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Original Investigation
September 25, 2019

Association of Frailty With 30-Day Outcomes for Acute Myocardial Infarction, Heart Failure, and Pneumonia Among Elderly Adults

Author Affiliations
  • 1Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine; Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 2Division of Cardiology, Department of Medicine; Brigham and Women’s Hospital, Boston, Massachusetts
JAMA Cardiol. Published online September 25, 2019. doi:https://doi.org/10.1001/jamacardio.2019.3511
Key Points

Question  Does the addition of frailty to traditional comorbidity-based risk-adjustment models improve the prediction of 30-day mortality and readmission for these conditions?

Findings  In this cohort study of 785 127 participants, frailty as determined by an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision claims-based frailty score was associated with a higher risk of 30-day outcomes for acute myocardial infarction, heart failure, and pneumonia hospitalizations. When added to traditional comorbidities typically used in risk-adjustment models for these conditions, this claims-based frailty score significantly improved prediction of 30-day outcomes.

Meaning  Unless frailty is adequately captured in risk-adjustment metrics, it is possible that hospitals that care for a higher proportion of frail patients are disproportionately financially penalized for worse outcomes owing to unrecognized comorbidities among the patients they care for, rather than quality of care delivered.


Importance  The addition of a claims-based frailty metric to traditional comorbidity-based risk-adjustment models for acute myocardial infarction (AMI), heart failure (HF), and pneumonia improves the prediction of 30-day mortality and readmission. This may have important implications for hospitals that tend to care for frail populations and participate in Centers for Medicare & Medicaid Services value-based payment programs, which use these risk-adjusted metrics to determine reimbursement.

Objective  To determine whether the addition of frailty measures to traditional comorbidity-based risk-adjustment models improved prediction of outcomes for patients with AMI, HF, and pneumonia.

Design, Setting, and Participants  A nationwide cohort study included Medicare fee-for-service beneficiaries 65 years and older in the United States between January 1 and December 1, 2016. Analysis began August 2018.

Main Outcomes and Measures  Rates of mortality within 30 days of admission and 30 days of discharge, as well as 30-day readmission rates by frailty group. We evaluated the incremental effect of adding the Hospital Frailty Risk Score (HFRS) to current comorbidity-based risk-adjustment models for 30-day outcomes across all conditions.

Results  For 785 127 participants, there were 166 200 hospitalizations [21.2%] for AMI, 348 619 [44.4%] for HF, and 270 308 [34.4%] for pneumonia. The mean (SD) age at the time of hospitalization was 79.2 (8.9) years; 656 315 (83.6%) were white and 402 639 (51.3%) were women. The mean (SD) HFRS was 7.3 (7.4) for patients with AMI, 10.8 (8.3) for patients with HF, and 8.2 (5.7) for patients with pneumonia. Among patients hospitalized for AMI, an HFRS more than 15 (compared with an HFRS <5) was associated with a higher risk of 30-day postadmission mortality (adjusted odds ratio [aOR], 3.6; 95% CI, 3.4-3.8), 30-day postdischarge mortality (aOR, 4.0; 95% CI, 3.7-4.3), and 30-day readmission (aOR, 3.0; 95% CI, 2.9-3.1) after multivariable adjustment for age, sex, race, and comorbidities. Similar patterns were observed for patients hospitalized with HF (30-day postadmission mortality: aOR, 3.5; 95% CI, 3.4-3.7; 30-day postdischarge mortality: aOR, 3.5; 95% CI, 3.3-3.6; and 30-day readmission: aOR, 2.9; 95% CI, 2.8-3.0) and among patients with pneumonia (30-day postadmission mortality: aOR, 2.5; 95% CI, 2.3-2.6; 30-day postdischarge mortality: aOR, 3.0; 95% CI, 2.9-3.2; and 30-day readmission: aOR, 2.8; 95% CI, 2.7-2.9). The addition of HFRS to traditional comorbidity-based risk-prediction models improved discrimination to predict outcomes for all 3 conditions.

Conclusions and Relevance  Among Medicare fee-for-service beneficiaries, frailty as measured by the HFRS was associated with mortality and readmissions among patients hospitalized for AMI, HF, or pneumonia. The addition of HFRS to traditional comorbidity-based risk-prediction models improved the prediction of outcomes for all 3 conditions.