The Drug Burden Index and Level of Frailty as Determinants of Healthcare Costs in a Cohort of Older Frail Adults in New Zealand.

OBJECTIVES: Frailty is common in older people and is associated with increased use of healthcare services and ongoing use of multiple medications. This study provides insights into the healthcare cost structure of a frail group of older adults in Aotearoa, New Zealand. Furthermore, we investigated the relationship between participants' anticholinergic and sedative medication burden and their total healthcare costs to explore the viability of deprescribing interventions within this cohort. METHODS: Healthcare cost analysis was conducted using data collected during a randomized controlled trial within a frail, older cohort. The collected information included participant demographics, medications used, frailty, cost of service use of aged residential care and outpatient hospital services, hospital admissions, and dispensed medications. RESULTS: Data from 338 study participants recruited between 25 September 2018 and 30 October 2020 with a mean age of 80 years were analyzed. The total cost of healthcare per participant ranged from New Zealand $15 (US dollar $10) to New Zealand $270 681 (US dollar $175 943) over 6 months postrecruitment into the study. Four individuals accounted for 26% of this cohort's total healthcare cost. We found frailty to be associated with increased healthcare costs, whereas the drug burden was only associated with increased pharmaceutical costs, not overall healthcare costs. CONCLUSIONS: With no relationship found between a patient's anticholinergic and sedative medication burden and their total healthcare costs, more research is required to understand how and where to unlock healthcare cost savings within frail, older populations.

Catastrophic health expenditure among single empty-nest elderly with multimorbidity in rural Shandong, China: the effect of co-occurrence of frailty.

BACKGROUND: Previous studies have indicated that older adults with multimorbidity had higher risk of incurring catastrophic health expenditure (CHE). However, the effect of co-occurrence of frailty on CHE among single empty-nest elderly with multimorbidity remains unclear. This study aims to explore the effect of co-occurrence of frailty on CHE among single empty-nest elderly with multimorbidity, and whether this effect is moderated by economic status. METHODS: A cross-sectional household survey of the older adults in 2019 in Shandong province, China. A total of 606 single empty-nest elderly aged 60 years or older were included in this study. CHE was defined as the out-of-pocket payments for health care that equals or exceeds 40% of the household' s capacity to pay. Logistic regression models are employed to examine the effect of co-occurrence of frailty on CHE among single empty-nest elderly with multimorbidity. The interaction term is introduced to explore the economic status difference in this effect. RESULTS: The CHE incidence for single empty-nest elderly with multimorbidity alone is 64.2%, and the co-occurrence of frailty results in an increase by almost 1.3 times (84.0%) in CHE incidence among single empty-nest elderly with multimorbidity. The co-occurrence of frailty increases the risk of incurring CHE among the single empty-nest elderly with multimorbidity, with the odds of incurring CHE increased by 3.19 times (OR = 3.19; P = 0.005). Furthermore, the interaction analysis shows that the effect of co-occurrence of frailty on CHE among single empty-nest elderly with multimorbidity still exist in lower economic status groups (OR = 4.64; P = 0.027), but not in higher economic status (OR = 2.76; P = 0.062). CONCLUSIONS: This study demonstrates that there is a positive effect of co-occurrence of frailty on the CHE among the single empty-nest elderly with multimorbidity, and this effect varies by economic status. The health policy-makers should reorganize the healthcare system to make it pro-poor, so as to meet the multiple medical demand and reduce the potential economic burden and inequalities of older adults.

Economic evaluation of a multimodal intervention in pre-frail and frail older people with diabetes mellitus: the MID-FRAIL project.

Background: The aim of this study was to estimate the incremental cost-utility ratio (ICUR) of a multi-modal intervention in frail and pre-frail subjects aged ≥70 years with type-2 diabetes versus usual care group focused on quality adjusted life years (QALYs) in different European countries. Methods: The MID-FRAIL study was a cluster randomized multicentre trial conducted in seven European countries. A cost-utility analysis was carried out based on this study, conducted from the perspective of the health care system with a time horizon of one year. Univariate and probabilistic analysis were carried out to test the robustness of the results. Results: The cost estimation showed the offsetting health effect of the intervention program on total health care costs. The mean annual health care costs were 25% higher among patients in usual care. The mean incremental QALY gained per patient by the intervention group were 0.053 QALY compared with usual care practice. Conclusions: The MID-FRAIL intervention program showed to be the dominant option in comparison with usual care practice. It saved costs to the health care system and achieved worthwhile health gains. This finding should encourage its implementation, at least, in the trial participant countries.

