Economics of Frailty. Eamon O Shea

Transcription

1 Economics of Frailty Eamon O Shea

2 Patient Complexity Framework Demography Mutimorbidity Mental health Frailty Social capital Resource utilisation

3 WHO and Frailty Progressive age-related decline in physiological systems that results in decreased reserves of intrinsic capacity, leading to extreme vulnerability to stressors and a higher risk of adverse health outcomes, including mortality

4 Frailty Not always easy to define Physical disability, impairment in ADL or IADL, increased vulnerability to adverse outcomes Synonymous with disability, comorbidity and advanced old age Multi-system graded impairment robust, pre-frail, frail (Rockwood, 2005) Objective measurement of frailty still debated

5 Measurement Frailty phenotype physical syndrome - highly specified deficits in small number of areas: unintentional weight loss, exhaustion, physical activity, walk time, grip strength Frailty index state of poor health accumulation of health deficits. Calculation of deficit index. Deficits accumulate the count is more important than specific conditions or physical limitations

6 Association Between Frailty and Adverse Outcomes Reported in four large cohort studies Cardiovascular Health Study death, falls, ADL disability, hospitalisation Canadian Study of Health and Ageing death odds ratio of 7.34 Women s Health and Ageing Study death, ADL disability, nursing home entry Study of Osteoporotic Fracture - increased risk of falls, disability, death

7 TILDA Data on Frailty in Ireland 24% of community-living Irish people aged 65 years and older are frail, 45% are pre-frail (DEFICIT INDEX) The prevalence of frailty in those aged 65 years and older varied from 17% to 29% CHO regions 57% of Public Health Nursing service users aged 65 years and older are frail. But less than one third of frail older people access the Public Health Nursing service Frail older peoples healthcare entitlement, living arrangements, disability and severity of frailty are all important determinants for accessing PHN services

8 Cost Centres In-patient treatment hospitals, rehab, day patient Out-patient physician visits by specialty Therapeutic care physiotherapy, OT etc. Pharmaceuticals type, usage, dosage Nursing home care Professional home care Informal home care

9 Frailty and Costs International literature suggests strong association between frailty and cost Frailty index strongly associated with inpatient costs and drug costs Some studies show strong relationship to residential care costs Frailty effect is independent of age and comorbidity Frailty matters for resource use and costs

10 Frailty and Resource Use in Ireland Data from TILDA suggests that frailty is significant predictor of utilisation across many types of services- community, GP and hospital services Frailty explains some of the heterogeneity in service use in Ireland Frailty significant contributor to resource allocation for older people in Ireland

11 Potential Interventions Comprehensive geriatric assessment Physical activity/regular exercise training some systematic review evidence of improved outcomes of mobility and functional ability Nutritional interventions- protein supplements, vitamin D supplements Pharmacological interventions less not more But, with so much complexity, therapeutic interventions need to be ordered, tailored, multifaceted and measured

12 Effect Measurement in Frailty Interventions EQ-5D instrument for measuring HRQoL Non-disease specific instrument Five three level questions Five dimensions: mobility, self care, usual activities, pain/discomfort, anxiety/depression 243 possible health states Each state can be valued using TTO or Standard Gamble to obtain numeric value a QALY on a scale 1 equates to full health; zero to death

13 Decision Rules for Economic Evaluation Cost Effectiveness Plane Intervention is dominated Given, Intervention is unacceptable C Given, Intervention is unacceptable Control Given, Intervention is acceptable Given, Intervention is acceptable Intervention is dominant E 13

14 Policy Issues Weak and fragmented community-based care Absence of personalised care provision to reflect heterogeneity of need Funding models biased towards residential care Absence of community-based right to care Supply constrained hospital-centric system Significant information and knowledge deficits Poor co-ordination and integration of care

15 Conclusion Frailty is good predictor of adverse outcomes Frailty is good predictor of additional resource use Need to model the relationship between frailty and service use in Ireland Need more cost-effective studies on interventions to address frailty issue in older age