Original Research

Frailty Trends in an Older Veteran Subpopulation 1 Year Prior and Into the COVID-19 Pandemic Using CAN Scores

Fed Pract. 2023 June;40(6):194-198 | doi:10.12788/fp.0385

References

1. Rohrmann S. Epidemiology of frailty in older people. Adv Exp Med Biol. 2020;1216:21-27. doi:10.1007/978-3-030-33330-0_3

2. Bandeen-Roche K, Seplaki CL, Huang J, et al. Frailty in older adults: a nationally representative profile in the United States. J Gerontol A Biol Sci Med Sci. 2015;70(11):1427-1434. doi:10.1093/gerona/glv133

3. Siriwardhana DD, Hardoon S, Rait G, Weerasinghe MC, Walters KR. Prevalence of frailty and prefrailty among community-dwelling older adults in low-income and middle-income countries: a systematic review and meta-analysis. BMJ Open. 2018;8(3):e018195. Published 2018 Mar 1. doi:10.1136/bmjopen-2017-018195

4. Song X, Mitnitski A, Rockwood K. Prevalence and 10-year outcomes of frailty in older adults in relation to deficit accumulation. J Am Geriatr Soc. 2010;58(4):681-687. doi:10.1111/j.1532-5415.2010.02764.x

5. Rockwood K, Mitnitski A. Frailty in relation to the accumulation of deficits. J Gerontol A Biol Sci Med Sci. 2007;62(7):722-727. doi:10.1093/gerona/62.7.722

6. Buta BJ, Walston JD, Godino JG, et al. Frailty assessment instruments: Systematic characterization of the uses and contexts of highly-cited instruments. Ageing Res Rev. 2016;26:53-61. doi:10.1016/j.arr.2015.12.003

7. Cheng D, DuMontier C, Yildirim C, et al. Updating and validating the U.S. Veterans Affairs Frailty Index: transitioning From ICD-9 to ICD-10. J Gerontol A Biol Sci Med Sci. 2021;76(7):1318-1325. doi:10.1093/gerona/glab071

8. Fihn SD, Francis J, Clancy C, et al. Insights from advanced analytics at the Veterans Health Administration. Health Aff (Millwood). 2014;33(7):1203-1211. doi:10.1377/hlthaff.2014.0054

9. Ruiz JG, Priyadarshni S, Rahaman Z, et al. Validation of an automatically generated screening score for frailty: the care assessment need (CAN) score. BMC Geriatr. 2018;18(1):106. doi:10.1186/s12877-018-0802-7

10. Ruiz JG, Rahaman Z, Dang S, Anam R, Valencia WM, Mintzer MJ. Association of the CAN score with the FRAIL scale in community dwelling older adults. Aging Clin Exp Res. 2018;30(10):1241-1245. doi:10.1007/s40520-018-0910-4

11. Ofori-Asenso R, Chin KL, Mazidi M, et al. Global incidence of frailty and prefrailty among community-dwelling older adults: a systematic review and meta-analysis. JAMA Netw Open. 2019;2(8):e198398. Published 2019 Aug 2. doi:10.1001/jamanetworkopen.2019.8398

12. Marcucci M, Damanti S, Germini F, et al. Interventions to prevent, delay or reverse frailty in older people: a journey towards clinical guidelines. BMC Med. 2019;17(1):193. Published 2019 Oct 29. doi:10.1186/s12916-019-1434-2

13. Travers J, Romero-Ortuno R, Bailey J, Cooney MT. Delaying and reversing frailty: a systematic review of primary care interventions. Br J Gen Pract. 2019;69(678):e61-e69. doi:10.3399/bjgp18X700241

14. Orkaby AR, Nussbaum L, Ho YL, et al. The burden of frailty among U.S. veterans and its association with mortality, 2002-2012. J Gerontol A Biol Sci Med Sci. 2019;74(8):1257-1264. doi:10.1093/gerona/gly232

