JAMDA 16 (2015) 41e48

JAMDA
journal homepage: www.jamda.com

Original Study

Economic Evaluation of a Multifactorial, Interdisciplinary

Intervention Versus Usual Care to Reduce Frailty in Frail
Older People
Nicola Fairhall PhD a, Catherine Sherrington PhD b, Susan E. Kurrle MBBS, PhD c,
Stephen R. Lord PhD d, Keri Lockwood BHSci c, Kirsten Howard PhD e, Alison Hayes PhD e,
Noeline Monaghan MSc, Dip Law a, Colleen Langron MHSci c, Christina Aggar PhD f,
Ian D. Cameron MBBS, PhD a, *
a
Rehabilitation Studies Unit, Faculty of Medicine, The University of Sydney, Sydney, Australia
b
The George Institute for Global Health, The University of Sydney, Sydney, Australia
c
Rehabilitation and Aged Care Services, Hornsby Ku-ring-gai Hospital, Sydney, Australia
d
Neuroscience Research Australia, University of New South Wales, Sydney, Australia
e
Sydney School of Public Health, Faculty of Medicine, The University of Sydney, Sydney, Australia
f
Faculty of Nursing and Midwifery, The University of Sydney, Sydney, Australia

a b s t r a c t

Keywords: Objective: To compare the costs and cost-effectiveness of a multifactorial interdisciplinary intervention
Frailty versus usual care for older people who are frail.
randomized controlled trial Design: Cost-effectiveness study embedded within a randomized controlled trial.
cost-effectiveness
Setting: Community-based intervention in Sydney, Australia.
Participants: A total of 241 community-dwelling people 70 years or older who met the Cardiovascular
Health Study criteria for frailty.
Intervention: A 12-month multifactorial, interdisciplinary intervention targeting identified frailty char-
acteristics versus usual care.
Measurements: Health and social service use, frailty, and health-related quality of life (EQ-5D) were
measured over the 12-month intervention period. The difference between the mean cost per person for
12 months in the intervention and control groups (incremental cost) and the ratio between incremental
cost and effectiveness were calculated.
Results: A total of 216 participants (90%) completed the study. The prevalence of frailty was 14.7% lower in
the intervention group compared with the control group at 12 months (95% CI 2.4%e27.0%; P ¼ .02).
There was no significant between-group difference in EQ-5D utility scores. The cost for 1 extra person to
transition out of frailty was $A15,955 (at 2011 prices). In the “very frail” subgroup (participants met >3
Cardiovascular Health Study frailty criteria), the intervention was both more effective and less costly than
the control. A cost-effectiveness acceptability curve shows that the intervention would be cost-effective
with 80% certainty if decision makers were willing to pay $A50,000 per extra person transitioning from
frailty. In the very frail subpopulation, this reduced to $25,000.
Conclusion: For frail older people residing in the community, a 12-month multifactorial intervention
provided better value for money than usual care, particularly for the very frail, in whom it has a high
probability of being cost saving, as well as effective.
Ó 2015 AMDA e The Society for Post-Acute and Long-Term Care Medicine.

Frailty is a measurable biological syndrome that is associated with
costly adverse health outcomes, such as falls and disability, as well as
elevated levels of hospitalization and institutionalization.1,2 Between
Trial registration: ACTRN12608000250336.
The authors declare no conflicts of interest.
This study was funded by an Australian National Health and Medical Research
Council Health Services Research grant (reference number NHMRC 402791). The
salaries of CS, SL, SK, and IC are funded by Australian National Health and Medical
4% and 17% of older people are frail,3 and the aging of populations
globally will result in an increase in the prevalence, impact, and costs
of frailty in the near future. One of the key questions in aging research
Research Council grants or fellowships. The research was conducted independently
from the funding body.
* Address correspondence to Ian D. Cameron, Rehabilitation Studies Unit, Kolling
Institute of Medical Research, Royal North Shore Hospital, St Leonards, NSW 2035.
E-mail address: ian.cameron@sydney.edu.au (I.D. Cameron).

