Gender difference in the association of frailty and health care utilization among Chinese older adults: results from a population-based study

Health care utilization and costs for frail vs nonfrail patients with diffuse large B-cell lymphoma

ABSTRACT

Half of older patients with diffuse large B-cell lymphoma (DLBCL) receiving curative-intent treatment are frail. Understanding the differences in health care utilization including costs between frail and nonfrail patients can inform appropriate models of care. A retrospective cohort study was conducted using population-based data in Ontario, Canada. Patients aged ≥66 years with DLBCL who received frontline curative-intent chemoimmunotherapy between 2006 and 2017 were included. Frailty was defined using a cumulative deficit-based frailty index. Health care utilization and costs were grouped into 5 phases: (1) 90 days preceding first treatment; (2) early treatment (0 to +90 days after starting treatment); (3) late treatment (+91 to +180 days); (4) follow-up (+181 to -181 days before death); and (5) end of life (last 180 days before death). Costs were standardized to 30-day intervals (2019 Canadian dollars). A total of 5527 patients were included (median age, 75 years; 48% female). A total of 2699 patients (49%) were classified as frail. The median costs for frail vs nonfrail patients per 30 days based on phase of care were (1) $5683 vs $2586 ; (2) $13 090 vs $11 256; (3) $5734 vs $4883; (4) $1138 vs $686; and (5) $11 413 vs $9089; statistically significant in all phases. In multivariable modeling, frail patients had higher rates of emergency department visits and hospitalizations and increased costs than nonfrail patients through all phases except end-of-life phase. During end-of-life phase, a substantial portion of patients (n = 2569 [84%]) required admission to hospital; 684 (27%) required intensive care unit admission. Future work could assess whether certain hospitalizations are preventable, particularly for patients identified as frail.

Joint trajectories of physical frailty and social frailty and associations with adverse outcomes: A prospective cohort study

BACKGROUND

We examined joint trajectories of physical frailty and social frailty as well as their associations with adverse outcomes.

METHODS

We conducted a prospective cohort study by using five waves of national data from China Health and Retirement Longitudinal Study (CHARLS 2011-2020), involving 4531 participants aged ≥60 years. We identified 4-year trajectories at three examinations from 2011 to 2015 using parallel process latent class growth analysis. Adverse outcomes were obtained from 2015 to 2020 across two subsequent waves. We calculated hazard ratios (HR) using Cox proportional hazard models. We also conducted analyses by gender.

RESULTS

Three joint trajectories were identified, including persistent absence of physical and social frailty (58.5 %), no physical frailty but social frailty (28.1 %), and persistent combination of physical and social frailty (13.4 %). Compared with persistent absence of physical and social frailty, no physical frailty but social frailty and persistent combination of physical and social frailty were associated with higher risk of instrumental activities of daily living (IADL) disability (HR = 1.182-2.020, 95 % CI: 1.014-2.416) and all-cause mortality (HR = 1.440-2.486, 95 % CI: 1.211-3.009). The persistent combination of physical and social frailty was also associated with ADL disability (HR = 2.412, 95 % CI: 1.999-2.911) and falls (HR = 1.410, 95 % CI: 1.196-1.662). Gender differences were observed in relationships between joint trajectories and adverse outcomes.

CONCLUSION

Community-dwelling older adults exhibit distinct joint trajectories and those with persistent combination of physical and social frailty experience greatest risk of incident adverse outcomes. Clinical and public health measures targeting physical or social frailty should account for both and be gender-specific.

Frailty and its Associated Factors Among Rural Community-Dwelling Older Adults: A Cross-Sectional Study

To investigate the status quo and influencing factors of overall frailty and its 3 domains among rural community-dwelling older adults. This is a cross-sectional study. A convenience sample of 195 older adults from 6 villages in Bashang Area of Zhangjiakou City, Hebei Province, China, were recruited from August to September, 2022. The demographic characteristics, the Chinese version of Tilburg Frailty Indicator, Charlson Comorbidity Scale and Hospital Anxiety and Depression Scale were used to investigate frailty and its influencing factors. Univariate analysis and multiple linear regression analysis were employed. The prevalence of overall frailty among the older adults in Bashang Area was 85.13%. Multiple linear regression analysis showed that age, gender, marital status, regular exercise, comorbidity, and anxiety were the influencing factors of overall frailty. While anxiety was the only shared influencing factor for physical frailty, psychological frailty, and social frailty, age, gender, marital status, financial burden, the comorbidity, and regular exercise were factors which influenced 1 or 2 domains of frailty. The prevalence of overall frailty among the older adults in rural areas, Zhangjiakou City is high. It is influenced by many factors. Medical staff and policy makers should work hand in hand to improve frailty among rural community-dwelling older adults in China.