15. Bakouny Z, Paciotti M, Schmidt AL, Lipsitz SR, Choueiri TK, Trinh QD. Cancer screening tests and cancer diagnoses during the COVID-19 pandemic. JAMA Oncol. 2021;7(3):458-460. doi:10.1001/jamaoncol.2020.7600

16. Steffen R, Lautenschlager S, Fehr J. Travel restrictions and lockdown during the COVID-19 pandemic-impact on notified infectious diseases in Switzerland. J Travel Med. 2020;27(8):taaa180. doi:10.1093/jtm/taaa180

17. CDC Museum COVID-19 Timeline. Centers for Disease Control and Prevention. Updated March 15, 2023. Accessed May 12, 2023. https://www.cdc.gov/museum/timeline/covid19.html18. Nguyen JL, Benigno M, Malhotra D, et al. Pandemic-related declines in hospitalization for non-COVID-19-related illness in the United States from January through July 2020. PLoS One. 2022;17(1):e0262347. Published 2022 Jan 6. doi:10.1371/journal.pone.0262347

19. Ward RE, Orkaby AR, Dumontier C, et al. Trajectories of frailty in the 5 years prior to death among U.S. veterans born 1927-1934. J Gerontol A Biol Sci Med Sci. 2021;76(11):e347-e353. doi:10.1093/gerona/glab196

20. Bäckman K, Joas E, Falk H, Mitnitski A, Rockwood K, Skoog I. Changes in the lethality of frailty over 30 years: evidence from two cohorts of 70-year-olds in Gothenburg Sweden. J Gerontol A Biol Sci Med Sci. 2017;72(7):945-950. doi:10.1093/gerona/glw160

21. Piette JD, Holtz B, Beard AJ, et al. Improving chronic illness care for veterans within the framework of the Patient-Centered Medical Home: experiences from the Ann Arbor Patient-Aligned Care Team Laboratory. Transl Behav Med. 2011;1(4):615-623. doi:10.1007/s13142-011-0065-8

22. Rosland AM, Nelson K, Sun H, et al. The patient-centered medical home in the Veterans Health Administration. Am J Manag Care. 2013;19(7):e263-e272. Published 2013 Jul 1.

Methods

The Office of Clinical Systems Development and Evaluation (CSDE–10E2A) produces a weekly CAN Score Report to help identify the highest-risk patients in a primary care panel or cohort. CAN scores range from 0 (lowest risk) to 99 (highest risk), indicating how likely a patient is to experience hospitalization or death compared with other VA patients. CAN scores are calculated with statistical prediction models that use data elements from the following Corporate Data Warehouse (CDW) domains: demographics, health care utilization, laboratory tests, medical conditions, medications, and vital signs (eAppendix available online at 10.12788/fp.0385).

The CAN Score Report is generated weekly and stored on a CDW server. A patient will receive all 6 distinct CAN scores if they are: (1) assigned to a primary care PACT on the risk date; (2) a veteran; (3) not hospitalized in a VA facility on the risk date; and (4) alive as of the risk date. New to CAN 2.5 is that patients who meet criteria 1, 2, and 4 but are hospitalized in a VA facility on the risk date will receive CAN scores for the 1-year and 90-day mortality models.

Utilizing VA Informatics and Computing Infrastructure (VA HSR RES 13-457, US Department of Veterans Affairs [2008]), we obtained 2 lists of veterans aged 70 to 75 years on February 8, 2019, with a calculated CAN score of ≥ 75 for 1-year mortality and 1-year hospitalization on that date. A veteran with a CAN score of ≥ 75 is likely to be prefrail or frail.^9,10 Veterans who did not have a corresponding calculated CAN score on February 7, 2020, and February 12, 2021, were excluded. COVID-19 was declared a public health emergency in the United States on January 31, 2020, and the World Health Organization declared COVID-19 a pandemic on March 11, 2020.¹⁷ We picked February 7, 2020, within this time frame and without any other special significance. We picked additional CAN score calculation dates approximately 1 year prior and 1 year after this date. Veterans had to be alive on February 12, 2021, (the last date of the CAN score) to be included in the cohorts.

