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Pulmonary lobectomy represents the primary curative treatment for lung cancer in older adults, yet frailty’s impact on critical early postoperative outcomes remains inadequately characterized. This analysis examined the effect of preoperative frailty on early postoperative mortality and failure-to-rescue in a contemporary national cohort.

This retrospective cohort study analyzed older adults undergoing pulmonary lobectomy for lung cancer using the National Inpatient Sample (2016–2022). The Johns Hopkins Adjusted Clinical Groups (ACG) frailty indicator and Hospital Frailty Risk Score (HFRS) were used to identify frail patients. Multivariable logistic regression examined associations between frailty and failure-to-rescue (death after postoperative complications) and 14-day in-hospital mortality.

Among 110,460 patients aged ≥65 years, frailty prevalence was 5.7% (n = 6290) by ACG indicator and 19.8% (n = 21,915) by HFRS (≥5). Among ACG-defined frail patients, the most common frailty-defining conditions were dementia (37.8% of frail patients), malnutrition (36.0%), and weight loss (11.6%). Overall complication rate was 39.3%, but frail patients (HFRS ≥5) experienced higher rates (69.0% versus 32.0%), higher hospitalization costs (median $104,446 versus $88,532), and reduced likelihood of home discharge (83.3% versus 95.5%; all p < 0.001). Overall 14-day mortality was 0.8%. Frail patients had higher rates of failure-to-rescue (ACG: 3.7% versus 1.7%; HFRS: 4.1% versus 0.8%) and mortality (ACG: 2.1% versus 0.7%; HFRS: 2.8% versus 0.3%; all p < 0.001) compared with non-frail patients. After multivariable adjustment, frailty remained associated with failure-to-rescue (ACG: OR 2.01, 95% CI 1.36–3.06; HFRS: OR 4.66, 95% CI 3.27–6.63) and 14-day mortality (ACG: OR 2.70, 95% CI 1.77–4.10; HFRS: OR 9.30, 95% CI 6.52–13.26). Frailty accounted for 68% of early deaths within the frail cohort and 11% of all cohort deaths.

Preoperative frailty was associated with early postoperative mortality and failure-to-rescue rates following pulmonary lobectomy in older adults, emphasizing the need for systematic frailty assessment, enhanced perioperative surveillance, and targeted interventions for this population.