http://dx.doi.org/10.1016/j.jamda.2014.07.006
1525-8610/Ó 2015 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
42 N. Fairhall et al. / JAMDA 16 (2015) 41e48

Fig. 1. Definition of frailty components in the Frailty Intervention Trial (FIT).

is how frailty can be treated.4 Identification of cost-effective in-
terventions to reduce frailty may help health services to more effi-
ciently allocate health care resources to those older people most at risk.
There is a lack of evidence regarding the effectiveness of inter-
vention strategies targeting degree of frailty in older people who are
frail. Although several trials have assessed interventions to improve
functional outcomes in older people who are probably frail,5 to our
knowledge, only one study has examined the effect of an intervention
developed to specifically reverse the syndrome of frailty. In the Frailty
Intervention Trial (FIT), we found that a 12-month multifactorial
interdisciplinary intervention reduced degree of frailty and decreased
disability in older people who met the Cardiovascular Health Study
(CHS) frailty criteria.6,7 To date, there is no evidence on the economic
implications of interventions targeting degree of frailty in the frail
population. Identifying cost-effective means for reducing frailty has
the potential to guide appropriate use of the limited resources
available to improve outcomes in older people.
This article, therefore, reports an economic evaluation using data
obtained from the FIT trial.8 From a health care funder perspective,
we examined the cost-effectiveness of a multifactorial interdisci-
plinary intervention, as compared with usual care, in community-
dwelling frail older people.

Table 1 Methods
Unit Costs for Intervention, Health, and Social Care Resource Use
Participants and Setting
Unit Cost Basis of Estimate
Primary care
General practitioner $69 Level C consultation
The FIT was a prospective, assessor-blind, randomized, control-
appointments (20e40 minutes)* led, single-center trial. The study protocol was registered with the
Nursing or other health $51.15 30-minute consultationy
professional appointments
Hospital-based care Table 2
Hospital bed days DRG specific Australian Refined Characteristics of Participants in Intervention and Control Groups at Entry to Study
Diagnosis-Related Group
codesz Intervention, n ¼ 120 Control, n ¼ 121
Social care Demographic factors
Residential care (permanent, $93.21 Australian Government Age, y 83.4 (5.81; 71e99) 83.2 (5.91; 71e101)
high-care) (per day) Daily Aged Care Funding Gender, n males (%) 39 (33) 39 (32)
Residential care (permanent, $30.90 Instrument subsidy rates Lives alone, n (%) 60 (50) 51 (42)
low-care) (per day) per occupied place-day in Health
Residential care (respite, $105.78 Australiax Frailty criteria present,*n (%)
high-care) (per day) 3 77 (64) 79 (65)
Residential care (respite, $37.73 4 33 (28) 30 (25)
low-care) (per day) 5 10 (8) 12 (10)
Home help $37.74 1 hour duration, assuming Medical conditions,y 0e26 7.44 (2.90; 0e13) 7.37 (2.58; 0e12)
50% personal care and Mini Mental State Examination 26.6 (2.58; 19e30) 25.9 (3.14; 18e30)
50% domestic assistancejj score,z 0e30
Transport $12.39 Return tripjj Geriatric Depression Scale,z 4.76 (3.18; 0e14) 5.06 (3.19; 0e14)
Meal delivery $11.10 One meal deliveredjj 0e15
Health-related quality of life, 7.67 (1.47; 5e12) 7.83 (1.50; 5e13)
*Level C General Practitioner consultation (Medicare Benefits Schedule).13
y EuroQol-5D
Mean cost in Australia,16 weighted by 50% of participants in this category
Functioning
receiving community nursing, 25% public hospital service physiotherapy, 25%
Walks with walking aid, n (%) 95 (79) 92 (76)
podiatry.
z Walking speed, meters/second 0.45 (0.17; 0e1.00) 0.48 (0.16; 0e1.03)
The cost of hospital admissions were obtained from Australian Refined
Short Physical Performance 5.2 (1.89; 0e11) 5.74 (2.12; 0e12)
Diagnosis-Related Group cost weights (AR-DRG version 6.0). Hospital admission
Battery, 0e12
costs were calculated using the diagnosis and the length of hospital stay of each
Barthel Index, 0e100 93.9 (11.1; 45e100) 92.5 (14.3; 2e100)
participant. The average cost per hospital day was calculated for this sample
($1282.92) and was used where the cause of hospital admission was unknown. Values are mean (SD; range) unless stated otherwise.
x
The cost of days in residential aged care facilities were obtained from the *Frailty phenotype (modified from Cardiovascular Health Study criteria).8
y
Australian Government Department of Health and Ageing Daily Aged Care Funding Self-reported, doctor-diagnosed medical conditions.
z
Instrument subsidy rates,15 assuming participants received full funding support. Missing data for Geriatric Depression Scale (n ¼ 1), Mini Mental State Exami-
jj
Mean cost in Australia.16 nation (n ¼ 1).
Table 3
Cost of Delivering the Intervention

