Relationship of frailty with excess mortality during the COVID-19 pandemic: a population-level study in Ontario, Canada

Published: July 15, 2022
Category: Bibliography
Authors: A Chu, A Yu, D Lee, F McAlister, F Qiu, H Abdel-Qadir, H Ross, H Wijeysundera, I Roifman, J Kwong, J Udell, L Sun, M Kapral, P Austin, R Manoragavan
Countries: Canada
Language: English
Types: Health Risk, Population Health, Social Determinants
Settings: Health Plan



There is a paucity of the literature on the relationship between frailty and excess mortality due to the COVID-19 pandemic.


The entire community-dwelling adult population of Ontario, Canada, as of January 1st, 2018, was identified using the Cardiovascular Health in Ambulatory Care Research Team (CANHEART) cohort. Residents of long-term care facilities were excluded. Frailty was categorized through the Johns Hopkins Adjusted Clinical Groups (ACG® System) frailty indicator. Follow-up was until December 31st, 2020, with March 11th, 2020, indicating the beginning of the COVID-19 pandemic. Using multivariable Cox models with patient age as the timescale, we determined the relationship between frailty status and pandemic period on all-cause mortality. We evaluated the modifier effect of frailty using both stratified models as well as incorporating an interaction between frailty and the pandemic period.


We identified 11,481,391 persons in our cohort, of whom 3.2% were frail based on the ACG indicator. Crude mortality increased from 0.75 to 0.87% per 100 person years from the pre- to post-pandemic period, translating to ~ 13,800 excess deaths among the community-dwelling adult population of Ontario (HR 1.11 95% CI 1.09–1.11). Frailty was associated with a statistically significant increase in all-cause mortality (HR 3.02, 95% CI 2.99–3.06). However, all-cause mortality increased similarly during the pandemic in frail (aHR 1.13, 95% CI 1.09–1.16) and non-frail (aHR 1.15, 95% CI 1.13–1.17) persons.


Although frailty was associated with greater mortality, frailty did not modify the excess mortality associated with the pandemic.

frailty,COVID-19,Cox Models,mortality,pandemic

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