Statistical Analyses

The difference in CAN score from one year to the next was calculated for each patient. The difference between 2019 and 2020 was compared with the difference between 2020 to 2021 using a paired t test. Yearly CAN score values were analyzed using repeated measures analysis of variance. The number of patients that showed an increase in CAN score (ie, increased risk of either mortality or hospitalization within the year) or a decrease (lower risk) was compared using the χ² test. IBM SPSS v26 and GraphPad Prism v18 were used for statistical analysis. P < .05 was considered statistically significant.

Results

There were 3538 veterans at PVAHCS who met the inclusion criteria and had a 1-year mortality CAN score ≥ 75 on February 8, 2019.

We excluded 6 veterans from the final analysis due to lack of 1-year mortality CAN score for 2020 or 2021. The final number included in the analysis was 3532 (Figure 1). The mean (SD) age was 71.8 (1.3) years. There were 3488 male (98.8%) and 44 female (1.2%) veterans represented (Table 1).

Our data show a decrease in mean 1-year mortality CAN score in this subset of older frail veterans by 4.9 (95% CI, -5.3 to -4.5) in the year preceding the COVID-19 pandemic (Table 2). The 1-year mean mortality CAN score increased significantly by 0.2 (95% CI, -0.3 to 0.6; P < .0001 vs pre-COVID) in this same subset of patients after the first year of the COVID-19 pandemic (Figure 2).

Mean CAN scores for 1-year mortality were 81.5 (95% CI, 81.2 to 81.7), 76.5 (95% CI, 76.1 to 77.0), and 76.7 (95% CI, 76.2 to 77.2) for 2019, 2020, and 2021, respectively.

References

1. Rohrmann S. Epidemiology of frailty in older people. Adv Exp Med Biol. 2020;1216:21-27. doi:10.1007/978-3-030-33330-0_3

2. Bandeen-Roche K, Seplaki CL, Huang J, et al. Frailty in older adults: a nationally representative profile in the United States. J Gerontol A Biol Sci Med Sci. 2015;70(11):1427-1434. doi:10.1093/gerona/glv133

3. Siriwardhana DD, Hardoon S, Rait G, Weerasinghe MC, Walters KR. Prevalence of frailty and prefrailty among community-dwelling older adults in low-income and middle-income countries: a systematic review and meta-analysis. BMJ Open. 2018;8(3):e018195. Published 2018 Mar 1. doi:10.1136/bmjopen-2017-018195

4. Song X, Mitnitski A, Rockwood K. Prevalence and 10-year outcomes of frailty in older adults in relation to deficit accumulation. J Am Geriatr Soc. 2010;58(4):681-687. doi:10.1111/j.1532-5415.2010.02764.x

5. Rockwood K, Mitnitski A. Frailty in relation to the accumulation of deficits. J Gerontol A Biol Sci Med Sci. 2007;62(7):722-727. doi:10.1093/gerona/62.7.722

6. Buta BJ, Walston JD, Godino JG, et al. Frailty assessment instruments: Systematic characterization of the uses and contexts of highly-cited instruments. Ageing Res Rev. 2016;26:53-61. doi:10.1016/j.arr.2015.12.003

7. Cheng D, DuMontier C, Yildirim C, et al. Updating and validating the U.S. Veterans Affairs Frailty Index: transitioning From ICD-9 to ICD-10. J Gerontol A Biol Sci Med Sci. 2021;76(7):1318-1325. doi:10.1093/gerona/glab071

8. Fihn SD, Francis J, Clancy C, et al. Insights from advanced analytics at the Veterans Health Administration. Health Aff (Millwood). 2014;33(7):1203-1211. doi:10.1377/hlthaff.2014.0054

