For older adults undergoing emergency surgery, increasing levels of frailty increase the risk for adverse post-operative outcomes as well as further functional loss and deterioration after discharge, according to research published in The American Journal of Surgery. The study, which involved 52,356 patients aged 65 years and older, found that a higher frailty index associated with higher mortality and shorter length of survival in addition to increased risk for pneumonia, urinary tract infection, respiratory failure, acute kidney injury, and readmission.

“Frailty predicts worse outcomes across age groups, but the impact on return to home is greatest in ages 65-69,” wrote John O. Hwabejire, MD, MPH, of the Department of Surgery at Massachusetts General Hospital, and colleagues. “These findings support routine frailty screening and tailored care protocols for older adults needing emergency surgery.”

Analyzing Associations

Using data from the National Surgical Quality Improvement Program Participant Use Files from 2013 to 2020, the researchers evaluated the quantitative impact of frailty on outcomes for adults aged 65 years and older (median age, 76 years) admitted to the hospital directly from home who underwent emergency laparotomy. They calculated the associations between frailty and 30-day mortality, postoperative complications, unplanned readmissions, and discharge to home using scores from the five-item modified frailty index (mFI), applying multivariable logistic regression analysis to account for differences in patient and operative factors.

The researchers found that patients who were not considered frail had significantly lower mortality, complication rates, and unplanned readmissions compared with those deemed frail, and that the higher the frailty index score, the greater the likelihood of poorer postsurgical outcomes.

To gain insights into the implications of the study’s findings, Physician’s Weekly spoke with Galinos Barmparas, MD, medical director of trauma at Cedars-Sinai in Los Angeles, who was not involved in the study.

Physician’s Weekly: Given that frailty is known to increase patient risk, why was it important to study this topic?

Dr. Barmparas: This study adds a focused, data‑driven look at older adults undergoing emergency laparotomy. These patients are typically taken to the operating room for diagnoses such as perforated viscus or mesenteric ischemia, where baseline operative risk is already substantial. In this high-acuity setting, the authors quantify how outcomes shift when frailty is added to age and disease severity. That’s clinically important because frailty is still too often treated as a subjective “gestalt” variable rather than an explicit, measurable component of risk, especially when decisions need to be made quickly.

For physicians and colleagues, the key message is this: as this population grows, we need an objective, shared way to communicate risk in real time. That includes not only postoperative complications or death, but also the likelihood of prolonged recovery and loss of independence. This is crucial for our patients and their families, helping them make truly informed decisions under pressure.

What are the most important findings from the study?

The authors identified a strong, graded association between frailty and worse outcomes. To understand the risk for morbidity and mortality for these patients, look at their unadjusted 30-day mortality: it increased from 9.7% for patients who were non-frail (mFI=0) to 37.3% for patients who were highly frail (mFI=0.75–1.0). At the same time, discharge to home fell from 70.2% to 27.0% as frailty increased; that’s four out of five patients not going home!

Importantly, after adjusting for confounders, higher frailty remained independently associated with increased odds of mortality, major complications (such as pneumonia and respiratory failure), and hospital readmission. This frailty–outcome relationship persisted across all older age groups. These findings support routine frailty assessment, even among the “younger‑old,” undergoing emergency laparotomy.

What are the practical takeaways for clinicians?

We all recognize this, but it bears repeating, not all 75‑year‑olds are the same. Frailty meaningfully shapes operative risk and the subsequent clinical trajectory—short‑term (complications, length of stay) and long‑term (functional decline, loss of independence). Our responsibility is to make sure patients understand not only the risk of death, but also the likelihood of a difficult recovery, prolonged hospitalization, discharge to a facility, and the possibility that independence may not fully return.

That level of clarity helps patients—particularly those at the extremes of risk—make values‑based decisions. Statements like, “I do not want an operation if it means prolonged suffering,” or “A skilled nursing facility is not an acceptable outcome for me,” can only emerge when expectations are explicit.

Equally important, caring for these patients is inherently multidisciplinary. High‑quality care requires coordination among surgery, emergency medicine, anesthesia/ICU, geriatrics, nursing, case management/therapy, and often palliative care. Time and structure are needed to elicit patient values, define minimally acceptable outcomes, and align the treatment plan accordingly. Quantitative risk tools are not a panacea, but they improve precision, transparency, and team‑based planning. They help clinicians plan with patients—not just for them.