A cost utility analysis of treating different adult spinal deformity frailty states.

The aim of this study was to investigate the cost utility of treating non-frail versus frail or severely frail adult spinal deformity (ASD) patients. 79 surgical ASD patients >18 years with available frailty and ODI data at baseline and 2-years post-surgery (2Y) were included. Utility data was calculated using the ODI converted to the SF-6D. QALYs utilized a 3% discount rate to account for decline to life expectancy (LE). Costs were calculated using the PearlDiver database. ICER was compared between non-operative (non-op.) and operative (op.) NF and F/SF patients at 2Y and LE. When compared to non-operative ASD, the ICER was $447,943.96 vs. $313,211.01 for NF and F/SF at 2Y, and $68,311.35 vs. $47,764.61 for NF and F/SF at LE. Frail and severely frail patients had lower cost per QALY compared to not frail patients at 2Y and life expectancy, and had lower ICER values when compared to a non-operative cohort of ASD patients. While these results support operative correction of frail and severely frail patients, it is important to note that these patients are often at worse baseline disability, which is closely related to frailty scores, and have more opportunity to improve postoperatively. Furthermore, there may be a threshold of frailty that is not operable due to the risk of severe complications that is not captured by this analysis. While future research should investigate economic outcomes at extended follow up times, these findings support the cost effectiveness of ASD surgery at all frailty states.

The Australian National Aged Care Classification (AN-ACC): a new casemix classification for residential aged care.

OBJECTIVE: To develop a casemix classification to underpin a new funding model for residential aged care in Australia. DESIGN, SETTING: Cross-sectional study of resident characteristics in thirty non-government residential aged care facilities in Melbourne, the Hunter region of New South Wales, and northern Queensland, March 2018 - June 2018. PARTICIPANTS: 1877 aged care residents and 1600 residential aged care staff. MAIN OUTCOME MEASURES: The Australian National Aged Care Classification (AN-ACC), a casemix classification for residential aged care based on the attributes of aged care residents that best predict their need for care: frailty, mobility, motor function, cognition, behaviour, and technical nursing needs. RESULTS: The AN-ACC comprises 13 aged care resident classes reflecting differences in resource use. Apart from the class that included palliative care patients, the primary branches were defined by the capacity for mobility; further classification is based on physical capacity, cognitive function, mental health problems, and behaviour. The statistical performance of the AN-ACC was good, as measured by the reduction in variation statistic (RIV; 0.52) and class-specific coefficients of variation. The statistical performance and clinical acceptability of AN-ACC compare favourably with overseas casemix models, and it is better than the current Australian aged care funding model, the Aged Care Funding Instrument (64 classes; RIV, 0.20). CONCLUSIONS: The care burden associated with frailty, mobility, function, cognition, behaviour and technical nursing needs drives residential aged care resource use. The AN-ACC is sufficiently robust for estimating the funding and staffing requirements of residential aged care facilities in Australia.

Assessment of HF Outcomes Using a Claims-Based Frailty Index.