Who consumes curative care expenditure of medical institutions in Beijing: a case study based on System of Health Accounts 2011

BACKGROUND

China's health system is challenged by complex health problems experienced by different population groups and caused by multiple diseases. This study examined the distribution of curative care expenditure (CCE) of medical institutions in Beijing using beneficiary characteristics such as residency, gender, age, and disease. Suggestions are presented for the development of health policies.

METHODS

A total of 81 medical institutions with approximately 80 million patients in Beijing, China, were selected via a multistage stratified cluster random sampling approach. Based on this sample, the System of Health Accounts 2011 was used to estimate the CCE of medical institutions.

RESULTS

The CCE of medical institutions in Beijing was ¥246.93 billion in 2019. The consumption of patients from other provinces was ¥60.04 billion, accounting for 24.13% of the total CCE. The CCE of female consumption (52.01%/¥128.42 billion) exceeded that of male consumption (47.99%/¥118.51 billion). Almost half of the CCE (45.62%/¥112.64 billion) was consumed by patients aged 60 or above. Adolescent patients up to an age of 14 (including those aged 14) mainly chose secondary or tertiary hospitals for treatment. Chronic non-communicable diseases accounted for the largest share of CCE consumption, with circulatory diseases accounting for the highest proportion.

CONCLUSIONS

This study identified significant differences in CCE consumption in Beijing according to region, gender, age, and disease. Currently, the utilization of resources in medical institutions is not reasonable, and the hierarchical medical system is not sufficiently effective. Therefore, the government needs to optimize the allocation of resources according to the needs of different groups and rationalize the institutional process and functions.

Technology-based interventions for health challenges older women face amid COVID-19: a systematic review protocol

BACKGROUND

Pandemics, such as COVID-19, are dangerous and socially disruptive. Though no one is immune to COVID-19, older persons often bear the brunt of its consequences. This is particularly true for older women, as they often face more pronounced health challenges relative to other segments in society, including complex care needs, insufficient care provisions, mental illness, neglect, and increased domestic abuse. To further compound the situation, because protective measures like lockdowns can result in unintended consequences, many health services older women depend on can become disrupted or discontinued amid pandemics. While technology-based interventions have the potential to provide near-time, location-free, and virtually accessible care, there is a dearth of systematic insights into this mode of care in the literature. To bridge the research gaps, this investigation aims to examine the characteristics and effectiveness of technology-based interventions that could address health challenges older women face amid COVID-19.

METHODS

A systematic review of randomized trials reporting on technology-based interventions for older women (≥65 years) during COVID-19 will be conducted. The databases of Web of Science, ScienceDirect, PubMed/MEDLINE, PsycINFO, CINAHL, and Scopus will be searched. Retrieved citations will be screened independently by at least two reviewers against the eligibility criteria. Included studies will be assessed using the Cochrane ROB-2 tool. Data will be extracted independently by the reviewers. Where possible, meta-analyses will be performed on relevant study outcomes and analysed via odds ratios on the dichotomized outcomes. Where applicable, heterogeneity will be measured using the Cochrane Q test, and publication bias will be assessed via funnel plots and Egger's regression test.

DISCUSSION

Technology has the potential to transform healthcare for the better. To help society better safeguard vulnerable populations' health and quality of life, this investigation sets out to gauge the state-of-the-art development of technology-based interventions tailored to the health challenges older women face amid COVID-19. In light of the growing prevalence of population ageing and the inevitability of infectious disease outbreaks, greater research efforts are needed to ensure the timely inception and effective implementation of technology-based health solutions for vulnerable populations like older women, amid public health crises like COVID-19 and beyond.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020194003.