Intervention No. of Intervention Resource Use Unit Cost, $AUD Cost, $AUD Reference/Web Site
Participants (%)
Assessment stage
Nurse/administration staff to process referral 120 (100) 0.5 hours 72.54 4352.40 Nurse $37.20/hr þ on costs (¼ $48.36/h), Public
and screen for eligibility (frailty) hospital nursing award http://www.health.nsw.
gov.au/careers/conditions/Awards/nurses.pdf
Plus office overheads of 50%17
Physiotherapist 120 (100) 2 hours 48.96 11750.40 Public hospital physiotherapist award, $48.96/h,
http://www.health.nsw.gov.au/careers/
conditions/Awards/hsu_health_professional.pdf
1  20-minute interdisciplinary of participant’s 120 (100) Physiotherapist, geriatrician, rehabilitation specialist, dietician, nurse 15451.20 Geriatrician, rehabilitation specialist $120/h from
initial assessment trial financial sources.
Dietician $48.96/h, Public hospital dietician award,
http://www.health.nsw.gov.au/careers/
conditions/Awards/hsu_health_professional.pdf
Nurse $37.20/hr þ on costs (¼ $48.36/h), Public
hospital nursing award http://www.health.nsw.
gov.au/careers/conditions/Awards/nurses.pdf
9  5-minute interdisciplinary case-conference 120 (100) Physiotherapist, geriatrician, rehabilitation specialist, dietician, nurse 34765.20
discussions per participant over 12 months
Intervention stage Proportion by

N. Fairhall et al. / JAMDA 16 (2015) 41e48

unit cost
Exercise program: staffing 120 (100) Costed as 9 treatments each of 1-hour duration 48.96 52876.80
by physiotherapist
Exercise program: cost of staff travel time, 120 (100) Costed for 10 visits by physiotherapist 12.24 14688.00
average 15-minute round trip (1 assessment, 9 treatments)
Exercise program: cost of travel, average 12-km 120 (100) Costed for 10 visits (1 assessment, 9 treatment) 8.28 9936.00 Australian Tax Office Web site
round trip at $0.69 per km
Management by rehabilitation specialist or 22 (18) 2 specialist visits 120.00 5280.00
geriatrician
Dietician 41 (34) 4 dietician appointments 48.96 8029.44
Psychiatrist 4 (3) 2 specialist visits 260.30 2082.40 MBS Code 296
Phone calls 120 (100) Cost of 8 phone calls per participant 0.40 384.00
Equipment 20 steps 13.30 1732.00 Steps/wedges made by Willoughby Men’s Shed.
20 wedges 13.30 http://www.healthmg.com.au/X_Vest_Weighted_
5 weight vests 160.00 Vests_s/1931.htm
10 weight belts 40.00
Instruction booklets 120 (100) Exercise instruction booklets 0.50 60.00 www.officeworks.com.au/
Home medicine review 4 (3) 1 home medicine review (general practitioner 194.07 776.28 http://www.medicareaustralia.gov.au/provider/
referral, pharmacist review) pbs/fourth-agreement/hmr.jsp
Aged care assessment team 29 (24) ACAT assessment 195.84 5679.36 Senior social worker $48.96/h, Public hospital
award, http://www.health.nsw.gov.au/careers/
conditions/Awards/hsu_health_professional.pdf
Memory clinic 2 (2) 1 clinic appointment 282.95 565.90 MBS Code 143
Continence clinic 3 (3) 1 clinic appointment 96.72 290.16 Nurse $37.20/h þ on costs (¼ $48.36/h), Public
hospital nursing award http://www.health.nsw.
gov.au/careers/conditions/Awards/nurses.pdf
Optometrist 7 (6) Costed as optometrist appointment ($65.15) þ 21% 787.15 Day (2009)
getting glasses ($299) and follow-up appointment
($32.10).
Hearing Australia 10 (8) Costed as 2-hour audiologist appointment 97.92 979.20 Senior audiologist $48.96/h, Public hospital award,
http://www.health.nsw.gov.au/careers/
conditions/Awards/hsu_health_professional.pdf
Orthotics 4 (3) Cost of 1 pair of orthotics 29.95 119.80 http://www.footlogics.com.au/orthotics-insoles-
inserts-podiatry.html
Mobility aids changed 27 (23) 1275.00 http://www.mobsol.com.au/
(continued on next page)