OBJECTIVES: This study used a claims-based frailty index to investigate outcomes of frail patients with heart failure (HF). BACKGROUND: Medicare value-based payment programs financially reward and penalize hospitals based on HF patients' outcomes. Although programs adjust risks for comorbidities, they do not adjust for frailty. Hospitals caring for high proportions of frail patients may be unfairly penalized. Understanding frail HF patients' outcomes may allow improved risk adjustment and more equitable assessment of health care systems. METHODS: Adapting a claims-based frailty index, the study assigned a frailty score to each adult in the National in-patient Sample (NIS) from 2012 through September 2015 with a primary diagnosis of HF and dichotomized frailty by using a cutoff value established in the general NIS population. Multivariate regression models were estimated, controlling for comorbidities and hospital characteristics, to investigate relationships between frailty and outcomes. RESULTS: Of 732,932 patients, 369,298 were frail. Frail patients were more likely than nonfrail patients to die during hospital stay (3.57% vs. 2.37%, respectively; adjusted odds ratio [aOR]: 1.67; 95% confidence interval [CI]: 1.61 to 1.72; p < 0.001); were less likely to be discharged to home (66.5% vs. 79.3%, respectively; aOR: 0.58; 95% CI: 0.57 to 0.58; p < 0.001); were hospitalized for more days (5.89 vs. 4.63 days, respectively; adjusted coefficient: 0.21 days; 95% CI: 0.21 to 0.22; p < 0.001); and incurred higher charges ($47,651 vs. $40,173, respectively; adjusted difference = $9,006; 95% CI: $8,596 to $9,416; p < 0.001). CONCLUSIONS: Frail patients with HF had significantly poorer outcomes than nonfrail patients after accounting for comorbidities. Clinicians should screen for frailty to identify high-risk patients who could benefit from targeted intervention. Policymakers should perform risk adjustments for frailty for more equitable quality measurement and financial incentive allocation.

Relationship of a Claims-Based Frailty Index to Annualized Medicare Costs: A Cohort Study.

Background: Medicare uses the Centers for Medicare & Medicaid Services Hierarchical Condition Category (CMS-HCC) model to predict patients' annualized Medicare costs in value-based payment programs. The CMS-HCC model does not include measures of frailty, and prior research shows that it systematically underpredicts costs for frail Medicare beneficiaries. Objective: To determine whether a claims-based frailty index can improve Medicare cost prediction. Design: Retrospective cohort study. Setting: Medicare Current Beneficiary Survey linked to Medicare claims, 2006 to 2013. Participants: 16 535 community-dwelling, fee-for-service beneficiaries representing 26 705 patient-years. Measurements: Patient frailty status was classified using a validated claims-based frailty index. The association between the frailty index and annualized Medicare costs was examined, and regression methods were used to compare observed Medicare costs versus predictions based on the standard CMS-HCC model with and without the frailty index. Results: Mean costs were $5724 for the 8910 patients classified as robust (46.4% of patient-years), $12 462 for the 8405 prefrail patients (41.6%), $26 239 for the 2215 mildly frail patients (9.6%), and $44 586 for the 593 patients classified as moderately to severely frail (2.5%). The frailty index addition to the CMS-HCC model predicted on average an additional $2712, $7915, and $16 449 in costs for prefrail, mildly frail, and moderately to severely frail patients, respectively, beyond the CMS-HCC model alone. On average, the model with the frailty index addition resulted in more accurate predictions of costs for patients at all 4 levels of frailty. However, observed costs remained more widely distributed than predictions from the enhanced model at all levels of frailty. Limitation: The claims-based index is a proxy for frailty and is likely less accurate than an in-person examination. Conclusion: The CMS-HCC model with the frailty index addition is an improvement over current Medicare cost prediction. Primary Funding Source: None.

Cost-Effectiveness Analysis of Frailty Assessment in Older Patients Undergoing Coronary Artery Bypass Grafting Surgery.

BACKGROUND: In perioperative settings, frailty assessment has been shown to reduce mortality. This study examined the cost effectiveness of frailty assessment among patients aged 65 with coronary artery disease under consideration for coronary artery bypass grafting surgery. METHODS: A combined decision tree and Markov model was developed to estimate costs and quality-adjusted life years (QALYs) over a 21-year time horizon. Clinical parameters were obtained from published literature. Utilities were derived from the literature and the Canadian Community Health Survey. Costs were obtained from the Ontario fee schedule and published literature. Sensitivity and scenario analyses were conducted to assess the robustness of the results. Expected value of perfect information (EVPI) analysis was conducted to estimate the value of further research. RESULTS: The frailty assessment initiative had a lower average cost than no frailty assessment ($19,567 compared with $20,062). QALYs with frailty assessment were 0.47 years more than with no frailty assessment. Thus, frailty assessment was dominant compared with no frailty assessment. Results were robust to changes in the input parameters. At a willingness to pay (WTP) threshold of $50,000/QALY, there was 100% probability of frailty assessment being cost-effective, and the EVPI per patient was $0. Scenario and sensitivity analysis showed frailty screening remained cost effective when changing the cohort average age, removing health benefits for nonfrail patients, and using subjective judgement to modify effectiveness parameters. CONCLUSIONS: Frailty assessment may be good value for money. However, limited availability of geriatric consultation services, may hinder implementation. Thus, the estimated benefits of frailty screening may not be achievable in practice.

