Frailty assessment in primary health care and its association with unplanned secondary care use: a rapid review

Background The growing frail, older population is increasing pressure on hospital services. This is directing the attention of clinical commissioning groups towards more comprehensive approaches to managing frailty in the primary healthcare environment. Aim To review the literature on whether assessment of frailty in primary health care leads to a reduction in unplanned secondary care use. Design & setting A rapid review involving a systematic search of Medline and Medline In-Process. Method Relevant data were extracted following the iterative screening of titles, abstracts, and full texts to identify studies in the primary or community healthcare setting which assessed the effect of frailty on unplanned secondary care use between January 2005–June 2016. Results The review included 11 primary studies: nine observational studies; one randomised controlled trial (RCT); and one non-randomised controlled trial (nRCT). Eight out of nine observational studies reported a positive association between frailty and secondary care utilisation. The RCT and nRCT reported conflicting findings. Conclusion Older people identified as frail in a primary healthcare setting were more likely to be admitted to hospital. Based on the limited and equivocal trial evidence, it is not possible to draw firm conclusions regarding appropriate tools for the identification and management of frail older people at risk of hospital admission.


Introduction
The incidence of complete Achilles tendon rupture is 18 per 100 000 patient-years 1 and is usually diagnosed clinically by GPs.The extent of clinical misdiagnosis is unknown in Norway, but may be high. 2This is important as delayed treatment has unfavourable consequences. 1,3We report how a GP, with no clinical ultrasound experience, recorded images with a pocket-sized ultrasound device (PSUD) under supervision to confirm a complete Achilles tendon rupture.This could present a new indication for GP ultrasound.

Case report
A 36-year-old man experienced acute pain above the right heel accompanied by an audible snap while sprinting.He immediately had difficulty walking and 3 hours later consulted an on-call GP.Posterior ankle swelling with a tender depression 3 cm proximal to the calcaneum was found.Active plantar flexion against resistance was weak and Simmonds-Thompson test was 'partially positive' on applying a strong calf-squeeze.Based on these findings, calf muscle rupture was diagnosed as the Achilles tendon was thought to be intact.The patient was advised to elevate the foot and wait 2 weeks for improvement.Two days later a second GP, who was aware of a history of an audible snap, considered complete tendon rupture and reexamined the patient.Findings included an absent right heel raise due to weakness, minimal active plantar flexion against gravity and lying prone, significant right ankle swelling without bruising, and an altered angle of declination.Palpation elicited no ankle bony tenderness, yet a painful gap was identified 6 cm proximal from the calcaneal attachment, along the line of the Achilles tendon.Simmonds-Thompson's test was clearly positive.The positive Simmond's triad indicated a clinical diagnosis of complete rupture of the Achilles tendon.
A 3.4-8 MHz linear array probe PSUD (VScanÔ dual probe, GE Healthcare), set at a depth of 3.5 cm, was used under the supervision of a rheumatologist experienced in ultrasound.The tendon was enlarged from 1 cm to 6 cm above the calcaneal insertion, where a clear gap was seen (Figure 1).Two hours later a radiologist-performed ultrasound (LOGIQ E9Ô, GE Healthcare) and reported an enlarged distal tendon and a complete rupture at 5-6 cm from the calcaneal attachment, creating a 2.7 cm blood-filled gap (Figure 2).Surgical exploration 8 days post-injury found a complete Achilles tendon rupture '5-10 cm above the ankle joint'.

Discussion
Tromsø Hospital serves a large area with a population of approximately 160 000.Between 2010-2014 an average of 21 patients per year were referred by their GP for suspected Achilles rupture.

Introduction
The incidence of complete Achilles tendon rupture is 18 per 100 000 patient-years 1 and is usually diagnosed clinically by GPs.The extent of clinical misdiagnosis is unknown in Norway, but may be high. 2This is important as delayed treatment has unfavourable consequences. 1,3We report how a GP, with no clinical ultrasound experience, recorded images with a pocket-sized ultrasound device (PSUD) under supervision to confirm a complete Achilles tendon rupture.This could present a new indication for GP ultrasound.

