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Intermediate stage and frail older community-dwelling women had higher subsequent total healthcare costs and utilization after accounting for multimorbidity and functional limitations. Frailty phenotype assessment may improve identification of older adults likely to require costly, extensive care.

OBJECTIVES To determine the association of the frailty phenotype with subsequent healthcare costs and utilization. DESIGN Prospective cohort study (Osteoporotic Fracture in Men [MrOS]). SETTING Six US sites. PARTICIPANTS A total of 1,514 community‐dwelling men (mean age = 79.3 years) participating in the MrOS Year 7 (Y7) examination linked with their Medicare claims data. MEASUREMENTS At Y7, the frailty phenotype was operationalized using five components and categorized as robust, pre‐frail, or frail. Multimorbidity and a frailty indicator (approximating the deficit accumulation index) were derived from claims data. Functional limitations were assessed by asking about difficulty performing instrumental activities of daily living. Total direct healthcare costs and utilization were ascertained during 36 months following Y7. RESULTS Mean of total annualized costs (2018 dollars) was $5,707 (standard deviation [SD] = 8,800) among robust, $8,964 (SD = 18,156) among pre‐frail, and $20,027 (SD = 27,419) among frail men. Compared with robust men, frail men (cost ratio [CR] = 2.35; 95% confidence interval [CI] = 1.88‐2.93) and pre‐frail men (CR = 1.28; 95% CI = 1.11‐1.48) incurred greater total costs after adjustment for demographics, multimorbidity, and cognitive function. Associations of phenotypic pre‐frailty and frailty with higher total costs were somewhat attenuated but persisted after further consideration of functional limitations and a claims‐based frailty indicator. Each individual frailty component was also associated with higher total costs. Frail vs robust men had higher odds of hospitalization (odds ratio [OR] = 2.62; 95% CI = 1.75‐3.91) and skilled nursing facility (SNF) stay (OR = 3.36; 95% CI = 1.83‐6.20). A smaller but significant effect of the pre‐frail category on SNF stay was present. CONCLUSION Phenotypic pre‐frailty and frailty were associated with higher subsequent total healthcare costs in older community‐dwelling men after accounting for a claims‐based frailty indicator, functional limitations, multimorbidity, cognitive impairment, and demographics. Assessment of the frailty phenotype or individual components such as slowness may improve identification of older community‐dwelling adults at risk for costly extensive care.

Background/Aims: Recent changes in clinical practice guidelines and reimbursement policies may have affected the use of anemia-related medications and red blood cell (RBC) transfusions in peritoneal dialysis (PD) and hemodialysis (HD) patients. We sought to compare patterns of erythropoiesis-stimulating agents (ESA) and intravenous (IV) iron use, achieved hemoglobin levels, and RBC transfusion use in PD and HD patients. Methods: In quarterly cohorts of prevalent dialysis patients receiving persistent therapy (>3 months), 2007-2011, with Medicare Parts A and B coverage, we assessed ESA and IV iron use and dose, RBC transfusions, and hemoglobin levels. Quarterly transfusion rates were calculated. Results: Observable PD and HD patients numbered 14,958 and 221,866 in Q1/2007 and 17,842 and 256,942 in Q4/2011. Adjusted ESA use was lower in PD (71.4-80.1%) than in HD (86.9-92.0%) patients, decreasing from 80.1% (Q1/2010) to 71.4% (Q4/2011) in PD patients, and from 92.0 to 86.9% in HD patients. The mean adjusted ESA dose decreased by 67.5% in PD and 58.4% in HD patients. IV iron use tended to increase, peaking at 39.3% for PD (Q3/2011) and 80.5% for HD (Q2/2011) patients. Adjusted mean hemoglobin levels fell from 11.7 to 10.6 mg/dl in PD and from 12.0 to 10.7 mg/dl in HD ESA users; adjusted transfusion rates increased from 2.4 to 3.0 per 100 patient-months in PD and from 2.6 to 3.3 in HD patients. Conclusions: In patients receiving persistent dialysis, dose and frequency of ESA administrations decreased during the period 2007-2011. Mean hemoglobin levels decreased by more than 1 g/dl, while transfusion rates increased by approximately 25%.

Among women late in life, 5-year mortality risk was substantially increased among women with deficits in mobility even after accounting for cognition and traditional prognostic indicators. Similarly, deficits in cognition were associated with increased 5-year mortality despite consideration of mobility and conventional risk factors.

