The Impact of Preoperative Frailty on the Clinical and Cost Outcomes of Adult Cardiac Surgery in Alberta, Canada: A Cohort Study.

BACKGROUND: There is limited information about the impact of frailty on public payer costs in cardiac surgery. This study aimed to determine quality-adjusted life-years (QALYs) and costs associated with preoperative frailty in patients referred for cardiac surgery. METHODS: We retrospectively compared costs of frailty in a cohort of 529 patients aged ≥ 50 years who were referred for nonemergent cardiac surgery in Alberta. Patients were screened preoperatively for frailty, defined as a score of 5 or greater on the Clinical Frailty Scale. The primary outcome measure was public payer costs attributable to frailty, calculated in a difference-in-difference (DID) model. RESULTS: The prevalence of frailty was 10% (n = 51; 95% confidence interval [CI], 7%-12%). Median (interquartile range) costs for frail patients were higher in the first year postsurgery ($200,709 [$146,177-$486,852] vs $147,730 [$100,674-$177,025]; P < 0.001) compared to nonfrail; the difference-in-difference attributable cost of frailty was $57,836 (95% CI, $-28,608-$144,280). At 1 year, frail patients had fewer QALYs realized compared to nonfrail patients (0.71 [0.57-0.77] vs 0.82 [0.75-0.86], P < 0.001), whereas QALYs gained were similar (0.02 [-0.02-0.05] vs 0.02 [0.00-0.04], P = 0.58, median difference 0.003 [95% CI, -0.01-0.02]) in frail and nonfrail patients. CONCLUSIONS: Frailty screening identified a population with greater impairment in quality-of-life and greater healthcare costs. Costs attributable to frailty represent opportunity costs that should be considered in future cardiac surgical services planning in the context of our aging population and the growing prevalence of frailty.

CONTEXTE: Il existe peu de renseignements concernant les répercussions de la fragilité sur les coûts pour les payeurs publics en chirurgie cardiaque. Cette étude visait à déterminer les années de vie pondérées par la qualité (QALY, pour Quality-Adjusted Life-Years) et les coûts associés à la fragilité préopératoire chez les patients dirigés vers un service de chirurgie cardiaque. MÉTHODOLOGIE: Nous avons comparé de façon rétrospective les coûts de la fragilité dans une cohorte de 529 patients âgés de 50 ans ou plus qui ont été dirigés vers un service de chirurgie cardiaque pour une intervention non urgente en Alberta. Un dépistage de la fragilité, définie comme un score de 5 ou plus à l'échelle CFS (Clinical Frailty Scale), a été effectué avant l'intervention. Le principal critère d'évaluation était le coût attribuable à la fragilité pour les payeurs publics, calculé selon un modèle d'écart des différences. RÉSULTATS: La prévalence de la fragilité a été de 10 % (n = 51; intervalle de confiance [IC] à 95 % : 7 à 12 %). Les coûts médians (écart interquartile) dans la première année suivant l'intervention chirurgicale ont été plus élevés chez les patients fragiles que chez les patients non fragiles (200 709 $ [146 177 $ à 486 852 $] contre 147 730 $ [100 674 $ à 177 025 $]; p < 0,001); le coût attribuable de la fragilité selon le modèle d'écart des différences a été de 57 836 $ (IC à 95 % : −28 608 $ à 144 280 $). À 1 an, les patients fragiles avaient moins de QALY réalisées que les patients non fragiles (0,71 [0,57 à 0,77] contre 0,82 [0,75 à 0,86]; p < 0,001), alors que le nombre de QALY gagnées était similaire (0,02 [−0,02 à 0,05] contre 0,02 [0,00 à 0,04]; p = 0,58; différence médiane : 0,003 [IC à 95 % : −0,01 à 0,02]) chez les patients fragiles et non fragiles. CONCLUSIONS: Le dépistage de la fragilité a permis de repérer une population associée à une perte plus importante de qualité de vie et à des coûts plus élevés en soins de santé. Les coûts attribuables à la fragilité représentent des coûts de renonciation qui doivent être considérés dans la planification future des services de chirurgie cardiaque, dans le contexte du vieillissement de notre population et de la prévalence croissante de fragilité.

Implementation of population-level screening for frailty among patients admitted to adult intensive care in Alberta, Canada.

PURPOSE: A substantial proportion of patients admitted to intensive care units (ICUs) are frail; however, the epidemiology of frailty has not been explored at a population-level. Following implementation of a validated frailty measure into a provincial ICU clinical information system, we describe the population-based prevalence and outcomes of frailty in patients admitted to ICUs. METHODS: Retrospective cohort study of adult admissions to 17 ICUs. Data were captured using eCritical Alberta. A Clinical Frailty Scale (CFS) score assigned at ICU admission was used to define the exposure (CFS score ≥ 5). Primary outcome was hospital mortality. Secondary outcomes were ICU and hospital stay, and receipt of organ support. RESULTS: Fifteen thousand two hundred and thirty-eight patients (81%) were assigned a CFS score at ICU admission. Of these, 28% (95% confidence interval [CI], 27 to 28) were frail. Prevalence of frailty was 9-43% across ICUs. Frail patients were older [mean (standard deviation) 63 (15) vs 56 (17) yr; P < 0.001], more likely to be male (54% vs 46% female; P < 0.001), and had higher APACHE II scores [22 (8) vs 17 (8); P < 0.001] compared with non-frail patients. Frail patients received less mechanical ventilation (62% vs 68%; P < 0.001) and vasoactive therapy (24% vs 57%; P < 0.001), but more non-invasive ventilation (22% vs 9%; P < 0.001). Frail patients had higher hospital mortality (23% vs 9%; adjusted odds ratio, 1.80; 95% CI, 1.64 to 2.05, along with longer ICU stay (median [interquartile range] 4 [2-8] vs 3 [2-6] days; P < 0.001), and longer hospital stay (16 [8-36] vs 10 [5-20] days; P < 0.001) compared with non-frail patients. CONCLUSION: A validated measure of frailty can be implemented at the population level in ICU. Frailty is common in ICU patients and has implications for health service use and clinical outcomes.

Innovative Urgent Care for the Palliative Patient at Home.

Palliative and end-of-life patients in their homes are at risk of developing symptom crises requiring urgent care. The usual care for these patients involves transport to an Emergency Department (ED) despite the preference of most palliative patients to stay home. The objective of this initiative was to develop an innovative strategy to provide collaborative care in the home to alleviate symptoms and avoid transport. A partnership was created among Emergency Medical Services and Community Care staff, physicians, and leaders to enable patients to stay at home with existing resources during symptom crisis. As a result of the initiative, patients were able to stay at home more frequently. When patients required transport to the ED, it occurred after attempted symptom management in the home. A total of 110 calls were tracked in the first 18 months of the initiative. Of those, 61% ended with the patient staying home, in alignment with their preferred place of care at the end of life. A collaborative approach by care providers in the community enabled patients to stay home despite symptom crisis near the end of life.