43
 44 N. Fairhall et al. / JAMDA 16 (2015) 41e48

Australian New Zealand Clinical Trials Registry (ANZCTRN 1260

8000250336) and published.8 Ethics approval was provided by

http://www.paulswarehouse.com.au/b/0-59006/
MENS-WALKING/New-Balance-MW411BK-D-
Day only admission for the relevant Diagnosis-
Northern Sydney Central Coast Health Human Research Ethics

http://www.hipsaver.com.au/hipsaver-open-
Committee and participants gave written consent. A total of 241
participants were recruited after discharge from the Division of
Rehabilitation and Aged Care Services at Hornsby Ku-ring-gai Health
Service (Sydney, Australia) between January 2008 and June 2011.
Eligible participants were 70 years or older, met the CHS criteria for
frailty (met specified cutoffs for 3 or more of the following: weak
grip, slow gait, exhaustion, low energy expenditure, and weight
bottom-order.php
Reference/Web Site

loss),1 did not reside in a residential aged care facility, had no severe
Related Group

cognitive impairment (defined as a Mini-Mental State Examination9

Mens.aspx

score of 18 or less), and had a life expectancy exceeding 12 months

(estimated by modified Implicit Illness Severity Scale score of 3 or
less).10

Intervention
Cost, $AUD

183,422.16
8975.47

1890.00

696.00

Participants were randomized to receive either a 12-month

interdisciplinary, multifactorial intervention targeting the compo-
nents of frailty or usual care. The intervention, described elsewhere,8
was individualized to each participant based on the frailty criteria
Unit Cost, $AUD

present and incorporated the principles of geriatric evaluation and

management. It was delivered by an interdisciplinary team com-
1282.21

174.00

prising 2 physiotherapists, a geriatrician, rehabilitation physician,

5
35

55

70
130

dietician, and nurse. Participants received 10 physiotherapy visits and

were prescribed a home program of lower limb balance and strength
exercises to be undertaken for 20 to 30 minutes 3 to 5 times per week
3 pants and 1 set of removable hip protecting pads

for 1 year. Participants who met the weight loss frailty criterion un-
derwent dietician assessment and management. Medical manage-
ment included medication review and management of chronic health
conditions. Regular interdisciplinary case-conferences and case ma-
nagement by the treating physiotherapist facilitated coordination of
the intervention.
Cost of purchasing good shoes
Emergency department visit

The control group received the usual care provided to older resi-
dents of the Hornsby Ku-ring-gai area from community services and
their general practitioner, which may include assessment and de-
8  walking frame

livery of care needs, and medical and allied health management.

