Usefulness of frailty profile for targeting older heart failure patients in disease management programs: a cost-effectiveness, pilot study

Background Disease management programs (DMP) improve outcomes in patients with heart failure. Because older heart failure patients represent a heterogeneous population, the aim of this study was to determine which patients benefit mostly from a DMP, by means of their frailty profile. Setting Heart failure outpatient clinic. Methods Consecutive (n = 173) patients aged more than 70 years were randomized to a multidisciplinary DMP (n = 86) or usual care (n = 87). A modified frailty score (range 1-6) was used as an index of global functional impairment. Results Mild to moderate frailty (frailty score = 2-3) was associated with significant improvements in outcomes (death and/or heart failure admission, heart failure admissions and all-cause admissions) in DMP patients vs. usual care. Even in more frail patients (frailty score = 4-6) a significant reduction in heart failure admissions was observed. By contrast, nonfrail patients (frailty score = 1) did not derive significant benefit. In the cost-effectiveness analysis, the mean savings per patient, stratified according to their frailty score, were (sic) -1003.31 for frailty score 1 (95% confidence interval -3717.00-1709.00), (sic) 1104.72 for frailty score 2 (-280.6-2491.00), (sic) 2635.42 for frailty score 3 (352.60-4917.00, P = 0.025) and (sic) 419.53 for frailty score 4-6 (-1909.00-2749.00). Intervention was therefore significantly cost saving in moderately frail, but not in nonfrail or severely frail patients. Thus, DMP was dominant (i.e. both less costly and more effective than usual care) in moderately frail patients. At sensitivity analysis, DMP remained dominant even to changes in cost of intervention and hospitalizations. Conclusion This suggests that an intensive, hospital-based DMP appears to be more effective in older patients with mild-to-moderate levels of frailty. Thus, a multidimensional assessment of frailty seems to be a useful tool for appropriate selection of model of care. J Cardiovasc Med 11: 739-747 (C) 2010 Italian Federation of Cardiology.