Frailty Is Associated With Decreased Time Spent at Home After Critical Illness: A Population-Based Study

Abstract

Background: Frailty is characterized by vulnerability to stressors due to an accumulation of multiple functional deficits. Frailty is increasingly recognized as a risk factor for accelerated functional decline, increasing dependency, and risk of mortality. The objective of this study was to examine the association of frailty, at the time of critical care admission, with days alive at home and health care costs post-discharge. Methods: This retrospective cohort study used linked administrative data (2010-2016) in Ontario, Canada. We identified all patients admitted at the intensive care unit (ICU), aged 19 years and above, assessed using the Resident Assessment Instrument for Home Care (RAI-HC), within 6 months prior to index hospitalization including an ICU stay. Patients were stratified as robust, pre-frail, or frail based on a validated Frailty Index. The primary outcome was days alive at home in the year after admission. Secondary outcomes included mortality, health care–associated costs, ICU interventions, long-term care admissions, and hospital readmissions. Results: Frail patients spent significantly fewer days at home within 1 year of index hospitalization (mean 159 days vs 223 days in robust cohort, P < .001). Mortality was higher among frail patients at 1 year (59.6% in the frail cohort vs 45.9% in robust patients; odds ratio for death 1.59 [1.49-1.69]). Frail patients also had higher rates of long-term care admission within 1 year (30.1% vs 10.6% in robust patients). Total health care–associated costs per person alive were $30 450 higher the year after admission in the frail cohort. Conclusions: Frailty prior to ICU admission among patients who were eligible for RAI-HC assessment was associated with higher mortality and fewer days spent at home following admission. Frail patients had markedly higher rates of long-term care admission and increased costs per life saved following critical illness. These findings add to the discussion of risk–benefit trade-offs for ICU admission.

Baseline Frailty as a Predictor of Survival After Critical Care

“…(HCRS), Discharge Abstract Database (DAD), National Ambulatory Care Reporting System, and the Continuing Care Reporting System (CCRS) (e-Appendix 1). As in earlier studies of acute hospital care and older adults receiving home care services, 21,22 including of home care client outcomes after ICU admission, 23 these datasets were linked using unique identifiers.…”

“…18,19 Frailty Index scores of > 0.2 indicate varying degrees of ascending risk. 23,32 For ease of reporting frequencies and class-level hazard ratio statistics, we categorized individuals into levels using increments of 0.1. Finally, the Changes in Health, End-Stage Disease, Signs, and Symptoms Scale (CHESS), although it was not developed explicitly as a frailty measure, 33 performs well in predicting institutionalization, hospitalization, and mortality in home care populations.…”

Optimizing care for critically ill older adults

“…36 A 2017 meta-analysis of 10 prospective cohort studies of moderate quality (mean Newcastle-Ottawa Scale score 6.5) found that pre-hospital frailty was associated with increased hospital mortality (relative risk [RR] 1.71, 95% confidence interval [CI] 1.43-2.05) and long-term mortality (RR 1.53, 95% CI 1.40-1.68), independent of age or illness severity. 27 Several studies have reported an incremental increase in mortality for each additional point on the Clinical Frailty Scale (CFS), 27,33,37,38 particularly in those with severe or very severe frailty (CFS ≥ 7). 31,38 Understanding the impact of frailty on ICU prognosis shifts the concern from a patient's age toward their overall clinical status and trajectory before ICU admission.…”

“…27 Several studies have reported an incremental increase in mortality for each additional point on the Clinical Frailty Scale (CFS), 27,33,37,38 particularly in those with severe or very severe frailty (CFS ≥ 7). 31,38 Understanding the impact of frailty on ICU prognosis shifts the concern from a patient's age toward their overall clinical status and trajectory before ICU admission.…”

Optimisation des soins chez les personnes âgées gravement malades

“…Une méta-analyse de 2017 regroupant 10 études de cohorte prospectives de qualité modérée (score de Newcastle-Ottawa moyen 6,5) a révélé que la fragilité préhospitalière était associée à une hausse de la mortalité hospitalière (risque relatif [RR] 1,71, intervalle de confiance [IC] à 95 % 1,43–2,05) et de la mortalité à long terme (RR 1,53, IC à 95 % 1,40–1,68), indépendamment de l’âge ou de la gravité de la maladie 27 . Plusieurs études ont signalé une augmentation de la mortalité à chaque point additionnel à l’échelle de fragilité clinique (EFC) 27 , 33 , 37 , 38 , particulièrement chez les individus présentant une grande ou une très grande fragilité (EFC ≥ 7) 31 , 38 . Comprendre l’incidence de la fragilité sur le pronostic à l’USI fait que l’on s’intéresse moins à l’âge du patient et plus à son état clinique global et à sa trajectoire avant son admission à l’USI.…”