Frailty Index and Cardiovascular Disease among Middle-Aged and Older Chinese Adults: A Nationally Representative Cross-Sectional and Follow-Up Study

Evidence for the association between the frailty index and cardiovascular disease (CVD) is inconclusive, and this association has not been evaluated in Chinese adults. We aim to examine the association between the frailty index and CVD among middle-aged and older Chinese adults. We conducted cross-sectional and cohort analyses using nationally representative data from the China Health and Retirement Longitudinal Study (CHARLS). From 2011 to 2018, 17,708 participants aged 45 years and older were included in the CHARLS. The primary outcome was CVD events (composite of heart disease and stroke). Multivariable adjusted logistic regression and Cox proportional hazards models were used to estimate the association between the frailty index and CVD in cross-sectional and follow-up studies, respectively. A restricted cubic spline model was used to characterize dose−response relationships. A total of 16,293 and 13,580 participants aged 45 years and older were included in the cross-sectional and cohort analyses, respectively. In the cross-sectional study, the prevalence of CVD in robust, pre-frailty and frailty was 7.83%, 18.70% and 32.39%, respectively. After multivariable adjustment, pre-frailty and frailty were associated with CVD; ORs were 2.54 (95% confidence interval [CI], 2.28−2.84) and 4.76 (95% CI, 4.10−5.52), respectively. During the 7 years of follow-up, 2122 participants without previous CVD developed incident CVD; pre-frailty and frailty were associated with increased risk of CVD events; HRs were 1.53 (95% CI, 1.39−1.68) and 2.17 (95% CI, 1.88−2.50), respectively. Furthermore, a stronger association of the frailty index with CVD was observed in participants aged <55, men, rural community-dwellers, BMI ≥ 25, without hypertension, diabetes or dyslipidemia. A clear nonlinear dose−response pattern between the frailty index and CVD was widely observed (p < 0.001 for nonlinearity), the frailty index was above 0.08, and the hazard ratio per standard deviation was 1.18 (95% CI 1.13−1.25). We observed the association between the frailty index and CVD among middle-aged and elderly adults in China, independent of chronological age and other CVD risk factors. Our findings are important for prevention strategies aimed at reducing the growing burden of CVD in older adults.

Self-neglect among older adults admitted to a Chinese comprehensive hospital in the COVID-19 pandemic era: a cross-sectional study

This study aims to explore the prevalence of self-neglect and associated factors among older adults admitted to the hospital in the COVID-19 pandemic context. The cross-sectional study conducted at a Chinese comprehensive hospital between January and April 2021, 452 older adults were recruited to complete the Abrams Geriatric Self-Neglect Scale, Social Support Rate Scale, FRAIL scale, Barthel index, Patient Health Questionnaire-9, and 10-item Connor-Davidson Resilience Scale. Multivariate logistic regression was used to explore the factors associated with elder self-neglect. The results showed that the prevalence of self-neglect among our sample was 30.3%. Factors that were associated with the risk of elder self-neglect included male, having multiple children (≥4), receiving infrequent visits from children, frailty, and depression. There is a need to screen for self-neglect among older adults admitted to the hospital in the COVID-19 pandemic context. Tailored interventions are warranted to improve the quality of life of older adults.

The Role of Traditional Obesity Parameters in Predicting Frailty among Coronary Artery Disease Patients Undergoing Cardiac Catheterization

BACKGROUND

Obesity has been reported to be associated with frailty and coronary artery disease (CAD).

OBJECTIVE

The present study aimed to investigate the role of the seven traditional obesity parameters body mass index (BMI), waist-height ratio (WHtR), waist-hip ratio (WHR), body adiposity index (BAI), body shape index (BSI), waist circumference (WC), and hip circumference (HC) in the prediction of frailty among CAD patients undergoing cardiac catheterization.

DESIGN

A secondary data analysis was conducted. Setting. Three main hospitals were located at the northern and middle regions of Jordan. Participants. 220 hospitalized patients undergoing cardiac catheterization were recruited. Measurements. The traditional obesity parameters were measured using an anthropometric tape and weight scale and frailty was measured using the Tilburg Frailty Indicator (TFI). Data were analyzed using bivariate Pearson's correlation and forward linear regression analysis.

RESULTS

Total cholesterol, HC, triglycerides, age, random blood sugar, and WC had significant positive associations with and were predictors of frailty (p < 0.05). The model of the seven predictors explained 32.4% of the variance in frailty (p = 0.02).

CONCLUSION

The incidence of frailty can be predicted by the increase in total cholesterol, HC, triglycerides, age, random blood sugar, and WC. The results of this study may help healthcare providers, including nurses, to identify the factors that could lead to frailty among CAD patients undergoing cardiac catheterization.

