Comparative Analysis of the ASA-PS Score and Clinical Frailty Scale in Predicting Postoperative Intensive Care Unit Requirement in Geriatric Hip Fracture Surgery: A Retrospective Evaluation
Aug 2026· Journal of Clinical Medicine· Vol 15· 0 citations· 36 references
Medicine
TL;DR
In this study, ASA-PS and CFS demonstrated comparable performance in predicting ICU admission; however, neither scale retained independent predictive value after adjustment for age, coronary artery disease, and type of anesthesia.
Abstract
Background/Objectives: Identifying geriatric hip fracture patients who will require postoperative intensive care unit (ICU) admission remains a clinical challenge. The American Society of Anesthesiologists Physical Status (ASA-PS) classification and the Clinical Frailty Scale (CFS) are both used in preoperative risk stratification, yet their comparative utility for this purpose has not been well characterized. Methods: This single-center, retrospectively designed study included 243 patients aged 65 years or older who underwent hip fracture surgery between January 2023 and December 2025. The primary outcome was determined as postoperative ICU admission, while the secondary outcomes were in-hospital mortality and postoperative complications. Discriminative performance was assessed by ROC analysis with DeLong pairwise comparison. Multivariable logistic regression analysis was performed to identify independent predictors of ICU admission. Results: Postoperative ICU admission occurred in 72.8% of patients. On multivariable analysis, neither ASA-PS nor CFS independently predicted ICU admission. Age (OR 1.052, 95% CI 1.009–1.096; p = 0.017), coronary artery disease (OR 3.992, 95% CI 1.581–10.083; p = 0.003), and spinal anesthesia (OR 0.363, 95% CI 0.161–0.823; p = 0.015) were found to be independent determinants. The addition of either scoring system to this clinical model did not improve discriminative performance (AUC 0.712 vs. 0.709 for both). For in-hospital mortality, CFS demonstrated a markedly superior discriminative ability compared to ASA-PS (AUC 0.801 vs. 0.623; DeLong p = 0.047). Conclusions: In this study, ASA-PS and CFS demonstrated comparable performance in predicting ICU admission; however, neither scale retained independent predictive value after adjustment for age, coronary artery disease, and type of anesthesia. Moreover, incorporating either score into the existing clinical risk model did not meaningfully improve discriminative performance (AUC: 0.709 vs. 0.712). Conversely, CFS exhibited superior discriminative ability compared to ASA-PS for in-hospital mortality. Given the low number of mortality events (n = 13), this finding should be interpreted cautiously as exploratory and warrants confirmation in larger, prospective, multicenter studies.
The prognostic value of the 5-factor modified frailty index (mFI-5) in patients with proximal femur fractures who were monitored in the postoperative intensive care unit (ICU) and to evaluate its relationship with clinical outcomes was demonstrated.
Berkay Küçük, Osman Yağız Atlı· Journal of Medicine and Pall...· 0 citations
Background: Hip fracture surgery patients admitted to the intensive care unit (ICU) have high postoperative mortality, and early risk stratification remains challenging. This study aimed to evaluate the predictive value of the C-reactive protein/albumin ratio (CAR) for 30-day and 90-day mortality in hip fracture surgery patients admitted to the ICU. Methods: This retrospective cohort study included 134 adult patients who underwent surgery for hip fracture and were admitted to the ICU between June 2021 and June 2023. Demographic characteristics, comorbidities, APACHE II and SAPS II scores, and laboratory parameters measured within the first 24 h of ICU admission were recorded. CAR was calculated by dividing CRP (mg/L) by albumin (g/dL). The primary outcomes were 30-day and 90-day mortality. Cox proportional hazards regression analysis was performed to identify independent predictors of mortality, and receiver operating characteristic (ROC) curve analysis was used to assess the discriminative ability of CAR. Results: The 30-day and 90-day mortality rates were 10.4% and 22.4%, respectively. CAR and serum albumin levels were significantly associated with both 30-day and 90-day mortality (p < 0.01), whereas CRP alone was not. In ROC analysis, CAR demonstrated excellent predictive performance for 30-day mortality (AUC: 0.991; 95% CI: 0.975–1.000; cutoff: 38.46; sensitivity: 92.9%; specificity: 92.5%) and good performance for 90-day mortality (AUC: 0.847; 95% CI: 0.776–0.918; cutoff: 25.43). Cox regression analysis identified CAR as an independent predictor of both 30-day (Exp(B) = 1.048, p < 0.001) and 90-day mortality (Exp(B) = 1.025, p = 0.002). Conclusions: The CRP/albumin ratio is a strong and independent predictor of short- and mid-term mortality in hip fracture surgery patients admitted to the ICU. Due to its simplicity and rapid availability, CAR may serve as a practical adjunctive biomarker for early risk stratification in this high-risk population.
