PATIENT SAFETY
June 4, 2025

Improving Surgical Outcomes Through Frailty Screening: An Overview of the Risk Analysis Index

​​​​​​​AUTHOR BIOGRAPHIES
Matthew A. Taylor, PhD, Data Science & Research, Patient Safety Authority
​Matthew A. Taylor (MattTaylor@pa.gov) is a research scientist on the Data Science & Research team at the Patient Safety Authority, where he conducts research, uses data to identify patient safety concerns and trends, and develops solutions to prevent recurrence.

*Corresponding author

Daniel E. Hall, MD, MDiv, MHSc, VA Pittsburgh Healthcare System, Veterans Health Administration
Daniel E. Hall (Daniel.Hall2@va.gov) is a general surgeon and health services researcher based in Pittsburgh with national responsibility in the National Surgery Office for the Surgical Pause program. Informed by his clinical practice, his research and administrative efforts focus on improving the perioperative management and outcomes of high-risk, frail veterans considering surgical treatment.

*Corresponding author


ABSTRACT

Reports of Complications Related to Surgery or Invasive Procedures
More than 31,000 events involving complications related to a surgery or invasive procedure were reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS) in the five-year period between January 1, 2020, and December 31, 2024[1]. Of those events, more than 15,000 resulted in serious patient harm or death.

Patient Frailty and Preoperative Use of the Risk Analysis Index Tool
Patient frailty is a significant predictor of postoperative morbidity and mortality.1–5 The collective body of research over recent years has made a strong argument for preoperative use of a Risk Analysis Index (RAI) tool to evaluate the patients for frailty, as a proxy for physiologic reserve.3,5,6 The RAI tool can be completed by the patient/representative or staff and the scores are then tallied to estimate the degree of patient frailty. Higher RAI scores indicate that a patient would have greater frailty-associated risks. For ease of interpretation, the RAI scores are often grouped into the following four categories of patient status: robust, normal, frail, or very frail.

This tool is intended to be used with patients who are potential candidates for nonemergent or elective surgeries. Use of the RAI to identify patients who are frail or very frail may guide the surgeon and patient to consider preoperative rehabilitation (i.e., prehabilitation) or to not have surgery (i.e., opting for nonoperative treatments for symptom management, sometimes including palliative care).3–5,7–10 This decision among frail patients could reduce the likelihood of a morbidity and premature mortality.3,4,7–10 Overall, the use of RAI and related interventions have been associated with improved long-term outcomes for frail patients.

Keywords
RAI, surgical pause, mFI-5, morbidity, mortality, prehabilitation, screening tool

​References

  1. Arya S, Kim SI, Duwayri Y, et al. Frailty Increases the Risk of 30-Day Mortality, Morbidity, and Failure to Rescue After Elective Abdominal Aortic Aneurysm Repair Independent of Age and Comorbidities. J Vasc Surg. 2015;61(2):324-331. doi:10.1016/j.jvs.2014.08.11
    ​Google Scholar
  2. ​Revenig LM, Canter DJ, Master VA, et al. A Prospective Study Examining the Association Between Preoperative Frailty and Postoperative Complications in Patients Undergoing Minimally Invasive Surgery. J Endourol. 2014;28(4):476-480. doi:10.1089/end.2013.0496
    ​Google Scholar
  3. Agarwal N, Goldschmidt E, Taylor T, et al. Impact of Frailty on Outcomes Following Spine Surgery: A Prospective Cohort Analysis of 668 Patients. Neurosurgery. 2021;88(3):552-557. doi:10.1093/neuros/nyaa468
    ​​Google Scholar
  4. Arya S, Varley P, Youk A, et al. Recalibration and External Validation of the Risk Analysis Index: A Surgical Frailty Assessment Tool. Ann Surg. 2020;272(6):996-1005. doi:10.1097/SLA.0000000000003276
    ​​Google Scholar
  5. Bowers CA, Varela S, Conlon M, et al. Comparison of the Risk Analysis Index and the Modified 5-Factor Frailty Index in Predicting 30-day Morbidity and Mortality After Spine Surgery. J Neurosurg Spine. 2023;39(1):136-145. doi:10.3171/2023.2.SPINE221019
    ​ ​ Google Scholar
  6. Hall DE, Arya S, Schmid KK, et al. Development and Initial Validation of the Risk Analysis Index for Measuring Frailty in Surgical Populations. JAMA Surg. 2017;152(2):175-182. doi:10.1001/jamasurg.2016.4202
    ​Google Scholar
  7. Hall DE, Youk A, Allsup K, et al. Preoperative Rehabilitation is Feasible in the Weeks Prior to Surgery and Significantly Improves Functional Performance. J Frailty Aging. 2023;12(4):267-276. doi:10.14283/jf
    ​ ​Google Scholar​
  8. Varley PR, Borrebach JD, Arya S, et al. Clinical Utility of the Risk Analysis Index as a Prospective Frailty Screening Tool Within a Multi-Practice, Multi-Hospital Integrated Healthcare System. Ann Surg. 2021;274(6):e1230-e1237. doi:10.1097/SLA.0000000000003808
    ​​Google Scholar
  9. .Hall DE, Arya S, Schmid KK, et al. Association of a Frailty Screening Initiative With Postoperative Survival at 30, 180, and 365 Days. JAMA Surg. 2017;152(3):233-240. doi:10.1001/jamasurg.2016.4219
  10. George EL, Hall DE, Youk A, et al. Association Between Patient Frailty and Postoperative Mortality Across Multiple Noncardiac Surgical Specialties. JAMA Surg. 2021;156(1):e205152-e. doi:10.1001/jamasurg.2020.5152
    ​Google Scholar​