Clinical Research
Cost of Cardiac Surgery in Frail Compared With Nonfrail Older Adults

https://doi.org/10.1016/j.cjca.2017.03.019Get rights and content

Abstract

Background

Frailty is a risk factor for mortality, morbidity, and prolonged length of stay after cardiac surgery, all of which are major drivers of hospitalization costs. The incremental hospitalization costs incurred in frail patients have yet to be elucidated.

Methods

Patients aged ≥ 60 years were evaluated for frailty before coronary artery bypass grafting or heart valve surgery at 2 academic centres between 2013 and 2015 as part of the McGill Frailty Registry. Total costs were summed from the date of the index surgery to the date of hospital discharge. Mutivariable linear regression was used to determine the association between preoperative frailty status and total costs after adjusting for conventional surgical risk factors.

Results

Among 235 patients included in the analysis, the median age was 73.0 years (interquartile range [IQR], 70.0-78.0 years) and 68 (29%) were women. The median cost was $32,742 (IQR, $23,221-$49,627) in 91 frail patients compared with $23,370 (IQR, $19,977-$29,705) in 144 nonfrail patients. Seven extreme-cost cases > $100,000 were identified, and all of the patients in these cases exhibited baseline frailty. In the multivariable model, total costs were independently associated with frailty (adjusted additional cost, $21,245; 95% confidence interval [CI], $12,418-$30,073; P < 0.001) and valve surgery (adjusted additional cost, $20,600; 95% CI, $9,661-$31,539; P < 0.001).

Conclusions

Frailty is associated with a marked increase in hospitalization costs after cardiac surgery, an effect that persists after adjusting for age, sex, surgery type, and surgical risk score. Further efforts are needed to optimize care and resource use in this vulnerable population.

Résumé

Contexte

La fragilité est un facteur de risque de mortalité, de morbidité et de séjour prolongé après une intervention chirurgicale cardiaque, lesquels contribuent de façon importante aux coûts d’hospitalisation. Les coûts croissants d’hospitalisation des patients fragiles n’ont pas encore été élucidés.

Méthodologie

Des patients de 60 ans ou plus ont subi des évaluations visant à déterminer leur degré de fragilité avant un pontage aortocoronarien ou une intervention chirurgicale valvulaire dans deux centres d’étude entre 2013 et 2015; les résultats ont été consignés dans le registre de fragilité McGill (McGill Frailty Registry). Les coûts totaux ont été calculés à partir de la date de l’intervention chirurgicale de référence jusqu’à la date de sortie de l’hôpital. Une régression linéaire à variables multiples a servi à déterminer l’association entre l’état de fragilité préopératoire et les coûts totaux après correction tenant compte des facteurs de risque chirurgicaux conventionnels.

Résultats

Parmi les 235 patients inclus dans l’analyse, l’âge médian était de 73,0 ans (intervalle interquartile [IIQ] : 70,0-78,0 ans) et 68 (29 %) femmes étaient présentes. Le coût médian était de 32 742 $ (IIQ : 23 221 $-49 627 $) chez 91 patients fragiles comparativement à 23 370 $ (IIQ : 19 977 $-29 705 $) chez 144 patients non fragiles. Sept cas de coûts extrêmes supérieurs à 100 000 $ ont été recensés, tous chez des patients qui présentaient une fragilité au départ. Dans le modèle à variables multiples, les coûts totaux étaient indépendamment associés à la fragilité (coût supplémentaire corrigé : 21 245 $; intervalle de confiance [IC] à 95 % : 12 418 $-30 073 $; p < 0,001) et à l’intervention chirurgicale valvulaire (coût supplémentaire corrigé : 20 600 $; IC à 95 % : 9 661 $-31 539 $; p < 0,001).

Conclusions

La fragilité est associée à une augmentation marquée des coûts d’hospitalisation après une intervention chirurgicale cardiaque; cet effet persiste après correction tenant compte de l’âge, du sexe, du type d’intervention chirurgicale et du score de risque chirurgical. Des efforts supplémentaires sont nécessaires pour optimiser les soins et l’utilisation des ressources au sein de cette population vulnérable.