15  rubber tips
Resource Use

1  bed rail

Data Collection
3  cane

Data were collected via questionnaires and physical assessments

at baseline (before randomization), and at 3 and 12 months, and via
No. of Intervention

monthly calendars on which participants recorded health and com-

Participants (%)

munity service use. Participants were contacted by telephone for

further information if necessary. When hospitalization or admission
27 (23)

to a residential aged care facility was reported, the research nurse

4 (3)
7 (6)

verified admission details with the relevant facility.

Effectiveness Outcome Measures

Frailty was identified using the CHS definition of frailty (see

Figure 1).1 All participants were frail at baseline; that is, they met 3 or
more CHS frailty criteria. Participants were considered to have tran-
ACAT, Aged Care Assessment Team.

sitioned out of frailty if they met fewer than 3 CHS frailty criteria at
Access emergency department

follow-up.
The EQ-5D (EuroQol) measured health-related quality of life using
Hip protectors provided

5 items (mobility, self-care, usual activities, pain/discomfort, and

anxiety/depression).11 The 5 scores were combined to generate a
Table 3 (continued )

single utility value based on general population-based valuation

Intervention

studies in the United Kingdom.12 Quality adjusted life years (QALYs)

Footwear

were calculated using the EQ-5D at baseline and 3 and 12 months,

Total

and the number of QALYs gained or lost over the 12 months of follow-
up was calculated using trapezoidal integration.
 N. Fairhall et al. / JAMDA 16 (2015) 41e48 45

Resource Utilization

$19,949 ($28,562) $2,314,122 $1056 (8616 to 6503), P ¼ .79

$255 (421 to 89), P ¼ .003

$77,458 $523.11 (455 to 1501), P ¼ .29
$16 (209 to 177), P ¼ .87

$252 (756 to 251), P ¼ .32

$35,442 $240.67 (173 to 654), P ¼ .25

$332 (915 to 251), P ¼ .26

Between-Group Difference in

Data were collected on health and community service use. We

$21 (89 to 47), P ¼ .54

$16.97 (e58 to 92), P ¼ .66
recorded number and type of hospital inpatient bed days and number
of days in permanent or respite care in residential aged care facilities.
Participants reported the number of general practitioner, community
Cost (CI), P Value

nursing, and allied health professional consultations, and community

service utilization data involved occasions of service of home care and
transport, and number of meals provided.
To translate resource use into monetary values, prices or unit costs
were applied. Resources were valued using local or national costs as
$128,892

$135,445

$172,018
$7093

$14,905

$40,238
appropriate (Table 1). Dollar amounts are presented in 2011 Austra-
Total Cost

lian dollars. Discounting was not applied, as the time horizon was
limited to the 12-month trial duration.
We calculated the occasions of service delivery (professional
$59.11 ($268.75)
Occasions No. of Average Occasions Average Cost per

$1138 ($2391)

$645 ($3053)

$295 ($1261)

$1446 ($2598)
consultations or number of community service visits) and the num-
Participant (SD)

$1083 ($841)

$338 ($843)
$125 (305)
ber of users in the sample. Unit costs were obtained from the
Medicare Benefits Schedule13 for general practitioner services. The
costs of hospital admissions were obtained from National Hospital
Costs Data Collection (Round 14) using Australian Refined Diagnosis-
Related Group cost weights (AR-DRG version 5.2).14 Hospital admis-
admission (15.1)

6.93 days (32.76)

9.56 days (40.82)

1.57 days (7.12)

Participant (SD)

sion costs were calculated using the diagnosis and the length of
of Service Users of Service per

15.70 (12.19)

22.25 (46.74)

10.11 (24.65)
38.30 (68.85)
30.46 (75.99)

hospital stay of each participant. In the event that cause of hospital

15 days per
Intervention Group, n ¼ 120

admission was unknown, we used the average cost per hospital day
as calculated for this sample ($1282.92). The cost of residential aged
1.31

care facility use was obtained from the Australian Government

Department of Health and Ageing Daily Aged Care Funding Instru-
74

111

99

72
86
32

ment subsidy rates in high-level care, low-level care, and respite

Occasions of Service, Number of Users and Estimated Cost of Resource Use for the Exercise and Control Groups Over 12 Months

care.15 The unit costs of community services were sourced from a

$18,893 ($30,094) $2,229,381 152 (2227

$64859 1147 days

$141,399 831 days

$9206 188 days

recent systematic review.16 The cost of intervention delivery was

days)

$126,960 1868

$105,420 2648

$12402 1203
$132505 4558
$9923 3625

estimated with current hourly salary rates for the relevant profes-
sional groups and using schedules and published reports of tabulated
Total Cost

cost data for nonsalary components.