What is the surgeon’s role in decision‑making for emergency laparotomy, and how does this function within an interdisciplinary environment?

The appropriate approach depends on available hospital and community resources, but one principle is consistent: older, frail patients facing emergency surgery benefit when all supports are mobilized early. The era of a simple “operate versus don’t operate” framework is over; there is no universal pathway.

We constantly navigate two truths. Delay in many emergency abdominal conditions worsens outcomes. Conversely, nonoperative management—although sometimes appealing—may fail, and that failure can transform a challenging problem into a catastrophic one. This is why decision‑making must be deliberate, transparent, and values‑based.

As surgeons, our role is to bring clarity. That includes framing risk in terms that matter to patients—short‑term survival, complications, ventilator time, risk of not weaning, prolonged hospitalization, discharge to a long‑term facility, and the possibility of temporary or permanent loss of independence. We must also be honest that the surgery itself is only one determinant of outcome; physiologic reserve and frailty often matter more than technical execution.

A central component of our role is identifying the patient’s minimally acceptable outcome and acknowledging that “survival at any cost” is not aligned with everyone’s values.

Acute care surgeons, who manage trauma, emergency general surgery, and critical care, are uniquely positioned to coordinate this process in real time. We can optimize perioperative care, anticipate postoperative challenges, and integrate input from the necessary subspecialists. Supportive care should be engaged early—not only for end‑of‑life issues, but for communication, symptom management, and goals‑of‑care discussions. Geriatrics is also indispensable, offering expertise on cognition, baseline function, delirium prevention, and framing recovery around independence and functional outcomes.

Finally, disposition planning is part of the decision itself, not an afterthought. Discharge planning is often one of the most difficult aspects of caring for frail older adults after emergency surgery. Collaboration with social work, case management, patients, and families is essential to identify the best feasible destination and prioritize a pathway home whenever possible. Ultimately, high‑quality care requires a village, adequate resources, and collaborative practice.

In your experience, what does the decision‑making process involve?

My colleagues and I face these decisions daily, and there is rarely an easy path. These decisions are often made under significant time pressure—sometimes hours, sometimes minutes—while patients and families are trying to process an unfamiliar diagnosis and the reality that survival is only part of the outcome.

What patients often cannot fully appreciate initially is what a prolonged recovery truly entails: days to weeks in the ICU, a meaningful risk of not going directly home, and the possibility of additional interventions (ventilation, vasopressors, dialysis, feeding access, re‑imaging or procedures, delirium management, rehabilitation). Some are related to the surgical disease; others stem from limited physiologic reserve. The gap between “consenting to an operation” and “understanding the lived experience of recovery” is where conversations can fail if we are not explicit.

Frailty indices and risk‑stratification tools help bridge that gap. They do not decide for us, but they quantify risk, facilitate clearer communication, and allow us to frame outcomes around what matters—function and independence. In practice, I anchor decisions on two questions:

Will surgery meaningfully alter the trajectory of the acute problem?
What are the patient’s values and minimally acceptable outcomes?

When done well, the question becomes not “Can we operate?” but “Should we operate, given what this patient considers an acceptable life after surgery?” When time allows, early involvement of geriatrics and supportive care ensures that the plan aligns with both medical appropriateness and patient goals.

Is there anything else you feel clinicians should know regarding these findings?

It is essential for all clinicians to recognize that older, frail patients often have very limited physiologic reserve. As mentioned earlier, mobilizing all resources early—even when the patient initially appears relatively stable—is critical. The goal is not only to optimize the best‑case outcome, but also to reduce failure‑to‑rescue, prevent life‑altering complications, and ultimately prevent avoidable death.

We also need to be more consistent in using objective risk‑stratification tools. These tools help quantify risk, communicate it clearly to patients and families, and anticipate potential complications so we can plan proactively rather than reactively after deterioration begins.

Disclosure: Galinos Barmparas, MD, has disclosed no financial interests to Physician’s Weekly.

Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Physician’s Weekly, their employees, and affiliates.