In-Hospital Outcomes of Patients on Maintenance Dialysis With Frailty: 10-year Results From the US National Inpatient Sample Database.

OBJECTIVE: The in-hospital mortality rate of patients with end-stage renal disease (ESRD) is 6-8 times greater than that of the general population. A large fraction of patients with ESRD are frail, which further exacerbates this poor outcome. This study aimed to determine the impact of frailty on in-hospital outcomes of patients with ESRD. DESIGN AND METHODS: This population-based, retrospective study used data from the Nationwide Inpatient Sample (NIS), the largest all-payer US inpatient care database. Data of 1,424,026 hospitalized patients on maintenance dialysis between 2005 and 2014 were included. Patients were classified with respect to frailty status. Primary endpoints were all-cause in-hospital mortality, discharge disposition, length of hospital stay, and hospital costs. Patient characteristics included age, sex, race, income, insurance status, and Charlson's comorbidity index. Logistic regression and linear regression analyses were conducted to evaluate the associations between frailty and clinical outcomes. RESULTS: After adjustment for the confounders, hospitalized patients with frailty on maintenance dialysis were at double the risk of in-hospital mortality, 3 times the risk of discharge to long-term facilities, had hospital stays 5 days longer, and incurred $40,000 more in-hospital costs than those without frailty. The impact of frailty on all these in-hospital outcomes was greater among patients aged <65 years than among older adults. CONCLUSION: For hospitalized patients on maintenance dialysis, frailty independently predicts worse in-hospital outcomes, with stronger effects on younger patients. The development of adequate interventions for frailty in patients with ESRD and vigilance in treating this subgroup during hospitalization are highly warranted.

Life Course Socioeconomic Conditions and Frailty at Older Ages.

OBJECTIVES: This article aimed to assess associations of childhood socioeconomic conditions (CSC) with the risk of frailty in old age and whether adulthood socioeconomic conditions (ASC) influence this association. METHODS: Data from 21,185 individuals aged 50 years and older included in the longitudinal Survey of Health, Ageing, and Retirement in Europe were used. Frailty was operationalized as a sum of presenting weakness, shrinking, exhaustion, slowness, or low activity. Confounder-adjusted multilevel logistic regression models were used to analyze associations of CSC and ASC with frailty. RESULTS: While disadvantaged CSC was associated with higher odds of (pre-)frailty in women and men (odds ratio [OR] = 1.73, 95% confidence interval [CI] 1.34, 2.24; OR = 1.84, 95% CI 1.27, 2.66, respectively), this association was mediated by ASC. Personal factors and demographics, such as birth cohort, chronic conditions, and difficulties with activities of daily living, increased the odds of being (pre-)frail. DISCUSSION: Findings suggest that CSC are associated with frailty at old age. However, when taking into account ASC, this association no longer persists. The results show the importance of improving socioeconomic conditions over the whole life course in order to reduce health inequalities in old age.

Relation of Frailty to Cost for Patients Undergoing Transcatheter Aortic Valve Implantation.

Frailty is associated with significant morbidity and mortality for patients undergoing transcatheter aortic valve implantation (TAVI). In addition to clinical outcomes, cost is an important factor to inform clinical decision-making around TAVI. However, the association of frailty with cost is unknown. This study tested whether frailty was associated with cost for adult patients who underwent TAVI at a moderate-volume single center between December 2012 and April 2018 (n = 431). Frailty was determined from pre-TAVI clinical visits as a composite of 2 markers: 5-meter walk time (abnormal: >6 seconds or unable to perform) and serum albumin (abnormal: <3.5 g/dl). Patients were excluded if missing frailty assessment or covariate data (24). Cost data were derived from financial statements, and assigned at the department-level by charge code. Multivariable regression models were adjusted for age, gender, and procedural co-morbidities. Of 407 patients in the analytical sample (mean age 81 years, 49% female), 74 (18%) were determined to be frail. Adjusted mean total costs were $6,397 higher for frail patients ($78,823 vs $72,425, p = 0.042) compared with nonfrail. Higher total costs were driven by department-level charges associated with longer in-hospital length of stay (7.6 vs 3.3 days, p <0.001): room, physical therapy, pharmacy, laboratory, supply, and imaging services. Providers must address frailty proactively to salvage the benefit associated with TAVI.

