U.S. patients hospitalized with gastrointestinal bleeding who undergo endoscopy are significantly more likely to suffer cardiovascular, pulmonary, gastrointestinal, and infectious complications, as well as die, if they are classified as frail, according to a new study by University of Miami Miller School of Medicine researchers.
Frailty has been studied extensively in the context of major surgeries and chronic diseases, such as cirrhosis. But it has not been studied as a way to assess risk among patients undergoing endoscopy for gastrointestinal bleeding, according to a paper published online March 19 in the journal Gastrointestinal Endoscopy.
In fact, little data exist in the context of what might be viewed as more minor medical procedures in general. The findings from this study and others looking at frailty’s impact on procedural outcomes leads to the larger question: When is someone too frail to have a procedure?
“As gastroenterologists, we try to avoid subjecting patients to an endoscopy that will not necessarily be therapeutic. This study suggests that frailty assessments can provide a way to identify those patients most at risk for complications from endoscopy and allow us to really think about whether endoscopy is absolutely necessary,” said senior author Sunil Amin, M.D., M.P.H., assistant professor of clinical medicine and gastroenterology, and director of endoscopy at UM/Jackson Memorial Hospital and The Lennar Foundation Medical Center at the Miller School.
Endoscopies are recommended for patients admitted for gastrointestinal bleeds, the leading gastrointestinal condition resulting in hospitalizations in the U.S.
Counterbalancing benefits with risks
“The recommendation often is from the singular lens of the benefits of the endoscopy, without the counterbalanced risk of the procedure,” said study author David Goldberg, M.D., associate professor of medicine in the Division of Digestive Health and Liver Diseases at the Miller School. “These data would suggest the risks of complications are significantly higher in more frail patients, leading us to rethink our one-size-fits-all approach to performing endoscopies for gastrointestinal bleeds.”
Frailty, defined as functional declines across several organ systems, is common. In this study of more than 700,000 hospitalized patients, more than 44% were classified as frail.
Miller School investigators studied patients at U.S. hospitals admitted with gastrointestinal bleeds in 2016 and 2017, who underwent endoscopy and the Hospital Frailty Risk Score, which classifies patients as frail or non-frail. They found that more than 49% of frail patients had procedure-related adverse events versus 25.5% of non-frail patients. More than 32% of frail patients had cardiovascular complications versus 17.1% of non-frail patients; 18.5% of frail patients had pulmonary complications compared to 4.3% of non-frail patients; 10.1% had gastrointestinal complications compared to 6.1% in the non-frail group; and 9.1% of frail patients had infections versus 0.7% in the non-frail group. Nearly 5% of frail patients died during their hospital stays, compared to 0.5% of non-frail patients.
“The main takeaway from our study is that we show frailty assessment can be used as a marker to predict outcomes in patients with gastrointestinal bleeding who are being considered for endoscopy — either upper endoscopy or colonoscopy,” said first author Camilo Acosta, M.D., a resident in the Department of Medicine at the Miller School. “With gastrointestinal bleeding being such a ubiquitous condition, these results are impactful in the sense that they show we should be evaluating the frailty status of patients. Using this assessment can serve as a helpful guide to determine who is at increased risk for doing poorly with endoscopic interventions and thus can help us have better discussions with patients about benefits of therapies versus risks.”