Economic Evaluation
$70.08 ($323.14)
Occasions No. of Average Occasions Average Cost per

$885 ($1434)

$1169 ($4512)

$536 ($1925)

$1113 ($1913)
Participant (SD)

$1067 ($659)

$104 ($221)

$83 ($366)

We carried out a complete-case cost-utility and cost-effectiveness

analysis of the FIT intervention compared with control. We measured
costs from the health and community care funder perspective,
including both health and aged care, as these services make the
decisions about health care and essential service provision to older
admission (12.6)

(28.05)

(48.41)

(62.29)

(17.85)
(50.68)
(32.93)
(9.55)

(8.56)

community-dwelling Australians.
Participant (SD)
of Service Users of Service per

We compared the difference in cases of transition out of frailty

14 days per

15.46

17.32

12.54 days

17.35 days

2.02 days

8.41
29.50
7.51

and the difference in total costs between intervention and usual care
groups. Incremental cost-effectiveness ratios (ICERs) were deter-
1.14
Unit Costs Control Group, n ¼ 121

Total group health professional average (SD) [ $1012 ($1972)

mined to assess the additional expenditure required to achieve the

additional benefits of the intervention, calculated as:
Total group community services average [ $4027 ($5014)
66

119

105

1517 days 10

2099 days 11

77
77
17
Total group primary care average (SD) [ $1,075 ($754)
Total group hospital average (SD) [ $19,417 ($29,286)

Total costs ðinterventionÞ  total costs ðcontrolÞ

ICER ¼
135 (2012

244 days

Benefits ðinterventionÞ  benefits ðcontrolÞ

days)

2061

1001
3511
894
1,840

Planned analyses were in terms of the incremental cost per extra

patient experiencing transition out of frailty over 12 months and
specific

incremental cost per QALY gained over 12 months. To examine the

$51.15

Residential care (permanent, $93.21

Residential care (permanent, $30.90

$37.73

$12.39
$37.74
$11.10
DRG

joint probability distribution of costs and outcomes, we generated

$69

1000 cost and outcome pairs by bootstrap sampling with replace-

professional appointments

ment and plotted these on an incremental cost-effectiveness plane.

Residential care (respite,

A cost-effectiveness acceptability curve was derived to capture

Nursing or other health

uncertainty around the probability that the intervention is cost-

General practitioner
Hospital admissions

high-level care)

effective, given a decision maker’s willingness to pay for im-

low-level care)

low-level care)
consultation

provements in QALYs and frailty. A prespecified subgroup analysis

Meal delivery
Resource Use

Home help

examined the cost-effectiveness of the intervention stratified

Transport

by level of frailty at baseline: frail (met 3 CHS criteria) or very frail

Table 4

(met >3 CHS criteria). Analyses were undertaken in Stata v12 (Stata
Corp, College Station, TX).
46 N. Fairhall et al. / JAMDA 16 (2015) 41e48

Table 5
Scores for Intervention and Control Groups, and Difference Between Groups for Health-Related Outcomes

EuroQol-5D Utility Score,* Mean (SD) Frailty, n Frail (%)

Intervention Control Difference Between Groups, Adjusted Intervention Control Difference Between Groups, Adjusted for
for Month 0. Intervention Minus Control Month 0. Intervention Minus Control
(95% CI, P Value) (95% CI, P Value)
Month 0 0.67 (0.23) 0.66 (0.23) 120 (100) 121 (100)
Month 3 0.56 (0.31) 0.47 (0.34) 0.04 (0.10 to 0.03, P ¼ .24) 71 (64) 88 (75) 11.3% (23.3% to 0.7%, P ¼ .07)
Month 12 0.49 (0.32) 0.47 (0.34) 0.01 (0.07 to 0.10, P ¼ .74) 66 (62) 84 (77) 14.7% (27.0% to 2.4%, P ¼ .02)

CI, confidence interval.