Relation of Frailty to Outcomes in Percutaneous Coronary Intervention.

There is growing awareness that frailty may be an important marker of adverse outcomes in PCI but there is no literature from national cohorts. This study examines a national cohort of patients who underwent percutaneous coronary intervention (PCI) regarding the prevalence of frailty, changes over time, and associated outcomes. The National Inpatients Sample was used to identify adults who underwent PCI procedures between 2004 and 2014. Frailty risk was measured using a validated Hospital Frailty Risk Score (HFRS) using the cutoffs <5, 5-15 and >15 for low, intermediate and high HFRS. From 7,306,007 admissions, a total of 94.58% of admissions were for patients who had a low HFRS(<5), 5.39% had an intermediate HFRS(5-15) and 0.03% had a high HFRS(>15). The prevalence of intermediate or high frailty risk patients has increased over time from 1.9% in 2004 to 11.7% in 2014. The incidence of in-hospital death increased from 1.0% with low HFRS to 13.9% with high HFRS. Mean length of stay also increased from 2.9 days to 17.1 days from low to high HFRS. High frailty risk was independently associated with an OR 9.91 95%CI 7.17-13.71 for in-hospital death, OR 4.99 95%CI 3.82-6.51 for bleeding and OR 3.96 95%CI 3.00-5.23 for vascular injury as compared to patients with low risk of HFRS. While rare in frequency overall, frailty is increasing in prevalence in recent years and intermediate and high HFRS associated with increased odds of mortality compared to low risk of frailty.

Inadequate Risk Adjustment Impacts Geriatricians' Performance on Medicare Cost and Quality Measures.

OBJECTIVES: Medicare value-based payment programs evaluate physicians' performance on their patients' annual Medicare costs and clinical outcomes. However, little is known about how geriatricians, who disproportionately provide care for medically complex older adults, perform on these measures. DESIGN: A retrospective study using multivariable regression methods to estimate the association of geriatric risk factors with annualized Medicare costs and preventable hospitalization rates and to compare geriatricians' performance on these outcomes to other primary care physicians (PCPs) under standard Medicare risk adjustment and after adding additional adjustment for geriatric risk factors. SETTING: Eight years (2006-2013) of cohort data from the Medicare Current Beneficiary Survey. PARTICIPANTS: Medicare beneficiaries, aged 65 years and older, with primary care services contributing 27 027 person-years of data. MEASUREMENTS: Outcomes were costs and preventable hospitalization rates; geriatric risk factors were patient frailty, long-term institutionalization, dementia, and depression. RESULTS: Geriatricians were more likely to care for patients with frailty (22.8% vs 14.1%), long-term institutionalization (12.0% vs 4.7%), dementia (21.6% vs 10.2%), and depression (23.6% vs 17.4%) than other PCPs (P < .001 for each). Under standard Medicare risk adjustment, geriatricians performed more poorly on costs compared to other PCPs (observed-expected [O-E] ratio = 1.24 vs 0.99) and preventable hospitalizations (O-E ratio = 1.16 vs 0.98). Adding frailty, institutionalization, dementia, and depression to risk adjustment improved geriatricians' performance on costs by 25% and on preventable hospitalization rates by 35%, relative to other PCPs. Concurrent-year risk prediction that removed the influence of unpredictable acute events further improved geriatricians' performance vs other PCPs (O-E ratio = 0.99 vs 1.00). CONCLUSION: Medicare should consider risk adjusting for frailty, long-term institutionalization, dementia, and depression to avoid inappropriately penalizing geriatricians who care for vulnerable older adults. J Am Geriatr Soc 68:297-304, 2020.

