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Study design and aims Eligibility criteria or population Frailty assessment Secondary care use Observational evidence
Retrospective studiesClegg
2016,2
UKDesign: 5-year retrospective cohort (2008–2015).
Aim: Development and validation of an electronic frailty index (eFI) using primary care electronic health record data from the THIN database.Individuals aged 65–95 years registered to a Research One or THIN database practice.
Development cohort
(n = 207 814)
Internal validation cohort
(n = 207 720)
External validation cohort
(n = 516 007)An FI was created using the cumulative deficit model in a randomly split sample of the Research One database. External validation cohort
Hazard ratios (with 95% CI) for risk of unplanned hospital admissions for each degree of frailty:
Year 1
Mild 2.03 (1.96 to 2.10)
Moderate 3.50 (3.38 to 3.63)
Severe 5.58 (5.34 to 5.84)
Year 3
Mild 1.89 (1.85 to 1.93)
Moderate 3.03 (2.96 to 3.11)
Severe 4.66 (4.51 to 4.80)Donate-Martinez
2014,12
SpainDesign: 12-month retrospective
(2008–2009).
Aim: To determine the viability of the implementation of two screening tools — namely, the Probability of Repeated Admission (Pra) and the Community Assessment Risk Screen (CARS) — to detect patients at risk of hospital readmission.Community-dwelling patients in Spain aged ≥65 years.
(n = 500)Data related to the variables that comprise both Pra and CARS were collected with a reference date of December 2008. Pra was categorised as high, medium, and low risk of admission. CARs was categorised as high and low risk. Admissions, mean (SD):
Pra
P≤0.001
High 0.47 (0.86)
Medium 0.25 (0.61)
Low 0.12 (0.45)
CARS
P≤0.001
High 0.36 (0.76)
Low 0.11 (0.40)
Length of stay (days), mean (SD):
Pra
P≤0.001
High 2.29 (7.72)
Medium 0.98 (3.00)
Low 0.43 (2.08)
CARS
P ≤0.001
High 1.76 (5.28)
Low 0.44 (2.01)
ROC curve analysis, AUC:
Pra: 0.67
CARS: 0.69Cross-sectional studies Dent
2016,17
AustraliaDesign: Secondary cross-sectional.
Aim: To investigate specific health service provision among frail older people in the rural community of Port Lincoln,
south Australia.Participants aged ≥65 years who completed the LINKIN health study health census September–November 2010.
(n = 1796)An FI of cumulative deficits was used to classify frailty.
Frailty guidelines were used to construct an FI of 23 variables falling into three categories: comorbidities, functional measures, and quality of life. Frailty was dichotomised into frail and non-frail. Participants with ≥6 accumulated deficits were considered to be frail.
Participants with one or more missing FI variables were
excluded from final dataset (n = 1501 for final dataset).
Hospital admission as an inpatient over previous 12 months, by frailty category (n = 1490).
n (%):
Non-frail 73 (5)
Frail 55 (15)
OR = 2.39 (95% CI = 1.74 to 3.29)
P<0.001
Ng
2014,19
SingaporeDesign: Cross-sectional with 2-year validation follow-up.
Aim: Development of a simple frailty risk index (FRI), and evaluation for use in primary care on an external validation cohort of community-living older persons.Adults aged ≥55 years in the Singapore Longitudinal Ageing Studies.
Development cohort
n = 1685
Validation cohort
n = 2478The FRI was developed by identifying 13 salient and independent multisystem risk factors for the 5-criteria frailty phenotype used in the Cardiovascular Health Study (CHS): weakness, slowness, low physical activity, weight loss, and exhaustion. A risk score was assigned to each risk factor and the FRI was derived from summating risk scores associated with each risk factor. Validation cohort
Association of frailty defined by the FRI (as continuous variable) with self-reported hospitalisations:
OR = 1.14 (95% CI = 1.05 to 1.24),
P = 0.002
ROC curve analysis, AUC: 0.63Rochat
2010,18
AustraliaDesign: Cross-sectional.
Aim: To describe the relationship between frailty and use of several health and community services in community-dwelling older men.Men aged ≥70 years in the Concord Health and Ageing in Men Project. Frailty was assessed using a modified version of the CHS criteria:
Weight loss or shrinking, weakness, exhaustion, slowness, and low activity. Robust was categorised as meeting 0 criteria; pre-frail as
≤2 criteria; and frail as ≥3 criteria.Participants admitted for ≥1 night in hospital during previous 12 months, n (%):
Robust 152 (18.2), AOR 1.00 (reference)
Pre-frail 174 (25.7), AOR 1.34 (95% CI = 1.03 to 1.74)
Frail 81 (51.6), AOR 3.29 (95% CI = 2.18 to 4.96)McGee
2008,11
IrelandDesign: Cross-sectional.
Aim: To assess if those categorised as vulnerable by the Vulnerable Elders Survey (VES) were likely to use health services more frequently than others.Randomly selected community-dwelling individuals aged ≥65 years living at a private residential addresses and able to participate in a research interview.
(n = 2033)The VES is a 13-item questionnaire developed from studying >6000 community-dwelling Medicare beneficiaries aged ≥65 years. Health service use in previous 12 months (n = 2033), by VES score:
High VES score (32.1% of sample) versus low VES score (67.9% of sample)
Emergency department visits:
17% versus 8% P<0.001
Scheduled hospital inpatient stay:
21% versus 12%, P<0.001Longitudinal studies van Kempen
2015,13
NetherlandsDesign: 1-year longitudinal cohort (2010–2011).