9. Ruiz JG, Priyadarshni S, Rahaman Z, et al. Validation of an automatically generated screening score for frailty: the care assessment need (CAN) score. BMC Geriatr. 2018;18(1):106. doi:10.1186/s12877-018-0802-7

10. Ruiz JG, Rahaman Z, Dang S, Anam R, Valencia WM, Mintzer MJ. Association of the CAN score with the FRAIL scale in community dwelling older adults. Aging Clin Exp Res. 2018;30(10):1241-1245. doi:10.1007/s40520-018-0910-4

11. Ofori-Asenso R, Chin KL, Mazidi M, et al. Global incidence of frailty and prefrailty among community-dwelling older adults: a systematic review and meta-analysis. JAMA Netw Open. 2019;2(8):e198398. Published 2019 Aug 2. doi:10.1001/jamanetworkopen.2019.8398

12. Marcucci M, Damanti S, Germini F, et al. Interventions to prevent, delay or reverse frailty in older people: a journey towards clinical guidelines. BMC Med. 2019;17(1):193. Published 2019 Oct 29. doi:10.1186/s12916-019-1434-2

13. Travers J, Romero-Ortuno R, Bailey J, Cooney MT. Delaying and reversing frailty: a systematic review of primary care interventions. Br J Gen Pract. 2019;69(678):e61-e69. doi:10.3399/bjgp18X700241

14. Orkaby AR, Nussbaum L, Ho YL, et al. The burden of frailty among U.S. veterans and its association with mortality, 2002-2012. J Gerontol A Biol Sci Med Sci. 2019;74(8):1257-1264. doi:10.1093/gerona/gly232

15. Bakouny Z, Paciotti M, Schmidt AL, Lipsitz SR, Choueiri TK, Trinh QD. Cancer screening tests and cancer diagnoses during the COVID-19 pandemic. JAMA Oncol. 2021;7(3):458-460. doi:10.1001/jamaoncol.2020.7600

16. Steffen R, Lautenschlager S, Fehr J. Travel restrictions and lockdown during the COVID-19 pandemic-impact on notified infectious diseases in Switzerland. J Travel Med. 2020;27(8):taaa180. doi:10.1093/jtm/taaa180

17. CDC Museum COVID-19 Timeline. Centers for Disease Control and Prevention. Updated March 15, 2023. Accessed May 12, 2023. https://www.cdc.gov/museum/timeline/covid19.html18. Nguyen JL, Benigno M, Malhotra D, et al. Pandemic-related declines in hospitalization for non-COVID-19-related illness in the United States from January through July 2020. PLoS One. 2022;17(1):e0262347. Published 2022 Jan 6. doi:10.1371/journal.pone.0262347

19. Ward RE, Orkaby AR, Dumontier C, et al. Trajectories of frailty in the 5 years prior to death among U.S. veterans born 1927-1934. J Gerontol A Biol Sci Med Sci. 2021;76(11):e347-e353. doi:10.1093/gerona/glab196

20. Bäckman K, Joas E, Falk H, Mitnitski A, Rockwood K, Skoog I. Changes in the lethality of frailty over 30 years: evidence from two cohorts of 70-year-olds in Gothenburg Sweden. J Gerontol A Biol Sci Med Sci. 2017;72(7):945-950. doi:10.1093/gerona/glw160

21. Piette JD, Holtz B, Beard AJ, et al. Improving chronic illness care for veterans within the framework of the Patient-Centered Medical Home: experiences from the Ann Arbor Patient-Aligned Care Team Laboratory. Transl Behav Med. 2011;1(4):615-623. doi:10.1007/s13142-011-0065-8

22. Rosland AM, Nelson K, Sun H, et al. The patient-centered medical home in the Veterans Health Administration. Am J Manag Care. 2013;19(7):e263-e272. Published 2013 Jul 1.

Frailty Trends in an Older Veteran Subpopulation 1 Year Prior and Into the COVID-19 Pandemic Using CAN Scores

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Methods

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