How Frailty and Multimorbidity Affect Patient Costs

This analysis describes the relationship between frailty, multi-morbidity and patient costs. It was carried out as part of a wider population health overview at a CCG in 2017.

Frailty is defined by the electronic Frailty Index (eFI). There are four categories of frailty: fit, mild, moderate and severe.

Multi-morbidity is identified by the Johns Hopkins Adjusted Clinical Groups (ACG) System and is defined as an alteration in the structures or functions of the body that is likely to last longer than 12 months and is likely to have a negative impact on health or functional status.

We know from another analysis carried out at NHS Slough CCG that multi-morbidity is a key driver of cost, activity and future risk. We also know that multi-morbidity occurs across all of the adult age range, not just in the elderly.

In this analysis five categories of multi-morbidity were used to segment the patient population, based on the ACG System chronic condition count.

ReferenceChronic Condition Count% of Population
0050
1122
22-421
55-74
88 or more2

These reference categories are combined with the four frailty categories (Fit, Mild, Moderate, Severe) to further segment the CCG population as shown in the graph below. Note that only segments containing more than 100 patients are shown.

Activity and Cost by degree of Multi-morbidity and Frailty

The graph below shows the average total patient costs for each population segment of multi-morbidity and frailty.

Frailty multimorbidity segmentation chart

This heat map shows the degree of total cost and attendance for each frailty/multi-morbidity segment.

BandingPatient CountAvg. Total Cost (£)Avg. No. Emer AdmissionsAvg. No. Elec AdmissionsAvg. No. OP 1st AttendsAvg. No. OP Follow-up AttendsAvg. No. GP VisitsAvg. No. Distinct Drug Count
0 Fit83,7191990.020.030.240.310.51
0 Mild1364770.030.010.540.652.25
1 Fit36,8394660.040.10.430.881.13
1 Mild7347560.050.120.711.32.37
2 Fit28,67810690.090.30.742.051.95
2 Mild6,11713240.090.270.842.22.99
2 Mod55815650.130.20.92.454.513
5 Fit2,59535340.421.191.585.563.39
5 Mild3,87229360.30.681.313.943.712
5 Mod1,07527370.330.481.183.294.915
8 Fit296112591.562.172.8411.146.613
8 Mild1,17874421.121.362.317.025.116
8 Mod1,14472531.151.042.035.275.519
8 Sev23574741.310.671.864.756.722

Low heat map key High

These analyses indicate that when the number of chronic conditions is five or more, the degree of multi-morbidity has a stronger influence than the degree of frailty on patient costs.

The data clearly shows that the more frail patients are not being sent for elective admissions, and there may be various reasons for that. For example, some of the patients with moderate and severe frailty may have a low chance of an improved outcome from some admitted patient procedures.

We might expect to find that the less frail multi-morbid patients attend more outpatient appointments, if they are more mobile, but the chart and heat map show that they are also more likely to have had an emergency admission (from A&E to an inpatient stay).

Patient Population by Chronic Condition Count and Frailty

The table below shows the percentage of patients in each segment of chronic condition count and frailty, as defined above.

eFI
Category
Chronic Condition Count
012-45-78+
Fit50.4%22.0%17.0%1.5%0.2%
Mild0.1%0.4%3.7%2.2%0.7%
Moderate0.0%0.0%0.3%0.7%0.7%
Severe0.0%0.0%0.0%0.0%0.1%

We can group these patients into four areas that broadly indicate the populations requiring different levels of care.

eFI
Category
Chronic Condition Count
012-45-78+
FitMajority of the CCG population (93.6%) with little or no multi-morbidity or frailty. The ideal quadrant to be in.4.6% who are not frail but who are multi-morbid. They require intensive support and proactive management.
Mild
ModerateA small number of people (0.3%) who have little multi-morbidity but a high degree of frailty. It’s possible that their frailty is driven by disability or signs and symptoms.1.5% who are highly multi-morbid and frail. They require intensive support.
Severe

More from this analysis: The Relationship between Frailty and Risk.

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