The Hospital Frailty Risk Score and its association with in-hospital mortality, cost, length of stay and discharge location in patients with heart failure short running title: Frailty and outcomes in heart failure.

BACKGROUND: Little is known about frailty amongst patients hospitalized with heart failure (HF) on a national level. METHODS: We conducted a retrospective cohort study of patients admitted to hospital for HF in the United States. We examined how low, intermediate and high risk of frailty as defined by the Hospital Frailty Risk Score has changed over time and how it is related to inpatient mortality, length of stay, cost and discharge location. RESULTS: We included 11,626,400 inpatient episodes for HF. The proportions of patients that had low risk, intermediate and high risk of frailty were 80.0% (n = 9,300,873), 19.9% (n = 2,314,001) and 0.1% (n = 11,526). Intermediate or high risk of frailty increased from 9.9% in 2004 to 31.7% in 2014. Length of stay in hospital was greater in the high compared to low risk groups (11.3 days vs 4.6 days, respectively). The cost of admission was also greater in the high risk group ($23,084 ±â€¯39,681) compared to the low risk group ($9103 ±â€¯12,768). Intermediate and high risk of frailty groups were associated with increased in odds of mortality (OR 2.38 95% CI 2.22-2.34, p < 0.001 and OR 3.05 95%CI 2.57-3.62, p < 0.001, respectively) and discharge to nursing facilities (intermediate risk OR 1.52 95%CI 1.50-1.54, p < 0.001 and high risk OR 1.60 95%CI 1.35-1.90, p < 0.001). CONCLUSIONS: Frailty is significant and increasing in a national cohort of patients with HF in the United States. Patients at higher risk of frailty have increased in-hospital mortality, length of stay and inpatient costs, and a greater proportion are discharged to nursing home.

Patient frailty predicts worse perioperative outcomes and higher cost after radical cystectomy.

BACKGROUND: Relatively few studies investigated the importance of frailty in radical cystectomy (RC) patients. We tested the ability of frailty, using the Johns Hopkins Adjusted Clinical Groups indicator, to predict early perioperative outcomes after RC. METHODS: RC patients were identified within the National Inpatient Sample database (2000-2015). The effect of frailty, age and Charlson Comorbidity Index were tested in five separate multivariable models predicting: (1) complications, (2) failure to rescue (FTR), (3) in-hospital mortality, (4) length of stay (LOS) and (5) total hospital charges (THCs). All models were weighted and adjusted for clustering, as well as all available patient and hospital characteristics. RESULTS: Of 23,967 RC patients, 5833 (24.3%) were frail, 7721 (32.2%) were aged ≥75 years and 2832 (11.8%) had CCI ≥2. Frailty, age ≥75 years and CCI ≥2 were non-overlapping in 86.3% of the cohort. Any two or three of these features were recorded in 12.4 and 1.3%, respectively. Frailty was an independent predictor of all five examined endpoints and the magnitude of its association was stronger or at least equal than that of age ≥75 years and CCI ≥2. CONCLUSION: Frailty, advanced age and comorbidities represent non-overlapping patients' characteristics. Of those, frailty represents the most consistent and strongest predictor of early adverse outcomes after RC. Ideally, all three indicators should be considered in retrospective, as well as prospective analyses. Pre-surgical recognition of frail patients should be ideally incorporate in clinical practice in order to address these patients to multimodal pre-habilitation programs that may potentially improve the perioperative prognosis.

Prevalence, Outcomes, and Costs According to Patient Frailty Status for 2.9 Million Cardiac Electronic Device Implantations in the United States.