Background Visceral adipose tissue (VAT) measured by computed tomography (CT) is related to insulin resistance, lipids, and serum inflammatory markers. Our objective was to compare the strength of the associations of visceral adipose tissue (VAT) measured with dual energy x-ray absorptiometry (DXA-VAT) and computed tomography (CT-VAT) with insulin resistance, serum lipids, and serum markers of inflammation. Methodology For 1,117 men age 65 and older enrolled in the Study of Osteoporotic Fractures in Men (MrOS), the cross-sectional associations of DXA-VAT and CT-VAT with Homeostasis Model Assessment of insulin resistance (homa2ir), C-reactive protein (CRP), and HDL cholesterol were estimated with regression models, and compared using a Hausmann test. Results Adjusted for age and body mass index (BMI), DXA-VAT was moderately associated with homa2ir (effect size 0.38, 95% C.I. 0.28 to 0.47) and modestly associated with HDL cholesterol (DXA effect size −0.29, 95% C.I. −0.38 to −0.21). These associations were significantly greater than for CT-VAT with homa2ir (0.30, 95% C.I. 0.24 to 0.37; p-value for effect size difference 0.03) and CT-VAT with HDL cholesterol (-0.22, 95% C.I. −0.29 to −0.15; p-value for difference 0.005). Neither DXA-VAT nor CT-VAT were associated with CRP after adjustment for age and BMI (DXA-VAT effect size 0.14, 95% C.I. −0.04 to 0.32; CT-VAT effect size 0.08, 95% C.I. −0.08 to 0.25; p-value for difference 0.35). Conclusion DXA-VAT has similar or greater associations with insulin resistance, and HDL cholesterol as does CT-VAT in older men, confirming the concurrent validity of DXA-VAT. Investigations of how well DXA measurements of VAT predict incident cardiovascular disease events are warranted.

; for the Study of Osteoporotic Fractures (SOF) Research Group IMPORTANCE Advanced age is associated with lower use of drug treatment to prevent fractures, but concerns about comorbidities and prognosis increase the complexity of managing osteoporosis in this age group. OBJECTIVE To determine the association of disease definition, number of comorbidities, and prognosis with 5-year hip fracture probabilities among women who are 80 years and older. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study (4 US sites) included 1528 community-dwelling women identified as potential candidates for initiation of osteoporosis drug treatment. MAIN OUTCOMES AND MEASURES Women were contacted every 4 months to ascertain vital status and hip fracture. Five-year hip fracture probability was calculated accounting for competing mortality risk. Participants were classified into 2 distinct groups based on disease definition criteria proposed by the National Bone Health Alliance: with osteoporosis (n = 761) and without osteoporosis but at high fracture risk (n = 767). Comorbid conditions were assessed by self-report. Prognosis was estimated using a mortality prediction index. All analysis was performed between March 2018 and January 2019. RESULTS The study had 1528 participants, all of whom were women, with a mean (SD) age of 84.1 (3.4) years. During follow-up, 125 (8.0%) women experienced a hip fracture and 287 (18.8%) died before experiencing this event. Five-year mortality probability was 24.9% (95% CI, 21.8-28.1) among women with osteoporosis and 19.4% (95% CI, 16.6-22.3) among women without osteoporosis but at high fracture risk. In both groups, mortality probability similarly increased with more comorbidities and poorer prognosis. In contrast, 5-year hip fracture probability was 13.0% (95% CI, 10.7-15.5) among women with osteoporosis and 4.0% (95% CI, 2.8-5.6) among women without osteoporosis but at high fracture risk. The difference was most pronounced among women with more comorbidities or worse prognosis. For example, among women with 3 or more comorbid conditions, hip fracture probability was 18.1% (95% CI, 12.3-24.9) among women with osteoporosis vs 2.5% (95% CI, 1.3-4.2) among women without osteoporosis but at high fracture risk. CONCLUSIONS AND RELEVANCE Women 80 years and older who have osteoporosis, including those with more comorbidities or poorer prognosis, have a high 5-year probability of hip fracture despite accounting for competing mortality risk. In contrast, among women without osteoporosis but at high fracture risk, competing mortality risk far outweighs hip fracture probability, especially among those with more comorbidities or worse prognosis.