Author + information
- Received August 20, 2019
- Revision received December 10, 2019
- Accepted December 17, 2019
- Published online May 25, 2020.
- Sukruth A. Shashikumar, ABa,
- Alina A. Luke, MPHa,
- Kenton J. Johnston, PhDb and
- Karen E. Joynt Maddox, MD, MPHa,c,∗ ()
- aCardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
- bDepartment of Health Management and Policy, and Center for Outcomes Research, College of Public Health and Social Justice, Saint Louis University, St. Louis, Missouri
- cCenter for Health Economics and Policy, Institute for Public Health at Washington University, St. Louis, Missouri
- ↵∗Address for correspondence:
Dr. Karen E. Joynt Maddox, Washington University School of Medicine, 660 South Euclid Avenue, Saint Louis, Missouri 63110.
Objectives This study used a claims-based frailty index to investigate outcomes of frail patients with heart failure (HF).
Background Medicare value-based payment programs financially reward and penalize hospitals based on HF patients’ outcomes. Although programs adjust risks for comorbidities, they do not adjust for frailty. Hospitals caring for high proportions of frail patients may be unfairly penalized. Understanding frail HF patients’ outcomes may allow improved risk adjustment and more equitable assessment of health care systems.
Methods Adapting a claims-based frailty index, the study assigned a frailty score to each adult in the National in-patient Sample (NIS) from 2012 through September 2015 with a primary diagnosis of HF and dichotomized frailty by using a cutoff value established in the general NIS population. Multivariate regression models were estimated, controlling for comorbidities and hospital characteristics, to investigate relationships between frailty and outcomes.
Results Of 732,932 patients, 369,298 were frail. Frail patients were more likely than nonfrail patients to die during hospital stay (3.57% vs. 2.37%, respectively; adjusted odds ratio [aOR]: 1.67; 95% confidence interval [CI]: 1.61 to 1.72; p < 0.001); were less likely to be discharged to home (66.5% vs. 79.3%, respectively; aOR: 0.58; 95% CI: 0.57 to 0.58; p < 0.001); were hospitalized for more days (5.89 vs. 4.63 days, respectively; adjusted coefficient: 0.21 days; 95% CI: 0.21 to 0.22; p < 0.001); and incurred higher charges ($47,651 vs. $40,173, respectively; adjusted difference = $9,006; 95% CI: $8,596 to $9,416; p < 0.001).
Conclusions Frail patients with HF had significantly poorer outcomes than nonfrail patients after accounting for comorbidities. Clinicians should screen for frailty to identify high-risk patients who could benefit from targeted intervention. Policymakers should perform risk adjustments for frailty for more equitable quality measurement and financial incentive allocation.
Supported by U.S. National Institutes of Health T35 National Heart, Lung, and Blood Institute (NHLBI) training grant HL007815. Dr. Joynt Maddox has received research support from NHLBI grant R01HL143421, National Institute on Aging grant R01AG060935, and the Commonwealth Fund, and U.S. Department of Health and Human Services. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Heart Failure author instructions page.
- Received August 20, 2019.
- Revision received December 10, 2019.
- Accepted December 17, 2019.
- 2020 American College of Cardiology Foundation
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