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Frail heart failure patients use a considerable amount of healthcare resources, but frailty is modifiable and should be part of clinical evaluations, researchers suggested.

There were 20,264 outpatient visits, 1,440 emergency department (ED) visits, and 1,057 hospitalizations among 448 patients with heart failure after a 2-year mean follow-up, according to Véronique L. Roger, MD, of the Mayo Clinic in Rochester, Minn., and colleagues.

In the fully adjusted model, frailty was significantly associated with a 92% increased risk for ED visits (HR 1.92, 95% CI 1.30 to 2.83, P=0.001) and a 65% increased risk for hospitalizations (HR 1.65, 95% CI, 1.17 to 2.34, P=0.004), they wrote in the study published in the latest edition of JACC: Heart Failure.

There was no significant association between frailty and outpatient visits. Nor was there a significant difference regarding ejection fraction and healthcare utilization.

Roger and colleagues noted that frailty was highly prevalent among community patients with heart failure. The population-attributable risk associated with frailty was 35% for ED visits and 19% for hospitalization.

"This suggests that interventions aimed at reducing frailty could help decrease or control the already overwhelmingly high healthcare utilization and costs associated with heart failure," they concluded.

Heart failure already carries a considerable risk of morbidity and mortality, the researchers noted. In addition, heart failure patients over 65 top the list for hospitalizations.

Frailty certainly has an impact on patients with heart failure, but studies examining the association between frailty and healthcare utilization are lacking, Roger and colleagues pointed out.

"Thus, the relationship between frailty and all-cause hospitalizations, ED visits, and outpatient visits among community patients with heart failure is unknown, and demonstrating a robust association between frailty and outcomes could lead to changes in the clinical evaluation of patients with heart failure," they wrote.

The researchers wanted to determine the healthcare resources associated with frailty and heart failure, but they also went one step further by evaluating resource utilization in both the inpatient and outpatient settings.

For the study, they tapped into the Rochester Epidemiology Project, which links medical records from providers at Mayo Clinic, Olmsted Medical Center, and a few private providers in Rochester, Minn. They included 448 patients with heart failure from three counties: Olmsted, Dodge, and Fillmore. Enrollment spanned October 2007 to March 2011.

Patients completed questionnaires and a handgrip test, and had an echocardiography exam performed if needed.

A majority of patients were men (57%) and 67% had Charlson comorbidity indexes of 3 or greater. The incidence and prevalence of heart failure were 39% and 61%, respectively.

The condition of "frailty" was designated to heart failure patients who met three or more of the following criteria: unintentional weight loss, exhaustion, weak grip strength, slowness, and low physical activity.

Overall, 74% of the 448 patients had some type of frailty, broken down as 19% frail and 55% intermediate frail (meeting one or two criteria).

In the fully adjusted model, intermediate frail patients had a significant 60% increased risk for ED visits and a 22% increased risk for hospitalizations compared with those who were not frail.

The fully adjusted model included age, sex, ejection fraction, incident versus prevalent heart failure, chronic obstructive pulmonary disease, diabetes, anemia, and estimated glomerular filtration rate.

Researchers found similar results when they adjusted further for hypertension, prior myocardial infarction, atrial fibrillation, cancer, depression, body mass index, and smoking status, which suggested the findings were robust, they said.

Nearly half of the patients exhibited poor grip strength and two-fifths experienced exhaustion. Only 12% experienced three components of frailty, 6% four components, and 0.5% all five components.

Older age, diabetes, and prior myocardial infarctions were significant differences that separated frail patients from the nonfrail and intermediate frail.

The frail patients also were significantly more likely to have chronic obstructive pulmonary disease, atrial fibrillation, depression, anemia, lower estimated glomerular filtration rates, prevalent heart failure, and a Charlson comorbidity index of 3 or greater.

Researchers found higher rates of all cardiovascular and noncardiovascular conditions in the frail patients.

Limitations of the study include a modified definition of frailty because researchers lacked data on walking speed, although the definition they used is standardized and widely used, they said.

Also, the results might not apply to more diverse communities.

Nevertheless, researchers commented on the strengths of the study, which included "rigorous validation of each heart failure diagnosis" and a community patient population that included those with preserved and reduced ejection fraction.

From the American Heart Association:

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