Abstract
Background
In perioperative settings, frailty assessment has been shown to reduce mortality.
This study examined the cost effectiveness of frailty assessment among patients aged
65 with coronary artery disease under consideration for coronary artery bypass grafting
surgery.
Methods
A combined decision tree and Markov model was developed to estimate costs and quality-adjusted
life years (QALYs) over a 21-year time horizon. Clinical parameters were obtained
from published literature. Utilities were derived from the literature and the Canadian
Community Health Survey. Costs were obtained from the Ontario fee schedule and published
literature. Sensitivity and scenario analyses were conducted to assess the robustness
of the results. Expected value of perfect information (EVPI) analysis was conducted
to estimate the value of further research.
Results
The frailty assessment initiative had a lower average cost than no frailty assessment
($19,567 compared with $20,062). QALYs with frailty assessment were 0.47 years more
than with no frailty assessment. Thus, frailty assessment was dominant compared with
no frailty assessment. Results were robust to changes in the input parameters. At
a willingness to pay (WTP) threshold of $50,000/QALY, there was 100% probability of
frailty assessment being cost-effective, and the EVPI per patient was $0. Scenario
and sensitivity analysis showed frailty screening remained cost effective when changing
the cohort average age, removing health benefits for nonfrail patients, and using
subjective judgement to modify effectiveness parameters.
Conclusions
Frailty assessment may be good value for money. However, limited availability of geriatric
consultation services, may hinder implementation. Thus, the estimated benefits of
frailty screening may not be achievable in practice.
Résumé
Contexte
Il a été déterminé que l’évaluation de la fragilité permettait de réduire la mortalité
en contexte périopératoire. Les auteurs du présent article ont examiné le rapport
coût-efficacité de l’évaluation de la fragilité des patients âgés de 65 ans atteints
d’une coronaropathie chez qui un pontage aortocoronarien était envisagé.
Méthodologie
Les coûts et les années de vie ajustées en fonction de la qualité (AVAQ) ont été estimés
sur un horizon de 21 ans au moyen d’un arbre décisionnel et d’un modèle de Markov.
Les paramètres cliniques sont extraits d’études publiées, et les valeurs d’utilité
sont dérivées d’études publiées et de l’Enquête sur la santé dans les collectivités
canadiennes. Les coûts sont tirés du barème des frais et honoraires en vigueur en
Ontario et d’études publiées. Des analyses de sensibilité et de scénarios ont été
réalisées pour évaluer la robustesse des résultats. Enfin, une analyse de la valeur
espérée de l’information parfaite (VEIP) a été effectuée pour estimer la valeur de
recherches futures.
Résultats
Le coût moyen de l’exécution d’une évaluation de la fragilité était inférieur à celui
de la non-exécution d’une telle évaluation (19 567 $ comparativement à 20 062 $).
Les AVAQ associées à l’évaluation de la fragilité s’établissaient à 0,47 année de
plus que les AVAQ en l’absence d’évaluation. L’évaluation de la fragilité était donc
dominante par rapport à l’absence d’évaluation. Les résultats se sont révélés robustes
aux changements des paramètres d’entrée. À un seuil de volonté de payer de 50 000
$ par AVAQ, la probabilité que l’évaluation de la fragilité soit rentable était de
100 % et la VEIP par patient s’établissait à 0 $. Les analyses de scénarios et de
sensibilité ont montré que l’évaluation de la fragilité demeure rentable même lorsqu’on
change l’âge moyen de la cohorte, qu’on ne tient pas compte des bienfaits pour la
santé des patients qui ne sont pas considérés comme étant fragiles et qu’on modifie
de manière subjective les paramètres relatifs à l’efficacité.
Conclusions
L’évaluation de la fragilité pourrait permettre d’optimiser les ressources. Toutefois,
l’offre restreinte de services de consultation en gériatrie pourrait faire obstacle
à la mise en œuvre d’une telle initiative. Les avantages estimés d’une évaluation
de la fragilité ne sont donc peut-être pas réalisables dans la pratique.
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Article Info
Publication History
Published online: October 12, 2019
Accepted:
September 19,
2019
Received:
May 15,
2018
Footnotes
See page 9 for disclosure information.
Identification
Copyright
© 2019 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
