Frailty screening in CABG patients cuts costs, but there’s a catch

Frailty assessments are a good value for their money in older patients considering coronary artery bypass grafting (CABG), according to a study published in the Canadian Journal of Cardiology, but a limited geriatric consultation workforce could curb that benefit in real-life practice.

Corresponding author Ava John-Baptiste, PhD, of the Western Centre for Public Health and Family Medicine in London, Ontario, and colleagues found that screening for frailty in coronary artery disease patients aged 65 and up was not only useful for improving patients’ quality of life and increasing their odds of survival—it was also cost-efficient. Their findings contradict the popular notion that frailty assessments, while effective, might be more money than they’re worth.

CABG has been challenged in recent years by the rapid rise of percutaneous coronary intervention (PCI), but John-Baptiste and co-authors said it remains the most commonly performed cardiac surgery today. More than 6,000 CABG operations are performed in Ontario each year, and frailty—which itself is a risk factor for adverse events, procedural complications, prolonged recovery and functional decline—can be a major factor in up to 60% of older-adult cases.

“Although frailty assessment provides additional information not captured by traditional surgical risk assessment, few studies have examined the effectiveness of a frailty screening initiative for guiding surgical decision-making and improving outcomes,” the authors wrote. “To date, no study has examined the cost-effectiveness of frailty assessment in elderly patients undergoing CABG.”

So John-Baptiste and her team did just that, developing a combined decision tree and Markov model to estimate costs and quality-adjusted life years (QALYs) over a 21-year time horizon. They drew from medical literature, the Canadian Community Health Survey and the Ontario fee schedule for information about costs, utilities and clinical parameters in potential CABG patients in their mid-sixties.

The authors calculated an average cost of $19,567 for patients who went ahead with the frailty assessment prior to CABG—nearly $500 less than the $20,062 bill incurred by patients who didn’t undergo a frailty check. Furthermore, QALYs with frailty assessment were 0.47 years more than with no frailty assessment.

“Our model suggests frailty assessment is associated with cost savings, mainly resulting from shifting a proportion of frail patients scheduled for CABG to PCI,” John-Baptiste and colleagues wrote. “The model results were robust to a range of sensitivity and scenario analyses, due to the relatively inexpensive cost of frailty screening and the assumption that frailty screening, followed by confirmatory comprehensive geriatric assessment, is associated with no harms.”

The researchers reported a 100% probability of frailty assessment being cost-effective at a willingness to pay threshold (WTP) of $50,000/QALY. At the same WTP threshold, expected value of perfect information (EVPI) was $0.

John-Baptiste et al. said their results are positive, but they should be taken with a grain of salt. Just because frailty screenings are cost-effective doesn’t necessarily mean we have the resources to implement them on a wider scale.

“Frailty assessment may be good value for money,” the authors said. “However, limited availability of geriatric consultation services may hinder implementation. Thus, the estimated benefits of frailty screening may not be achievable in practice.”