The Marginal Cost of Frailty Among Medicare Patients on Hemodialysis

Abstract

Introduction: Dialysis patients incur disproportionately high costs compared with other Medicare beneficiaries. Care for frail individuals may be even more costly. We examined the extent to which frailty contributes to higher costs among dialysis patients. Methods: We used ACTIVE/ADIPOSE (A Cohort to Investigate the Value of Exercise/Analyses Designed to Investigate the Paradox of Obesity and Survival in ESRD) enrollees (adult hemodialysis patients evaluated from June 2009 to August 2011) in a retrospective cohort analysis. Individuals using Medicare as the primary payer were included. Fried's frailty phenotype was evaluated at baseline, 12, and 24 months. Costs were derived from linkage with the US Renal Data System (USRDS) and Medicare claims data. We used generalized estimating equations (GEEs) incorporating time-updated frailty and costs to evaluate adjusted point estimates and the marginal cost associated with being frail. We also investigated if frail patients who died during the study incurred higher costs than those who survived. Results: Among 771 enrollees in ACTIVE/ADIPOSE, 425 met inclusion criteria. Mean age was 56 AE 13 years, body mass index (BMI) 29.2 AE 7.1 kg/m 2 , 42.4% were women, and 29.0% were frail at baseline. Over a mean follow-up of 2.3 years, frail individuals incurred 22% (95% confidence interval [CI] 9.6%-35.8%) higher costs compared with nonfrail individuals ($87,600 per patient per year [pppy], 95% CI 76,800-100,000, vs. $71,800 pppy, 95% CI 64,800-79,600), the difference was driven primarily by higher inpatient expenditures. The difference between frail and nonfrail patients' inpatient expenditures was even more pronounced among those who died during the study compared with those who survived. Conclusions: Frail dialysis patients incur a significantly higher cost relative to their nonfrail counterparts, primarily driven by higher inpatient costs. Frail patients near end of life incur even higher costs.

Association between Multidimensional Prognostic Index and Hospitalization and Mortality among Older Adults with Chronic Kidney Disease on Conservative or on Replacement Therapy

“…Our study focused on MPI and outcomes also in patients on replacement therapy, considering the clinical relevance of predicting hospitalizations and survival in HD and PD patients. In this light, recent data showed that HD patients with frailty incurred higher healthcare costs with respect to those without frailty over a mean follow-up of 2.3 years [8]. In addition, we have previously shown that HD patients may present neurological and psychological dysfunctions that were associated with impaired quality of life [19].…”

“…Studies support the idea that multidimensional assessment represents an important aspect in predicting shortand long-term all-cause mortality in older CKD patients [5][6][7]. This is crucial also in considering the high prevalence of frailty in this population negatively impacting on several outcomes [8].…”

Comparing the Fried frailty phenotype versus the Veterans Affairs frailty index among dialysis dependent patients

“…13 Fried frailty phenotype was defined as the presence of 3 or more of the following five criteria: weight loss, exhaustion, low physical activity, slow gait speed, and weakness. 4,11 Weight loss was defined as having more than 10 pounds unintentional weight loss over the preceding 12 months. 5 Exhaustion was defined as having a positive response to two questions regarding endurance and energy from the Center for Epidemiological Studies Depression questionnaire.…”

“…5,[8][9][10] In a broader perspective, the cost of medical treatment for ESKD patients is already inordinate compared to other diseases and frailty only perpetuates this disproportionality within the dialysis population. 11 The underutilization of frailty as a modifiable disease state to improve mortality in dialysis patients stems mainly from the lack of a universal operational definition. Operational definitions of frailty are divided into three constructs: physical construct of frailty or frail phenotype, subjective construct of frailty or the frailty score, and a deficit construct of frailty better known as the frailty index.…”

Polypharmacy and Frailty among Hemodialysis Patients

“…The patients were followed for 3 years with frailty and laboratory measurements assessed at baseline, 12, and 24 months. The procedure for obtaining demographic and comorbid conditions and a description of lab processing have been described in a previous study [17,18].…”