KINGSTON, Ont., EDMONTON, Alta. — Canada's health system too often fails to deliver the complex care that frail patients need between urgent health events.
When a frail older patient has an acute health crisis in Canada, the system usually delivers excellent service.
But health - like quality care - is determined by more than just response to medical emergencies.
The truth is, we rarely deliver quality chronic care, comprehensive home care or continuous care, and in particular, poorly handle transitions between care settings and providers.
We also often neglect more cost-effective interventions with proven health and quality of life benefits, such as social supports that can help people age in place.
Our overemphasis on acute care needs, and the consequent neglect of other aspects of the health system, have serious consequences - especially for those who are frail. These consequences include worsened health outcomes and increased health costs.
The burden of 'frailty' in Canada is steadily growing. Today, approximately 25 per cent of those over age 65 and 50 per cent of those over 85 - more than one million Canadians - are medically frail. In 10 years, well over two million Canadians may be living with frailty.
Frailty is defined as a state of increased vulnerability, with reduced reserve and loss of function across multiple body systems. Frailty reduces the ability to cope with normal or minor stresses, such as infections, which can cause rapid and dramatic changes in health.
Frail people are at higher risk for worsened health outcomes and death than we would expect based on age alone.
The risk of becoming frail increases with age, but the two are not the same.
Frail Canadians are the major consumers of health care in all settings. Of the $220 billion spent on health care annually in Canada (11 per cent of gross domestic product), 45 per cent is spent on those over 65 years old, although they only represent 15 per cent of the population.
In spite of higher utilization of health care resources for those who are frail, many therapies haven't been evaluated in this population and we don't know if they are beneficial, cause harm, are cost-effective or waste resources.
Are we overtreating some frailty with ineffective therapies and tests, yet not providing adequate social and medical supports in other areas?
The answer is almost certainly yes.
It's time we improved the quality and quantity of care for frail Canadians - and improved the health system for everyone in the process. Here's how:
We need to break down silos of care based on single diseases, single organ failure, settings of care or clinical disciplines. Addressing frailty requires a co-ordinated, multidisciplinary approach. Instead of having multiple specialist appointments and replicating tests across different facilities, we could have one-stop shops that cater to the needs of patients, not providers.
We need to address the needs of frail elderly in a more equitable health system across the country. As we outlined in our brief to the Finance Committee 2017 pre-budget consultations, we could establish funding based on age and frailty instead of the current per capita model.
Funding enhancements should be directed towards strengthening primary health care, along with social and economic supports. Most frail adults live in the community; strengthening primary care and community supports are crucial to help them age in their preferred settings.
We need to provide patients, clinicians and decision-makers with high-quality evidence on the effectiveness of treatments for the frail. Most research excludes the very sick and the elderly. Without evidence, aggressive and expensive therapies are often overused without improvement in outcomes, resulting in poor quality of life and wasted resources.
We need to improve the recognition and assessment of frailty to aid in implementing more appropriate care and planning.
Identifying the most vulnerable of our aging population will allow us to institute appropriate care plans and improve supports - so we can improve outcomes, quality of life and the use of resources.
John Muscedere is the scientific director and CEO of the Canadian Frailty Network (CFN), a not-for-profit organization funded by the government of Canada's Networks of Centres of Excellence program. CFN's mandate is to improve the care for frail elderly Canadians and their families within the health care system. Fred Horne is a health policy consultant and adjunct professor with the University of Alberta's School of Public Health. He was Alberta minister of Health from 2011 to 2014 and served as chair of the Provincial and Territorial Ministers of Health. He is a member of the CFN Board of Directors.
John Muscedere and Fred Horne