Prevalence, outcomes and costs according to patient frailty status for 2.9 million cardiac electronic device implantations in the United States

Abstract

Background: Little is known about the impact of frailty on length of stay (LOS), cost and inhospital procedural outcomes of cardiac implantable electronic device (CIED) implantation procedures.

Methods: All de novo CIED implantations recorded in the United States (2004-2014) from a national database were stratified according to the Hospital Frailty Risk Score into low-risk (LRF;<5), intermediate-risk (IRF;5-15) and high-risk (HRF;>15) frailty groups. Regression analyses were performed to assess the association between frailty and procedural outcomes.

Results: Out of 2,902,721 implantations, LRF, IRF and HRF were 77.6%, 21.2% and 1.2%, respectively. Frailty increased from 2004 to 2014 (IRF: 14.3% to 32.5%, HRF: 0.2% to 3.3%). Complications were 2-3 fold higher in the IRF and HRF groups, while all-cause mortality was 4 to 9-fold higher in IRF (2.9%) and HRF (5.3%) groups, depending on the type of CIED (p<0.001for all). Rates of complications increased over the study years and all-cause mortality declined, especially in the higher frailty risk groups (2004 vs. 2014;Mortality: IRF:3.8 vs. 2.2%, HRF:9.9 vs. 4.5%;Bleeding: IRF:3.7 vs. 9.0%, HRF:3.9 vs. 12.2%;Thoracic: IRF:4.3 vs. 6.0%, HRF:2.9 vs. 9.1%;Cardiac: IRF:0.5 vs. 0.9%, HRF:0.5 vs. 0.9%). Rising frailty was associated with increase in cost (p<0.001) and LOS (median 3, 8, 11 days for LRF, IRF, HRF respectively, p<0.001). The cost for HRF patients receiving a defibrillator was approximately quarter million US dollars per patient.

Conclusion: Frailty is associated with worse clinical outcomes, higher cost and LOS independent of age or CIED type. Our findings emphasize the importance of frailty assessment.