Design: Retrospective cohort, two health systems
Population: 600,759 patients assessed in outpatient surgical clinics
Primary outcome: 180-day all-cause mortality
Effect: c 0.868 and 0.827 (existing); 0.872 and 0.839 (recalibrated)

The Risk Analysis Index is a widely used surgical frailty screen, last calibrated on data from 2010 to 2014. A JAGS study tested whether its scoring has drifted, using 410,715 outpatient surgical clinic patients from one US health system and 190,044 from the Veterans Health Administration.

The existing questionnaire-based score predicted 180-day mortality well (c 0.868 and 0.827). Recalibrating the weights improved discrimination only slightly (to 0.872 and 0.839) and changed little around the frailty threshold. Decision analysis suggested 1,400 to 6,000 patients would need screening with a revised score to reclassify one additional patient as frail.

The conclusion is practical: the current tool remains fit for purpose, and units using it need not change. Cancer remains the largest single contributor to the score.

The current Risk Analysis Index questionnaire remains valid for predicting 180-day mortality before surgery.
Recalibrating the score added almost nothing to clinical classification.
Use a frailty screen in older surgical candidates to inform shared decision-making and prehabilitation.
A frail result should prompt discussion of goals and alternatives, not automatic exclusion from surgery.

Why it matters

Clinicians can trust a widely adopted frailty tool without retraining on a new version.

The statistics, in plain English

A c-statistic of 0.87 means the score ranks a patient who died above one who survived about 87% of the time, which is strong. A gain to 0.872 is negligible.