Catastrophic Health Expenditure Associated With Frailty in Community-Dwelling Chinese Older Adults: A Prospective Cohort Analysis

Background: Catastrophic health expenditure (CHE) represents a key indicator for excessive financial burden due to out-of-pocket (OOP) healthcare costs, which could push the household into poverty and is highly pronounced in households with members at an advanced age. Previous studies have been devoted to understanding the determinants for CHE, yet little evidence exists on its association with frailty, an important geriatric syndrome attracting growing recognition. We thus aim to examine the relationship between frailty and CHE and to explore whether this effect is moderated by socioeconomic-related factors. Methods: A total of 3,277 older adults were drawn from two waves (2011 and 2013) of the China Health and Retirement Longitudinal Study (CHARLS). CHE was defined when OOP healthcare expenditure exceeded a specific proportion of the capacity of the household to pay. Frailty was measured following the Fried Phenotype (FP) scale. Mixed-effects logistic regression models were employed to assess the longitudinal relationship between frailty and CHE, and stratification analyses were conducted to explore the moderation effect. Results: The incidence of CHE among Chinese community-dwelling older adults was 21.76% in 2011 and increased to 26.46% in 2013. Compared with non-frail individuals, prefrail or frail adults were associated with higher odds for CHE after controlling for age, gender, residence, education, marriage, income, health insurance, smoking, drinking, and comorbidity (prefrail: odds ratio (OR) = 1.32, 95%CI = 1.14-1.52; frail: OR = 1.67, 95%CI = 1.13-2.47). Three frailty components including weakness, exhaustion, and shrinking contributed to a significantly increased likelihood of CHE (all p < 0.05), while the other two components including slowness and inactivity showed a non-significant effect (all p > 0.05). Similar effects from frailty on CHE were observed across socioeconomic-related subgroups differentiated by gender, residence, education, household income, and social health insurance. Conclusions: Frailty is a significant predictor for CHE in China. Developing and implementing cost-effective strategies for the prevention and management of frailty is imperative to protect households from financial catastrophe.

Frailty Status Among the Elderly of Different Genders and the Death Risk: A Follow-Up Study

Background: Frailty in the elderly population is currently a frontier and focus in the field of health and aging. The goal of this study was to explore the frailty status among the elderly of different genders and its influence on the risk of death during 11 years.

Methods: Frailty index (FI) was used to evaluate the frailty status in the elderly based on the baseline data conducted in 2009; and death as outcome variables collected in 2020 were analyzed. The difference of the frailty level and mortality of different genders was compared. Cox regression and Kaplan–Meier curves were applied to evaluate the influence on the risk of death and the 11-year survival of the elderly at different level of frailty, respectively.

Results: Totally, 1,246 elderly people were recruited. The mortality in men (43.7%, 227/519) was statistically higher than that in women (34.3%, 249/727) (x² = 11.546, P = 0.001). Deficits accumulated exponentially with age, and at all ages, women accumulated more deficits than do men on average (B = 0.030 vs. 0.028, t = 4.137, P = 0.023). For any given level of frailty, the mortality rate is higher in men than in women, and the difference in mortality between genders reached the peak when FI value was 0.26. Cox regression analysis showed that FI value had a greater impact on the risk of death in older men (HR = 1.171, 95%CI: 1.139~1.249)than that in older women (HR = 1.119, 95%CI: 1.039~1.137). Survival analysis showed that the median 11-year survival time in women was longer than that in men (95.26 vs. 89.52 months, Log rank = 9.249, P = 0.002). Kaplan–Meier curves showed that the survival rate decreased with the increase of frailty, and at the same level of frailty, survival time in older women was longer than that in older men, except for severe frailty (FI ≥ 0.5).

Conclusion: The frailty status and its influence on mortality are different among the older people of different genders; therefore, specific interventions for frailty should be conducted in the elderly population of different genders, as well as of different degrees of frailty.

Gender differences in the impact of frailty on 90-day hospital readmission in heart failure patients: a retrospective cohort study

AIMS

Frequent hospital readmissions after heart failure (HF) are common, however, there is limited data on the association between frailty status and hospital readmission in HF patients. This study aimed to examine the 90-day hospital readmission rates and gender differences in the impact of frailty on 90-day hospital readmission in HF patients.

METHODS AND RESULTS

We retrospectively analysed hospital discharge records of 279 patients (men = 169, women = 110) who were diagnosed with HF between January 2017 and December 2018. Frailty was assessed using the Korean version of the FRAIL scale. A logistic regression analysis was conducted to explore the factors predicting 90-day hospital readmission by gender. The prevalence of frailty and 90-day hospital readmissions were ∼54.4% and 22.7% in women, compared with 45.6% and 27.8% in men, respectively. Frail patients with HF have an increased risk of 90-day hospital readmission in both males and females. Particularly, women with frailty had a higher risk of 90-day hospital readmission [adjusted odds ratio (OR) 6.72, 95% confidence interval (CI) 1.41-32.09] than men with frailty (adjusted OR 4.40, 95% CI 1.73-11.17).