*Higher score represents better health.

Results
Participant characteristics are shown in Table 2. The groups were
similar at baseline; 90% (216/241) of the randomized participants
completed the study. Most losses to follow-up were due to death
(22/25); participants who had died at 12 months were assumed to have
no improvement in frailty and EQ-5D utility score was set as zero from
the date of death. Ninety-nine percent (238/241) of respondents were
included in the economic evaluation; 3 participants withdrew from the
study before 3 months and were not included. For the 7 participants
whose cause of hospital admission was unknown, we used the mean
cost per bed day for the sample. Among the 238 participants in the
economic evaluation, none had missing data for the frailty outcome
and for the 6 participants who had missing EQ-5D at 3 months, QALYs
were calculated from baseline and 12-month EQ-5D values.
Intervention Costs
The costs incurred in delivering the 12-month intervention are
shown in Table 3. The total cost was $183,422.16, with an average cost
per participant of $1528.52.
Resource Utilization
Table 4 shows the unit costs, occasions of service, number of users,
and estimated cost of resource use for the exercise and control group
over 12 months. There were no significant between-group differences
in cost for any service except meal delivery, where the mean cost was
$255 greater in the intervention group (95% confidence interval
[CI] 89 to 421, P ¼ .003) compared with the control group.
After controlling for baseline score, there was no statistically signifi-
cant difference between EQ-5D utility scores in the intervention and
control groups at 3 months (0.04, 95% CI 0.10e0.03, P ¼ .24) or at
12 months (0.01, 95% CI 0.07e0.10, P ¼ .74) (see Table 5).
Economic Evaluation
The cost per extra person achieving a transition out of frailty was
$15,955 (all participants) and for the “frail” subgroup the cost was
$41,428. In the “very frail” subgroup, the intervention was dominant
(ie, both more effective and less costly than control) (Table 6).
The cost-effectiveness acceptability curve (Figure 2) shows that for
the frailty outcome, the intervention is cost-effective, with an 80%
probability of being cost-effective at a decision maker’s willingness to
pay $50,000 per extra person transitioning from frailty. It is more
cost-effective among the very frail than the frail subpopulation, with
80% chance of being cost-effective at a willingness to pay of $25,000
for this subgroup. Additionally, for all persons, there is a 30% proba-
bility that the intervention is both cost-saving and effective, and 63%
probability in the very frail subgroup. Results for all participants
and subgroup analyses are presented on cost-effectiveness planes
(Appendix Figure 1).
The intervention did not significantly improve QALYs in either the
full participant group or either of the subgroups (P > .05) and
therefore we did not calculate an ICER for the cost-utility analysis.
However, taking uncertainty into account, the bootstrapped repli-
cates indicated that there was a 10.8% probability of being cost saving
across the entire participant population, a slightly higher probability
of being cost saving in the very frail subgroup (17.8%), and a slightly
lower probability in the frail subgroup (8.2%).

Health-Related Outcomes Discussion

The prevalence of frailty was lower in the intervention group This is the first known economic evaluation of an intervention
compared with the control group at 12 months (absolute difference specifically designed to reduce frailty in an older population. The
14.7%, 95% CI 2.4%e27.0%, P ¼ .02, number needed to treat ¼ 6.8). results indicate that the multifactorial intervention is good value for

Table 6
Cost per Extra Person ($A) Who Transitioned out of Frailty in Intervention and Control Groups, Between-Group Difference, and Incremental Cost-Effectiveness Ratio

