A practical risk scale for predicting morbidity and mortality in the emergency general surgical setting: a prospective multicenter study

Background: Low albumin is a poor prognostic factor for surgical outcomes. We aimed to examine the predicative ability of easily obtainable point of care variables in combination to low albumin level to derive a practical risk scale for predicting older adults at risk of poor outcomes on admission to the emergency general surgical setting. Methods: This is an international multi-center prospective cohort study conducted as part of the Older Persons Surgical Outcomes Collaboration (www.OPSOC.eu). The effect of having hypoalbuminemia (defined as albumin ≤3.5g/dL) on selected outcomes was examined using fully adjusted multivariable models. In a subgroup of patients with hypoalbuminemia, we observed four risk characteristics (Male, Anemia, Low albumin, Eighty-five and over [MALE]). Subsequently, the impact of incremental increase in MALE score (each characteristic scoring 1 point (maximum score 4) on measured outcomes was assessed. Results: The cohort consisted of 1406 older patients with median (IQR) age of 76 (70-83) years. In fully adjusted models, hypoalbuminemia was significantly associated with undergoing emergency surgery (1.32 (95%CI 1.03-1.70); p=0.03), 30-day mortality (4.23 (2.22-8.08); p<0.001), 90-day mortality (3.36 (2.14-5.28); p<0.001) (primary outcome), and increased hospital length of stay, irrespective of whether a patient received emergency surgical intervention. Every point increase in MALE score was associated with higher odds of mortality, with a MALE score of 4 being associated with 30-day mortality (adjusted OR(95% CI)=33.38 (3.86-288.7); p=0.001) and 90-day mortality (11.37 (3.85-33.59); p<0.001) compared to the reference category of those with MALE score 0. Conclusions: The easy to use and practical MALE risk score calculated at point of care identifies older adults at a greater risk of poor outcomes, thereby allowing clinicians to prioritize patients who may benefit from early comprehensive geriatric assessment in the emergency general surgical setting.