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.

Review of risk assessment tools to predict morbidity and mortality in elderly surgical patients.

BACKGROUND: Informed surgical consent requires accurate estimation of risks and benefits. Multiple risk assessment tools are available; however, most are not widely used or are specific to certain interventions. Assessing surgical risk is especially challenging in elderly patients because of their range of comorbidities, level of frailty, or severity of illness and a number of available surgical interventions. DATA SOURCES: We searched MEDLINE from January 2014 to July 2017 for studies that used risk assessment tools in studies on elderly surgical patients. We then sought the original articles describing each assessment tool and subsequent validation studies. CONCLUSIONS: We identified risk assessment tools that can improve surgical risk assessment in elderly surgical patients. The majority of the identified tools are not commonly used for pre-operative risk assessment. NSQIP-PMP, mFI and SURPAS are promising tools. Age is commonly used to predict risk, but frailty may be a more appropriate measure.

A prospective multicenter cohort study of frailty in younger critically ill patients.

BACKGROUND: Frailty is a multidimensional syndrome characterized by loss of physiologic and cognitive reserve that heightens vulnerability. Frailty has been well described among elderly patients (i.e., 65 years of age or older), but few studies have evaluated frailty in nonelderly patients with critical illness. We aimed to describe the prevalence, correlates, and outcomes associated with frailty among younger critically ill patients. METHODS: We conducted a prospective cohort study of 197 consecutive critically ill patients aged 50-64.9 years admitted to intensive care units (ICUs) at six hospitals across Alberta, Canada. Frailty was defined as a score ≥5 on the Clinical Frailty Scale before hospitalization. Multivariable analyses were used to evaluate factors independently associated with frailty before ICU admission and the independent association between frailty and outcome. RESULTS: In the 197 patients in the study, mean (SD) age was 58.5 (4.1) years, 37 % were female, 73 % had three or more comorbid illnesses, and 28 % (n = 55; 95 % CI 22-35) were frail. Factors independently associated with frailty included not being completely independent (adjusted OR [aOR] 4.4, 95 % CI 1.8-11.1), connective tissue disease (aOR 6.0, 95 % CI 2.1-17.0), and hospitalization within the preceding year (aOR 3.3, 95 % CI 1.3-8.1). There were no significant differences between frail and nonfrail patients in reason for admission, Acute Physiology and Chronic Health Evaluation II score, preference for life support, or treatment intensity. Younger frail patients did not have significantly longer (median [interquartile range]) hospital stay (26 [9-68] days vs. 19 [10-43] days; p = 0.4), but they had greater 1-year rehospitalization rates (61 % vs. 40 %; p = 0.02) and higher 1-year mortality (33 % vs. 20 %; adjusted HR 1.8, 95 % CI 1.0-3.3; p = 0.039). CONCLUSIONS: Prehospital frailty is common among younger critically ill patients, and in this study it was associated with higher rates of mortality at 1 year and with rehospitalization. Our data suggest that frailty should be considered in younger adults admitted to the ICU, not just in the elderly. Additional research is needed to further characterize frailty in younger critically ill patients, along with the ideal instruments for identification.

Frailty is associated with postoperative complications in older adults with medical problems.

We sought to test whether frailty may be predictive of operative risk in older adults with medical problems. One hundred and twenty-five patients at least 70 years of age had a previously developed frailty screen, the Edmonton Frail Scale (EFS), administered at a pre-surgical clinic, prior to elective non-cardiac surgery. A blinded chart audit assessed for postoperative medical complications, length of stay and inability to be discharged home. The mean age of patients was 77 (range 70-92) and most (82%) underwent orthopedic procedures. Increasing frailty was associated with postoperative complications (p=0.02), increased length of hospitalization (p=0.004) and inability to be discharged home (p=0.01), independent of age. EFS scores of 3 or less were associated with a lower risk of having a complication (age-adjusted OR 0.27, 95% CI 0.09-0.80, likelihood ratio of 0.33) and a higher chance (80%) of being discharged home (p<0.02). EFS scores exceeding 7 were associated with increased complications (OR 5.02, 95% CI 1.55-16.25, likelihood ratio of 3.9) and a lower chance of being discharged home (40%, p<0.02). This study suggests that a frailty screen can refine risk estimates of postoperative complications in older adults undergoing elective non-cardiac surgery.