoperative mortality, RAI showed superior discrimination C-statistic 0.793 (95%CI: 0.773-0.813), compared to mFI-5 C-statistic 0.671 (95%CI 0.650–0.691), and patient age C-statistic 0.686 (95%CI 0.666-0.707). Risk-adjusted analyses were performed, and the RAI had a stepwise increasing effect size across frailty strata: typical patients HR 2.55 (95%CI 2.03-3.19), frail patients HR 3.48 (95%CI 2.49-4.86), and very frail patients HR 4.90 (95%CI 2.87–8.37). We found increasing postoperative mortality effect sizes within Clavein-Dindo complication strata, consistent across obesity categories, exponentially increasing with frailty, and multiplicatively enhanced within CD, frailty and obesity strata.

Conclusion

In this study of 149 163 patients classified as obese and undergoing spine procedures in an international prospective surgical database, the RAI demonstrated superior discrimination compared to the mFI-5 and patient age in predicting postoperative mortality risk. The deleterious effects of frailty and obesity were synergistic as their combined effect predicted worse outcomes.

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Fig. 1: Receiver operating characteristics analysis evaluating the discrimination of 30-day postoperative mortality for frailty risk-assessment tools (risk analysis index, and 5-factor modified frailty), and increasing patient age in spine patients classified as obese.
Fig. 2

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Data availability

The data utilized in this study is publicly available and can be accessed by researchers upon request. Detailed information about the dataset, including access requirements and procedures, can be found on the ACS website. Data sharing adheres to the guidelines and policies set forth by the data provider.

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Acknowledgements

The STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) reporting requirements were strictly adhered for this observational study.

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Authors and Affiliations

  1. Department of Emergency Medicine, University of New Mexico Hospital, Albuquerque, NM, USA

    Oluwafemi P. Owodunni

  2. Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA

    Oluwafemi P. Owodunni, Evan N. Courville, Uchenna Peter-Okaka & Christian A. Bowers

  3. Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, NM, USA

    Evan N. Courville, Christian B. Ricks & Meic H. Schmidt

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Contributions

OPO: conceptual design, validation, methodology, formal analysis, visualization, writing initial draft, data curation, project administration. CAB: supervision, data acquisition. ENC, UP-O, CBR, MHS, and CAB: critical review, editing. All authors read and approved the final version of the manuscript All individuals listed as authors confirm their significant contributions to the publication, including concept, design, analysis, writing, or revision, and they accept public responsibility for the content.

Corresponding author

Correspondence to Oluwafemi P. Owodunni.

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Ethics

This study adhered to the ethical requirements of the institutional and national research committees, as well as the Helsinki Declaration of 1964 and its updates or similar ethical standards. The University of New Mexico’s Institutional Review Board approved this study, and the research was conducted according to the ACS-NSQIP’s data user agreement guidelines.

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Owodunni, O.P., Courville, E.N., Peter-Okaka, U. et al. Multiplicative effect of frailty and obesity on postoperative mortality following spine surgery: a deep dive into the frailty, obesity, and Clavien-Dindo dynamic. Int J Obes 48, 360–369 (2024). https://doi.org/10.1038/s41366-023-01423-0

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