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mFI-5 Preoperative Frailty
mFI-5: A highly validated subset of the NSQIP database. A score of 2 or more indicates frailty and highly elevated surgical morbidity.
Select Present Factors
1. Diabetes Mellitus
History of diabetes requiring oral agents or insulin.
2. Hypertension
Hypertension requiring medication.
3. Congestive Heart Failure
History of CHF within 30 days prior to surgery.
4. COPD or Severe Pulmonary Disease
History of severe COPD, pneumonia, or recent ventilator dependency.
5. Non-Independent Functional Status
Partially or totally dependent in ADLs prior to illness/surgery.
Guidelines & Evidence
Clinical Details
Section 1
When to Use
When to Use
Preoperative risk stratification for older adults undergoing major surgery.
Predicting 30-day mortality, postoperative complications, and non-home discharge.
Used extensively across surgical specialties (orthopaedics, vascular, general, neurosurgery).
Database Derived
The mFI-5 was derived from the massive ACS-NSQIP database. It distills the complex 11-item and 70-item historical frailty indices down to the 5 most statistically powerful predictors of surgical morbidity, making it highly practical for the preoperative clinic.
Section 2
Formula & Logic
Scoring
5 binary items scored 0 or 1.
Total score: 0–5.
Score is often expressed as a ratio (e.g., 2/5 = 0.4).
mFI-5 ≥ 2 (or ≥ 0.4) is universally considered frail and at high risk.
The 5 Items
Diabetes
History of diabetes mellitus (oral agents or insulin).
Hypertension
Hypertension requiring medication.
Congestive Heart Failure
History of CHF within 30 days prior to surgery.
COPD
History of severe COPD or pneumonia.
Functional Status
Non-independent functional status prior to surgery (partially or totally dependent in ADLs).
Section 3
Pearls/Pitfalls
Functional Status is King
Of the 5 items, "Non-independent functional status" carries the highest predictive weight. An 85-year-old who is completely independent (score 0) often has a lower surgical risk than a 65-year-old dependent on nursing care.
Section 4
Next Steps
Management
Section 5
Evidence Appraisal
Primary Reference
New 5-Factor Modified Frailty Index Using American College of Surgeons NSQIP Data.
Subramaniam S et al. • J Am Coll Surg.. 2018;226(2):173-181. Derived and validated the 5-item index, proving it was non-inferior to the older 11-item index in predicting mortality.
Section 6
Origins
Simplifying the NSQIP
As surgical risk calculators became overly cumbersome, researchers analyzed millions of records in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database to find the absolute minimum variables needed to accurately quantify frailty.