BACKGROUND: Little is known about the impact of frailty on length of stay (LOS), cost, and in-hospital procedural outcomes of cardiac implantable electronic device (CIED) implantation procedures. METHODS: All de novo CIED implantations recorded in the United States (2004-2014) from a national database were stratified according to the Hospital Frailty Risk Score into low-risk (LRF; <5), intermediate-risk (IRF; 5-15), and high-risk (HRF; > 15) frailty groups. Regression analyses were performed to assess the association between frailty and procedural outcomes. RESULTS: Of 2,902,721 implantations, LRF, IRF, and HRF were 77.6%, 21.2%, and 1.2%, respectively. Frailty increased from 2004 to 2014 (IRF: 14.3% to 32.5%, HRF: 0.2% to 3.3%). Complications were 2- to 3-fold higher in the IRF and HRF groups, whereas all-cause mortality was 4- to 9-fold higher in the IRF (2.9%) and HRF (5.3%) groups, depending on the type of CIED (P < 0.001 for all). Rates of complications increased over the study years and all-cause mortality declined, especially in the higher frailty risk groups (2004 vs 2014; mortality: IRF: 3.8% vs 2.2%, HRF: 9.9% vs 4.5%; bleeding: IRF: 3.7% vs 9.0%, HRF: 3.9% vs 12.2%; thoracic: IRF: 4.3% vs 6.0%, HRF: 2.9% vs 9.1%; cardiac: IRF: 0.5% vs 0.9%, HRF: 0.5% vs 0.9%). Rising frailty was associated with an increase in cost (P < 0.001) and LOS (median 3, 8, 11 days for LRF, IRF, HRF, respectively, P < 0.001). The cost for patients with HRF receiving a defibrillator was approximately a quarter million USD$ per patient. CONCLUSIONS: Frailty is associated with worse clinical outcomes, higher cost, and LOS independent of age or CIED type. Our findings emphasize the importance of frailty assessment.

Structuring a conceptual model for cost-effectiveness analysis of frailty interventions.

BACKGROUND: Frailty is a major health issue which impacts the life of older people, posing a significant challenge to the health system. One of the key emerging areas is the development of frailty interventions to halt or reverse the progression of the condition. In many countries, economic evidence is required to inform public funding decisions for such interventions, and cost-effectiveness models are needed to estimate long-term costs and effects. Such models should capture current clinical understanding of frailty, its progression and its health consequences. The objective of this paper is to present a conceptual model of frailty that can be used to inform the development of a cost-effectiveness model to evaluate frailty interventions. METHODS: After critical analysis of the clinical and economic literature, a Delphi study consisting of experts from the disciplines of clinical medicine and epidemiology was undertaken to inform the key components of the conceptual model. We also identified relevant databases that can be used to populate and validate the model. RESULTS: A list of significant health states/events for which frailty is a strong independent risk factor was identified (e.g., hip fracture, hospital admission, delirium, death). We also identified a list of important patient attributes that may influence disease progression (e.g., age, gender, previous hospital admissions, depression). A number of large-scale relevant databases were also identified to populate and validate the cost-effectiveness model. Face validity of model structure was confirmed by experts. DISCUSSION AND CONCLUSIONS: The proposed conceptual model is being used as a basis for developing a new cost-effectiveness model to estimate lifetime costs and outcomes associated with a range of frailty interventions. Using an appropriate model structure, which more accurately reflects the natural history of frailty, will improve model transparency and accuracy. This will ultimately lead to better informed public funding decisions around interventions to manage frailty.

Methodological weaknesses in the measurement approaches and concept of housing affordability used in housing research: A qualitative study.

Housing affordability (HA) is considered an important determinant of a country's socioeconomic development and stability. However, its optimal measurement has remained a major concern worldwide. In recent decades, methodological development and researches on housing affordability measurement approaches (HAMA) have accelerated and continue to grow exponentially. Despite this intensive global development, very few attempts have been made to present the theoretical bases and track the developmental trends of these approaches. Thus, this study attempts to fill this literature gap and extend prior studies by exploring several alternatives of HAMA; with a focus on their methodological weaknesses. This paper highlights three emerging novel methodologies, which complement the relative strength of the conventional approaches. Findings suggest that the main research evidence which summarizes the weaknesses in the conventional measures is; their inability to incorporate sustainability features and over reliance on economic dimension. While the complexity of emerging methodologies, though deepen the overall understanding of multiple concerns that breed HA problems. But are less transparent, more data intensive, and their computation is very demanding, with a high tendency that their complex nature could weaken their uptake by researchers. This study raises concern over the nearly sole reliance on the conventional approaches in the reformations of policy instrument, despite their overwhelming weaknesses. It reiterates the need for reconsideration and offers new insight, but not conclusive information on better ways to conceptualize and measure HA.