CONCLUSION

Our findings highlight that readmission within 90 days of hospitalization for HF can be predicted by patients' frailty. More importantly, we found that women with frailty have a greater risk of readmission than men with frailty. Screening for frailty should therefore be integrated into the assessment of HF patients. Tailored interventions for preventing adverse outcomes should consider gender-associated factors in HF patients with frailty.

Frailty Predicts Increased Health Care Utilization Among Community-Dwelling Older Adults: A Longitudinal Study in China

OBJECTIVES

Frailty, a multidimensional syndrome characterized by vulnerability to stressors, is an emerging public health priority with high prevalence in older adults. Frailty has been identified to predictive negative health outcomes, yet quantified evidence regarding its effect on health care systems is scarce. This study examines how frailty affects health care utilization, and explores whether these associations varied by gender.

DESIGN

Cohort study with a 2-year follow-up.

SETTING

and Participants: Data were derived from 2 waves (2011 and 2013) of the China Health and Retirement Longitudinal Study, and 3119 community-dwelling participants aged ≥60 years were analyzed.

METHODS

Frailty was assessed by a validated frailty phenotype scale, and measures for health care utilization were self-reported. Panel data approach of mixed-effects regression models was used to examine the associations.

RESULTS

Longitudinal results demonstrated that compared with robustness, prefrailty and frailty were both significantly associated with increased likelihood of outpatient visit, inpatient visit, and inpatient length of stay, even after adjusting for multimorbidity in multivariate analyses (all P < .05). Every 1-component increase in frailty was also found to significantly increase the risk for health care utilization [any outpatient visit: adjusted odds ratio (OR) 1.30, 95% confidence interval (CI) 1.14-1.48; number of outpatient visits: adjusted incident rate ratio (IRR) 1.34, 95% CI 1.18-1.53; any inpatient visit: adjusted OR 1.44, 95% CI 1.22-1.71; number of inpatient visits: adjusted IRR 1.40, 95% CI 1.20-1.62; inpatient length of stay: adjusted IRR 1.50, 95% CI 1.18-1.92]. The preceding associations were similarly observed irrespective of gender.

CONCLUSIONS AND IMPLICATIONS

Frailty is a significant predictor for increased health care utilization among community-dwelling older adults. These findings have important implications for routine clinical practice and public health investment. Early screening and intervention for potentially modifiable frailty could translate into considerable savings for households and health care systems.

Association of Frailty Status with Risk of Fall among Middle-Aged and Older Adults in China: A Nationally Representative Cohort Study

OBJECTIVES

To investigate the association between frailty status and risk of fall among middle-aged and older Chinese people.

DESIGN

A nationally representative prospective cohort study.

SETTING AND PARTICIPANTS

The study included 13,877 community-dwelling participants aged 45 years and above from the China Health and Retirement Longitudinal Study.

METHODS

Frailty status was identified by the frailty index of health deficit accumulation. 34 variables at baseline were selected to calculate the frailty index. We excluded participants with incomplete information in construction of the frailty index at baseline. Falls were measured based on the respondents' self-report. We used a logistic regression model to estimate the associations between the frailty status and risk of fall, and subgroup analyses and sensitivity analyses were further conducted.

RESULTS

Of 13,877 participants, 2310 (16.6%) had falls during the observation period. 9027 (65.0%) participants were classified as robust, 4019 (29.0%) participants were classified as pre-frail, and 831 (6.0%) participants were classified as frail. Our results indicated per 0.01 increment in the frailty index was significantly associated with an increased risk of fall among middle-aged and older participants (OR: 1.52, 95%CI: 1.45-1.60). Such association was stronger when frailty was presented as a categorical variable, with an OR of 1.75 (95%CI: 1.59-1.93) for pre-frail and 3.04 (95%CI: 2.60-3.56) for frail. The area under the curve of the logistic model was 0.612 (95%CI: 0.600-0.625). Each 0.01 increment of the frailty index was association with a higher risk of fall among middle-aged (45-59years) participants (OR: 1.44, 95%CI: 1.29-1.60) than among older (≥60 years) participants (OR: 1.28, 95%CI: 1.16-1.41) at baseline (p=0.015 for interaction).

CONCLUSION

Frailty was significantly associated with an increased risk of fall among community-dwelling middle-aged and older people in China. It is necessary to screen and recognize frailty status to prevent falls among middle-aged and older adults.