Impact of the COVID-19 Pandemic on Mortality and Health Resource Use in an Aged Population and Differences According to Frailty Status

Research Article

J Fam Med. 2023; 10(3): 1334.

Impact of the COVID-19 Pandemic on Mortality and Health Resource Use in an Aged Population and Differences According to Frailty Status

Mateu Serra-Prat1,2*; Júlia Serra-Colomer3; Àngel Lavado4; Mateu Cabré5; Emili Burdoy6

1Research Unit, Consorci Sanitari del Maresme, Spain

2CIBER-Liver and Digestive Diseases (CIBEREHD), ISCIII, Spain

3Department of Social Sciences, Pompeu Fabra University, Spain

4Information Management Unit, Consorci Sanitari del Maresme, Spain

5Internal Medicine Department, Consorci Sanitari del Maresme, Spain

6Primary Care Department, Consorci Sanitari del Maresme, Spain

*Corresponding author: Mateu Serra-Prat Research Unit, Hospital de Mataró, Carretera de Cirera s/n, 08304 Mataró, Spain. Tel. + 34 93 741 77 00 ext. 2282 Email: mserra@csdm.cat

Received: May 10, 2023 Accepted: June 13, 2023 Published: June 20, 2023

Abstract

Background: The COVID-19 pandemic severely affected the aged population and healthcare system functioning.

Aim: To evaluate the impact of COVID-19 on mortality and health resource use in an aged population and to determine whether the impact differed according to frailty status.

Methods: A population-based observational longitudinal study comparing pre-pandemic and pandemic variables was performed using data retrospectively collected from computerized clinical histories. The study population included all inhabitants aged =65 years corresponding to three primary care centres in Barcelona province (Spain). Data were collected on mortality, institutionalization, hospital admissions, emergency visits, outpatient visits, primary care visits, and day hospital sessions in the pre-pandemic (2018-2019) and pandemic (2020-2021) periods. Frailty status was established according to the Electronic Screening Index of Frailty (e-SIF).

Results: 9315 individuals were included in the pre-pandemic cohort (75.4 years, 56% women) and 9774 in the pandemic cohort (73.3 years, 56% women). Compared with the pre-pandemic period, in the pandemic period, mortality overall increased by 21.7% (14.7% for non-frail and 33.0% for frail individuals); emergency visits, hospitalizations, and day hospital sessions decreased by 23.1%, 12.1%, and 3.7%, respectively, and primary care visits increased by 15.0%.

Conclusions: For the population aged =65 years in the COVID-19 pandemic period, the mortality of frail individuals was greater than overall mortality for this population, and frailty prevalence overall decreased by 5%. In terms of resource use, use of hospital services decreased and of primary care services increased.

Keywords: COVID-19 pandemic; Frailty; Mortality; Health resource use; Aged

Introduction

COVID-19 was first described in China at the end of 2019 but rapidly spread around the world in early 2020, causing a pandemic with very severe health and socioeconomic consequences. From the first confirmed case in Spain in January 2020 until April 2023, 13.8 million cases were confirmed and deaths numbered 120,715 [1]. A total lockdown in Spain was declared that lasted from March to May 2020. During 2020 and 2021, the healthcare system was severely affected to the point of collapse due to patient overload and healthcare provider illness. Hospitals were forced to reorganize normal operations to deal with the different pandemic outbreaks, resulting in the cancellation of planned interventions, longer waiting lists, a doubling in the number of Intensive Care Unit (ICU) beds, bed relocations, etc. Workload and care pressures also affected the primary healthcare sector, which had to cancel non-urgent visits and to deploy telecare to prioritize more seriously ill patients who required immediate care [2]. Over this period, urgent illnesses were prioritized, and care for all other non-urgent illnesses was postponed. In addition, the fact that many people were afraid to go to hospitals or health centres to avoid possible infection has resulted in delayed diagnoses and increased mortality due to non-COVID-19-related illnesses [3]. It is suspected that healthcare organizational changes due to the COVID-19 pandemic mostly affected the aged population, especially more frail and more vulnerable individuals facing mobility and technological barriers.