Intervention Mean (SD) Control Mean (SD) Mean Difference (Bootstrapped 95% CI) ICER $A per Additional
Patient Experiencing
Transition From Frailty
All participants n ¼ 119 n ¼ 119
Total cost per participant ($) 25,030 (29,827) 22,885 (32,354) 2145 (5698e10,221)
QALYs over 12 months 0.52 (0.26) 0.54 (0.27) 0.022 (0.088e0.459)
Transition from frailty 0.34 (0.48) 0.21 (0.41) 0.13 (0.03e0.25) 15,955
“Frail” subgroup n ¼ 77 n ¼ 78
Total cost per participant ($) 23,006 (26,323) 18,550 (29,540) 4456 (4240e13,415)
Transition from frailty 0.39 (0.49) 0.28 (0.46) 0.11 (0.04e0.25) 41,428
“Very frail” subgroup n ¼ 42 n ¼ 41
Total cost per participant ($) 28,742 (35,416) 31,133 (36,081) 2391 (17,127e12,991)
Transition from frailty 0.26 (0.45) 0.07 (0.26) 0.19 (0.05e0.35) Dominant

CI, confidence interval; ICER, incremental cost-effectiveness ratio; QALY, quality-adjusted life year.
 N. Fairhall et al. / JAMDA 16 (2015) 41e48
Fig. 2. Cost-effectiveness acceptability curve for transition from frailty outcome among
total population and subpopulations who are frail or very frail at baseline. Ceiling value
represents decision maker’s willingness to pay for each additional patient achieving
transition from frailty.
money in terms of improving transition from frailty in all frail par-
ticipants, but particularly in the very frail. In very frail patients, our
intervention was both effective and less costly than usual care; in
economic terms, it was dominant over usual care.
There was a significantly lower prevalence of frailty in the inter-
vention group compared with the control group at 12 months, with a
cost of $A15,955 for one extra person to stop being frail. Considering
the poor outcomes associated with frailty, this may be considered a
worthwhile investment.
The lack of between-group difference in quality of life may be
related to the EQ-5D measure and the domains it includes. This
measure may not be sensitive enough, or include the most appro-
priate dimensions of quality of life to detect clinically important
differences in this population. There are no specific utility-based
quality-of-life measures designed for use in an older frail popula-
tion; however, the ICECAP-O18 may be a more appropriate measure of
well-being in older people.
This study is unique, as it included only people who met a stan-
dardized measure of frailty. Previous studies have analyzed the cost-
effectiveness of interventions in older people who were probably
frail. The Otago Exercise Program was cost saving in terms of falls
prevented in people older than 80,19 but an inpatient rehabilitation
program was not cost-effective compared with standard care for in-
patients with reduced functioning.20
This study has several strengths. The trial design was sound and the
conduct, analysis, and reporting follow best-practice methods for the
reporting of economic evaluations.21 There were small losses to
follow-up that were similar in both groups. The approach to costing
was comprehensive; in addition to health care provision, we collected
costs for a wide variety of social care, including residential aged care
facilities, transport, home help, and meals. Recall bias was minimized
by the frequent (monthly) collection of health and social care resource
utilization.
There are some limitations to the study. The results are only
generalizable to frail older people living in the urban Australian
community who do not have severe cognitive impairment. Due to a
lack of national data registries, data on health care and service use
were often self-reported, which is a potential source of bias. However,
the randomization process, minimal dropouts, and a high rate of data
completeness add confidence to our results. We cannot report long-
term costs and consequences of the intervention because the time
horizon for this study was 12 months and lifetime estimates for costs
47
and health outcomes were not modeled. Finally, we may have un-
derestimated the cost of residential aged care because the costs in
urban settings are probably higher than those derived from the
national data sources we used.22
Conclusion
For frail older people residing in the community, a 12-month
multifactorial intervention provided good value for money, particu-
larly for the very frail, where it has a high probability of being cost
saving as well as effective.
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Appendix

Appendix Fig. 1. Incremental cost-effectiveness planes for costs and frailty outcomes
of 1000 bootstrapped replicates (gray circles) and point estimate (black) for (A) all
patients, (B) frail patients, (C) very frail patients.