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Canadian Journal of Cardiology

Cost-Effectiveness Analysis of Frailty Assessment in Older Patients Undergoing Coronary Artery Bypass Grafting Surgery

Published:October 12, 2019DOI:https://doi.org/10.1016/j.cjca.2019.09.025

      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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