Interventions to improve the outcomes of frail people having surgery: A systematic review

Background
Frailty is an important prognostic factor for adverse outcomes and increased resource use in the growing population of older surgical patients. We identified and appraised studies that tested interventions in populations of frail surgical patients to improve perioperative outcomes.
Methods
We systematically searched Cochrane, CINAHL, EMBASE and Medline to identify studies that tested interventions in populations of frail patients having surgery. All phases of study selection, data extraction, and risk of bias assessment were done in duplicate. Results were synthesized qualitatively per a prespecified protocol (CRD42016039909).
Results
We identified 2 593 titles; 11 were included for final analysis, representing 1 668 participants in orthopedic, general, cardiac, and mixed surgical populations. Only one study was multicenter and risk of bias was moderate to high in all studies. Interventions were applied pre- and postoperatively, and included exercise therapy (n = 4), multicomponent geriatric care protocols (n = 5), and blood transfusion triggers (n = 1); no specific surgical techniques were compared. Exercise therapy, applied pre-, or post-operatively, was associated with significant improvements in functional outcomes and improved quality of life. Multicomponent protocols suffered from poor compliance and difficulties in implementation. Transfusion triggers had no significant impact on mortality or other outcomes.
Conclusions
Despite a growing literature that demonstrates strong independent associations between frailty and adverse outcomes, few interventions have been tested to improve the outcomes of frail surgical patients, and most available studies are at substantial risk of bias. Multicenter, low risk of bias, studies of perioperative exercise are needed, while substantial efforts are required to develop and test other interventions to improve the outcomes of frail people having surgery.

背景
衰弱（frailty）是日益增长的老年手术患者群体中，与不良结局及医疗资源消耗增加相关的重要预后因素。本研究旨在检索并评价针对衰弱手术患者人群开展的、旨在改善围手术期（perioperative）结局的干预类研究。
方法
本研究系统检索了考克兰图书馆（Cochrane）、护理及相关健康文献累积索引（CINAHL）、荷兰医学文摘（EMBASE）以及医学文摘数据库（Medline），以筛选针对衰弱手术患者人群开展的干预类研究。研究筛选、数据提取以及偏倚风险评估的所有环节均由两名研究者独立重复完成。研究结果按照预先指定的研究方案（CRD42016039909）进行定性综合分析。
结果
本研究共检索到2593篇文献标题，最终纳入11项研究进行最终分析，共涉及1668名受试者，涵盖骨科、普通外科、心脏外科及混合外科手术人群。仅1项研究为多中心研究，所有纳入研究的偏倚风险均为中至高等级。干预措施于术前及术后实施，包括运动疗法（n=4）、多组分老年护理方案（n=5）以及输血阈值干预（n=1），未比较特定手术技术差异。术前或术后实施的运动疗法可显著改善受试者的功能结局与生活质量。多组分老年护理方案存在依从性差、实施难度大的问题。输血阈值干预对受试者死亡率及其他结局无显著影响。
结论
尽管现有研究文献日益增多，证实衰弱与不良结局之间存在显著独立关联，但目前针对衰弱手术患者开展的改善结局的干预措施研究仍较为匮乏，且多数已有的相关研究存在较高偏倚风险。未来亟需开展多中心、低偏倚风险的围手术期运动疗法相关研究，同时也需要投入大量精力开发并验证其他干预措施，以改善衰弱手术患者的临床结局。