Section snippets

Study design

We conducted a post hoc analysis of the McGill Frailty Registry, which prospectively enrolled older adults undergoing cardiac surgery at 2 tertiary care academic centres in Montreal, Canada. Patients aged ≥ 60 years were evaluated before elective and urgent CABG or heart valve surgery. Costing data were available from April 1, 2013-March 31, 2014 for the Jewish General Hospital (JGH) and from April 1, 2014-March 31, 2015 for the Royal Victoria Hospital (RVH) based on the date of implementation

Results

A total of 235 patients were included in the analysis. The median age was 73.0 years (IQR, 70.0-78.0 years), and 68 (29%) patients were women. We were able to extract costing data for all patients who underwent cardiac surgery during the calendar years studied. Baseline demographics, clinical characteristics, geriatric domains, and operative data are shown stratified by total cost < $20,000 (corresponding to the 20th percentile), $20,000-$39,000, and ≥ $40,000 (corresponding to the 80th

Discussion

To our knowledge, this is the first study to investigate the incremental cost associated with preoperative frailty in older adults undergoing cardiac surgery. We found that frail patients incurred, on average, an additional $21,245 in total hospitalization costs. This sizeable cost difference was related to a marked increase in major postoperative complications and hospital length of stay. Frailty remained a powerful predictor of hospitalization costs even after adjusting for potential

Conclusions

Frail older adults undergoing cardiac surgery incur substantially higher hospitalization costs than do their nonfrail counterparts. Our study has added to the emerging body of evidence linking frailty with increased costs in noncardiac surgery and inpatient medical care. Given the expansion of the frail older adult population and their growing need for cardiovascular care, these findings have considerable implications for our constrained health care system. Further research is needed to better

Acknowledgements

The authors would like to acknowledge Amanda Trnkus and Marie-Claude Ouimet for their role in managing the McGill Frailty Registry.

Funding Sources

J.A. is supported by a Clinical Research Scholar Award from the Fond de Recherche du Québec en Santé (FRQS) and the Canadian Institutes for Health Research (CIHR). M.G. is supported by the McGill University Strauss Clinical Fellowship.

Disclosures

The authors have no conflicts of interest to disclose.

References (39)

  • S.M. McNallan et al.

    Frailty and healthcare utilization among patients with heart failure in the community

    JACC Heart Fail

    (2013)
  • J. Nilsson et al.

    EuroSCORE predicts intensive care unit stay and costs of open heart surgery

    Ann Thorac Surg

    (2004)
  • G.J. Arnaoutakis et al.

    Society of Thoracic Surgeons risk score predicts hospital charges and resource use after aortic valve replacement

    J Thorac Cardiovasc Surg

    (2011)
  • M.R. Reynolds et al.

    Cost-effectiveness of transcatheter aortic valve replacement with a self-expanding prosthesis versus surgical aortic valve replacement

    J Am Coll Cardiol

    (2016)
  • D.T. Engelman et al.

    Impact of body mass index and albumin on morbidity and mortality after cardiac surgery

    J Thorac Cardiovasc Surg

    (1999)
  • L.M. van Venrooij et al.

    The impact of low preoperative fat-free body mass on infections and length of stay after cardiac surgery: a prospective cohort study

    J Thorac Cardiovasc Surg

    (2011)
  • L.M. van Venrooij et al.

    Preoperative unintended weight loss and low body mass index in relation to complications and length of stay after cardiac surgery

    Am J Clin Nutr

    (2008)
  • J.A. Barreto-Filho et al.

    Trends in aortic valve replacement for elderly patients in the United States, 1999-2011

    JAMA

    (2013)
  • A. Kilic et al.

    Understanding variability in hospital-specific costs of coronary artery bypass grafting represents an opportunity for standardizing care and improving resource use

    J Thorac Cardiovasc Surg

    (2014)
  • Cited by (64)

    • Preoperative frailty based on laboratory data and postoperative health outcomes in patients undergoing coronary artery bypass graft surgery

      2022, Heart and Lung
      Citation Excerpt :

      Collectively, these imply that preoperative frailty is associated with postoperative maladaptation and the increased need for care. A previous study showed that the cost of cardiac surgery is higher in frail patients than in non-frail patients, with the nursing cost being the most increased.28 This means that frailty significantly increases the level of postoperative care.

    View all citing articles on Scopus

    See editorial by Yanagawa et al., pages 959–960 of this issue.

    See page 1025 for disclosure information.

    View full text