Aim: To determine the predictive value of EASY-Care Two Step Older Persons Screening (EASY-Care TOS) for negative health outcomes within 12 months from assessment.Patients aged ≥70 years from participating GP practices.
(n = 520)Participants were assessed with the complete EASY-Care TOS procedure. All subsequent assessment steps were finished, irrespective of the outcome (usually a two-step process), during routine primary care visits. Patients were assigned as frail or not-frail. Hospital admission during previous 12 months for participants classified as frail (n = 195) or not frail (n = 325), n (%):
Frail 39 (22.0)
Not frail 41 (12.9)
Absolute difference = 9.1 (95% CI = 2.0 to 16.2), P = 0.01.Sha
2005,20
USDesign: Cross-sectional.
Aim: To describe the patterns of physical symptoms in older adults and to examine the validity of symptoms in predicting hospitalisation and mortality.Individuals aged ≥60 years completing a screening for self-reported symptoms during a routine primary care visit.
(n = 3498)Self-reported symptoms were collected using an abbreviated primary healthcare evaluation of mental disorders screening instrument (PRIME-MD). Hospitalisations in the year following screening according to medical records by number of reported symptoms, n (%):
0–2 symptoms
171 (16.2)
OR = 1.0 (reference)
3–4 symptoms
191 (20.9)
OR = 1.2 (95% CI = 0.9 to 1.5)
5–7 symptoms
218 (22.3)
OR = 1.2 (95% CI = 0.9 to 1.5)
8–12 symptoms
154 (27.9)
OR = 1.4 (95% CI = 1.0 to1.9)aCoelho
2014,16
PortugalDesign: 10-month longitudinal.
Aim: To compare how different frailty measures predict short-term adverse outcomes, namely Frailty Phenotype (FP), Groningen Frailty Indicator (GFI), and Tilburg Frailty Indicator (TFI).Individuals aged ≥60 years based in the community (n = 252) Part A of TFI was used to assess life-course determinants of frailty and comorbidity, while FP, GFI, and part B of TFI were used to measure frailty. Hospitalisations in the previous 12 months χ2:
FP P = 0.29b
Non-frail, n (%)
Yes: 6 (54.5)
No: 61 (72.6)
Frail, n (%)
Yes: 5 (45.5)
No: 23 (27.4)
GFI P = 0.08
Non-frail, n (%)
Yes: 3 (27.3)
No: 46 (54.8)
Frail, n (%)
Yes: 8 (72.7)
No: 38 (45.2)
TFI P = 0.09
Non-frail, n (%)
Yes: 3 (27.3)
No: 46 (54.8)
Frail, n (%)
Yes: 8 (72.7)
No: 38 (45.2)RCT and nRCT evidence Study design and aims Eligibility criteria or population Frailty assessment or group assignment Trial outcome
(secondary care use)Ruikes
2016,14
NetherlandsDesign: Two-arm, 12-month nRCT (September 2011–September 2012).
Aim: To evaluate the effectiveness of a GP–led extensive, multicomponent programme for the prevention of functional decline.
Risk of bias: High.
GP practices with sufficient numbers of patients aged ≥70 years and adequate facilities to enable programme implementation.
Exclusion criteria: Admission to a residential or nursing home and/or critical or terminal illness (n = 536).Six intervention practices were informed about the programme and six control practices were not (usual care).
After Easy-Care TOS assessment, GP and practice nurse or research assistant made a final decision on the presence of frailty.
Intervention: The Care Well primary care programme, consisting of four key elements: multidisciplinary team meetings, proactive care planning, case management, and medication review.Data collected at baseline and 12 months through a home visit by either a trained nurse (in the intervention arm) or a research assistant (in the control arm).
Hospital admissions during follow-up, n (%):
Intervention:
52 (18.1)
Control:
57 (22.9)
OR = 0.74
(95% CI = 0.48 to 1.14),
P = 0.17.Imhof
2012,15
SwitzerlandDesign: RCT.
Aim: To evaluate the effects of a 9-month advanced
practice nurse (APN) in-home health consultation programme (HCP) on quality of life and health.
Risk of bias: Low.
Inclusion criteria: German-speaking, community-dwelling individuals aged ≥80 years, cognitively able to understand study and consent.
Exclusion criteria: End of life, with a major psychiatric diagnosis, or severe cognitive
impairment.
Intervention: n = 231Participants were randomly assigned to the intervention or control group following two baseline assessment visits with an APN, which included a standardised comprehensive geriatric assessment (CGA).
All participants received health care as usual.
Intervention: In addition to usual care, a complementary 9-month in-home HCP was delivered by one of four APNs. The HCP comprises a CGA and consultations that identify and consider the health problems and concerns of the participants.
The intervention included four home visits (mean length 46 ± 6 minutes) after 4, 12, 24, and 36 weeks, and three telephone calls (mean length 17 ± 4 minutes) after 8, 18, and 30 weeks. Total intervention time per participant averaged 4 hours.Outcomes were collected at 3, 6 and 9 months.
With regard to hospitalisations, multilevel analysis showed no evidence of effect for intervention (P = 0.86), time course (P = 0.33), or interaction (P = 0.24). However, hospitalisations (number of 3-month periods with a planned or unplanned hospital admission or emergency department visit) were lower in the intervention group, n (%):
Intervention versus control
47 (23) versus 68 (33)
Relative risk = 0.70
Numbers needed to treat
= 10.0, P = 0.03.aP<0.05. bFisher’s exact test. AUC = area under curve. AOR = adjusted odds ratio. nRCT = non-randomised controlled trial. OR = odds ratio. RCT = randomised controlled trial. ROC = receiver operating characteristic.
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Frailty assessment in primary health care and its association with unplanned secondary care use: a rapid review
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