Ayşe Yılmaz, V. G. Soylu, Ö. Taşkın et al.· Life· 0 citations
Background/Objectives: Frailty is increasingly recognized as a clinically relevant marker of reduced physiological reserve in surgical oncology. The modified 5-item frailty index (mFI-5) is simple and practical, but its clinical significance in oral squamous cell carcinoma (OSCC) remains incompletely defined. This study evaluated the association between mFI-5-defined frailty and postoperative complications, especially postoperative delirium, as well as survival outcomes in patients undergoing surgery for OSCC. Methods: We retrospectively analyzed 127 patients who underwent surgical resection for OSCC with postoperative high care unit (HCU) management between 2013 and 2021. Frailty was defined as an mFI-5 score of ≥2. Clinical characteristics, postoperative outcomes, HCU stay, length of hospital stay, overall survival (OS), and disease-free survival (DFS) were compared between frail and non-frail groups. Univariable logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for postoperative complications. An exploratory multivariable logistic regression analysis for postoperative delirium was performed using age ≥65 years and sex as covariates. Delirium was retrospectively assessed from clinical documentation considered consistent with DSM-5 criteria. Results: Twenty-one patients (16.5%) were classified as frail. Postoperative delirium occurred more frequently in frail patients than in non-frail patients (42.9% vs. 19.8%; p = 0.023). In a multivariable logistic regression model adjusted for age ≥65 years and sex, mFI-5-defined frailty was significantly associated with postoperative delirium (adjusted OR, 3.07; 95% CI, 1.08–8.60; p = 0.035). No significant association was observed for pneumonia, surgical site infection, or free-flap reoperation. Frailty was not significantly associated with HCU stay, length of hospital stay, OS, or DFS. Conclusions: mFI-5-defined frailty was associated with postoperative delirium but not with survival outcomes in this OSCC cohort. Because this retrospective study was limited by sample size, comorbidity-driven mFI-5 scoring, non-standardized delirium screening, and potential residual confounding, mFI-5 should be interpreted as a convenient screening marker rather than a stand-alone predictor. Comprehensive perioperative assessment incorporating frailty, nutrition, sarcopenia, cognition, tumor burden, and treatment-related factors may better identify patients at risk.
K. Yamagata, S. Fukuzawa, Shohei Takaoka et al.· Diagnostics· 0 citations
Background The incidence of prolonged length of stay in the post-anesthesia care unit (PACU) is high among elderly patients undergoing painless gastrointestinal endoscopy, and the value of frailty assessment for perioperative risk stratification in this population remains unclear. Methods A total of 500 elderly patients undergoing outpatient painless gastrointestinal endoscopy were enrolled. Preoperative frailty was assessed using the Fried Frailty Phenotype, and perioperative clinical data were collected. Independent risk factors for prolonged PACU length of stay were identified through Logistic regression analysis, and a predictive model was constructed. Results Frailty severity showed a dose-dependent relationship with the incidence of intraoperative and postoperative adverse events and PACU length of stay. Multivariable analysis revealed that frailty was the strongest independent risk factor for prolonged PACU length of stay (OR = 4.278, 95%CI: 2.207-8.286, P < 0.001). The constructed multivariable predictive model had an area under the curve of 0.804, with a sensitivity of 82.4% and a specificity of 77.1%. Conclusions Frailty significantly increases the risk of prolonged PACU length of stay in elderly patients undergoing painless gastrointestinal endoscopy. The predictive model based on frailty status has favorable clinical application value.
Zhilin Chen, Jinguang Zhang, Wu-Dong Zhuang et al.· Frontiers in Medicine· 0 citations
BACKGROUND
Postoperative delirium remains a common complication in older surgical patients. Frailty and cognitive impairment are established risk factors but are often assessed independently. We examined whether a pragmatic 2×2 cognitive-frailty phenotype framework stratifies postoperative delirium risk.
METHODS
This retrospective cohort study included patients aged ≥70 yr undergoing elective noncardiac, noncranial surgery at a tertiary centre from February 2022 to July 2024. Cognition and frailty were assessed using the Mini-Cog and Clinical Frailty Scale. Patients were classified into four phenotypes: intact, frail-only, cognitive-only, and cognitive-frailty. POD was assessed using the 4A's Test (4AT) in the PACU on the day of surgery and in surgical wards on postoperative days 1 and 2. The primary outcome was overall postoperative delirium, defined as at least one positive 4AT assessment. The secondary outcome was postoperative length of stay (LOS).
RESULTS
Among 3353 patients, 61% were intact, 20% frail-only, 11% cognitive-only, and 8% cognitive-frailty. Overall postoperative delirium incidence was 7.5%, increasing from 4.2% in the intact to 24.0% in the cognitive-frailty phenotype (P<0.001). Compared with intact, postoperative delirium risk was highest in the cognitive-frailty phenotype (adjusted odds ratio [aOR] 4.79, 95% confidence interval [CI] 3.22-7.11), followed by the cognitive-only phenotype (aOR 2.41, 95% CI 1.60-3.63) and the frail-only phenotype (aOR 1.72, 95% CI 1.20-2.47). Median postoperative LOS increased from 2.6 to 4.5 days across phenotypes (P<0.001).
CONCLUSIONS
In this cohort of older surgical patients, a pragmatic two-dimensional cognitive-frailty framework based on bedside screening tools demonstrated a clear gradient in postoperative delirium risk. This might support perioperative risk stratification, preventive strategies, and future research.
Yotam Weiss, S. Zarour, V. Rabkin et al.· British Journal of Anaesthes...· 0 citations
