Does frailty predict hospitalization, emergency department visits, and visits to the general practitioner in older newly-diagnosed cancer patients? Results of a prospective pilot study

Abstract

Research on the use of health care by older newly-diagnosed cancer patients is sparse. We investigated whether frailty predicts hospitalization, emergency department (ED) and general practitioner (GP) visits in older cancer patients in a prospective pilot study. Newly-diagnosed cancer patients aged 65 years and over were recruited in the Segal Cancer Centre, Jewish General Hospital, Montreal, Canada. One hundred ten patients participated, mean age 74.1, 70% women. During 1 year follow-up, 52 patients (47.3%) had cancer-related hospitalizations, 23 patients (20.9%) had ED visit and 17 patients (15.5%) had GP visit. No frailty marker predicted hospitalization or visits to the GP. Cognitive impairment suspicion was the only frailty marker that predicted ED visits (odds ratio 4.97; 95%CI 1.14–21.69). Although health care use was considerable in this sample, most frailty markers were not associated with health care use in this pilot study.

Introduction

Cancer is a significant health problem in older persons [1], [2]. Nevertheless, the manifestations and course of cancer in the older population have not been well investigated and remain poorly understood [3], [4], [5], [6], [7], [8]. The USA National Cancer Center Network (NCCN) and the International Society of Geriatric Oncology (SIOG) have both recommended some form of geriatric assessment despite that the optimal form has yet to be established but they expect benefits in terms of independence and quality of life [9], [10]. However, a geriatric assessment is time consuming and the benefits have not yet been demonstrated in this patient population. A more sensitive way to characterize health and functional status it to use the concept of frailty. It represents a state of reduced homeostasis and resistance to stress that leads, in turn, to increased vulnerability and risk of adverse outcomes. Fried et al. [11] have developed a now commonly used approach to measure frailty which includes weakness, poor endurance, reduced physical activity, slow walking speed, and unintentional weight loss during the preceding year. More recently, it has been suggested to include mood disturbance and cognitive impairment suspicion as characteristics of frailty [12], [13], [14], [15].

Unlike their non-frail contemporaries, frail older individuals appear unable to withstand stressors, such as environmental stress, injury, and acute illness. These stressors may provoke a downward spiral, whereby the frail older individual is unable to recover and return to the baseline state [11], [16], [17]. In older patients, cancer treatments are considered strong stressors that will reveal which patients have sufficient functional reserve to regain stable homeostasis [5], [17].

Some of the adverse outcomes of cancer and its treatment are hospitalization or emergency department or general practitioner visits. However, no study has investigated if frailty predicts the use of health care services in older newly-diagnosed cancer patients.

Furthermore, research on the use of health care services by older cancer patients is sparse and most of the research conducted is focused on end of life care. Nevertheless, the prospective studies by Kurtz et al. [18], [19] examined the use of care in the US after the cancer diagnosis, following 909 participants for 1 year. These authors reported that those with poor physical functioning and more co morbidities had increased service utilization. As the patients were included 4–6 weeks after surgery or within 2–4 weeks of the start of radiation or chemotherapy treatments, the baseline physical functioning was perhaps already compromised by the treatments received. Stafford et al. reported higher services use (defined as Medicare reimbursements) in older cancer patients compared to older patients with other co morbidities in the US [20], but the timing of the cancer diagnosis in relation to the service use was not reported. Lastly, the study of Johansson et al. [21] in Sweden investigated the determinants of cancer patient's hospital utilization in the first 2 years after diagnosis. They reported that in addition to treatment and stage of cancer, co-morbidity, low physical functioning, pain and some economic variables predicted the number of days spent in hospital but again some of these participants had received treatment prior to the baseline interview.

On this background of little research, it remains important to examine the predictive ability of the concept of frailty particularly if this concept is to be useful in clinical practice. Early identification of patients that are high users of care might contribute to the development of interventions to improve patient management and reduce inpatient service use. As there was no prospective observational study on health, frailty and adverse outcomes of cancer and its treatment, the aims of our pilot study were (1) to assess the feasibility of recruitment, retention and the methods used in this study and (2) to describe the health and vulnerability of older cancer patients and to explore the association between frailty and use of health care (hospitalization, emergency department (ED) and general practitioner (GP) visits). This paper presents the results of the second aim. The results of the first aim will be presented in a separate paper.