Frailty, a highly prevalent geriatric syndrome (10-15% of the population aged =65) [4], is characterized by a decrease in the body’s functional reserves and ability to respond to external stressors, and leads to increased vulnerability to disease, adverse health outcomes, functional decline, disability, and dependence [5]. Frailty has also been associated with an increased use of healthcare and community services, as frail individuals are at a higher risk of hospitalization and admission to nursing homes, and more frequently use emergency, outpatient, and primary care services [6,7]. The healthcare burden gradually increases as frailty increases; for instance, the healthcare cost for frail individuals is calculated to be 2.4 times greater than for non-frail individuals [8,9].

The aim of this study was to evaluate the impact of COVID-19 on mortality and health resource use in an aged population and to determine whether the impact differed according to frailty status.

Methods

Study Design and Population

A population-based observational longitudinal study with follow-up was conducted from 1 January 2018 to 1 January 2022 to compare the pre-pandemic and pandemic periods (2018-2019 and 2020-2021, respectively). Data were obtained retrospectively from computerized primary care and hospital medical records. The study population included all inhabitants aged =65 years corresponding to three primary care centres managed by Maresme Health Consortium (CSdM) in the province of Barcelona (Catalonia, Spain). Included in the pre-pandemic cohort (2018-2019) and the pandemic cohort (2020-2021) were 9315 and 9774 individuals aged =65 years, respectively. The study protocol was approved by the local ethics committee (reference: CEIm CSdM 06/20).

Study Variables

Frailty status was established according to the Electronic Screening Index of Frailty (e-SIF), a validated tool that considers 42 clinical conditions documented in computerized clinical notes to classify individuals in one of four possible categories: robust, pre-frail, frail, and very frail [10]. Frailty scores were calculated for data corresponding to 1 January 2018, to 1 January 2020 and to 1 January 2022. For both the pre-pandemic and pandemic periods, data were collected (including date of event occurrence) on mortality, institutionalization in convalescent units and nursing homes, hospital admissions, emergency visits, outpatient visits, primary care visits, and day hospital sessions. Data for the e-SIF variables and for age, sex, health resource use, and mortality were sourced from primary care computerized medical histories, the pharmaceutical receipt database, and the hospital information system.

Statistical Analysis

The main sociodemographic and clinical characteristics of the study population were described using mean and Standard Deviation (SD) values for numerical variables and percentages for categorical variables. Prevalence of frailty (including frail and very frail categories) and its 95% CI at the beginning of each period and mortality rate (and its 95% CI) during each period were estimated for all study population and for age and sex groups. Since age distributions were somewhat different in the two periods, frailty prevalence and mortality rates were standardized by the direct method to enable comparison. Health resources were described for each study period using means and 95% CI for the overall population and for age, sex and frailty groups. Within each period, comparisons between age and sex groups (both with two categories) were done using the Mann-Whitney U test and comparisons for the four frailty categories were done using the Kruskal-Wallis test. Statistical significance in all statistical tests was set to p<0.05.

Results

For the pre-pandemic period (2018-2019), 9315 individuals were included with a mean (SD) age of 75.4 (7.96) years, and for the pandemic period (2020-2021), 9774 individuals were included with a mean (SD) age of 73.3 (7.87) years. Women represented 56% of the population in both periods. Table 1 shows frailty prevalence rates on 1 January 2018, 2020, and 2022 for the entire study population and by sex and age. The standardized frailty prevalence rates were 12.3%, 14.4%, and 13.6% on 1 January 2018, 2020, and 2022, respectively. For all three dates, prevalence was higher in women than in men and increased with age. Frailty prevalence increased by 16.7% on 1 January 2020 over 1 January 2018 and decreased by 5.4% on 1 January 2022 over 1 January 2020. Table 2 shows the standardized mortality rates for the pre-pandemic and pandemic periods for the entire study population, by sex and age, and for the non-frail and frail groups. In the pandemic period compared to the pre-pandemic period, overall mortality for the population aged =65 years increased by 21.7%: by 15.5% in men and 22.3% in women, and by 14.7% in non-frail and 33.0% in frail individuals.