Case report
A 36-year-old man experienced acute pain above the right heel accompanied by an audible snap while sprinting.He immediately had difficulty walking and 3 hours later consulted an on-call GP.Posterior ankle swelling with a tender depression 3 cm proximal to the calcaneum was found.Active plantar flexion against resistance was weak and Simmonds-Thompson test was 'partially positive' on applying a strong calf-squeeze.Based on these findings, calf muscle rupture was diagnosed as the Achilles tendon was thought to be intact.The patient was advised to elevate the foot and wait 2 weeks for improvement.Two days later a second GP, who was aware of a history of an audible snap, considered complete tendon rupture and reexamined the patient.Findings included an absent right heel raise due to weakness, minimal active plantar flexion against gravity and lying prone, significant right ankle swelling without bruising, and an altered angle of declination.Palpation elicited no ankle bony tenderness, yet a painful gap was identified 6 cm proximal from the calcaneal attachment, along the line of the Achilles tendon.Simmonds-Thompson's test was clearly positive.The positive Simmond's triad indicated a clinical diagnosis of complete rupture of the Achilles tendon.
A 3.4-8 MHz linear array probe PSUD (VScanÔ dual probe, GE Healthcare), set at a depth of 3.5 cm, was used under the supervision of a rheumatologist experienced in ultrasound.The tendon was enlarged from 1 cm to 6 cm above the calcaneal insertion, where a clear gap was seen (Figure 1).Two hours later a radiologist-performed ultrasound (LOGIQ E9Ô, GE Healthcare) and reported an enlarged distal tendon and a complete rupture at 5-6 cm from the calcaneal attachment, creating a 2.7 cm blood-filled gap (Figure 2).Surgical exploration 8 days post-injury found a complete Achilles tendon rupture '5-10 cm above the ankle joint'.

Introduction
The incidence of complete Achilles tendon rupture is 18 per 100 000 patient-years 1 and is usually diagnosed clinically by GPs.The extent of clinical misdiagnosis is unknown in Norway, but may be high. 2This is important as delayed treatment has unfavourable consequences. 1,3We report how a GP, with no clinical ultrasound experience, recorded images with a pocket-sized ultrasound device (PSUD) under supervision to confirm a complete Achilles tendon rupture.This could present a new indication for GP ultrasound.

Case report
A 36-year-old man experienced acute pain above the right heel accompanied by an audible snap while sprinting.He immediately had difficulty walking and 3 hours later consulted an on-call GP.Posterior ankle swelling with a tender depression 3 cm proximal to the calcaneum was found.Active plantar flexion against resistance was weak and Simmonds-Thompson test was 'partially positive' on applying a strong calf-squeeze.Based on these findings, calf muscle rupture was diagnosed as the Achilles tendon was thought to be intact.The patient was advised to elevate the foot and wait 2 weeks for improvement.Two days later a second GP, who was aware of a history of an audible snap, considered complete tendon rupture and reexamined the patient.Findings included an absent right heel raise due to weakness, minimal active plantar flexion against gravity and lying prone, significant right ankle swelling without bruising, and an altered angle of declination.Palpation elicited no ankle bony tenderness, yet a painful gap was identified 6 cm proximal from the calcaneal attachment, along the line of the Achilles tendon.Simmonds-Thompson's test was clearly positive.The positive Simmond's triad indicated a clinical diagnosis of complete rupture of the Achilles tendon.
A 3.4-8 MHz linear array probe PSUD (VScanÔ dual probe, GE Healthcare), set at a depth of 3.5 cm, was used under the supervision of a rheumatologist experienced in ultrasound.The tendon was enlarged from 1 cm to 6 cm above the calcaneal insertion, where a clear gap was seen (Figure 1).Two hours later a radiologist-performed ultrasound (LOGIQ E9Ô, GE Healthcare) and reported an enlarged distal tendon and a complete rupture at 5-6 cm from the calcaneal attachment, creating a 2.7 cm blood-filled gap (Figure 2).Surgical exploration 8 days post-injury found a complete Achilles tendon rupture '5-10 cm above the ankle joint'.

Discussion
Tromsø Hospital serves a large area with a population of approximately 160 000.Between 2010-2014 an average of 21 patients per year were referred by their GP for suspected Achilles rupture.

Introduction
The incidence of complete Achilles tendon rupture is 18 per 100 000 patient-years 1 and is usually diagnosed clinically by GPs.The extent of clinical misdiagnosis is unknown in Norway, but may be high. 2This is important as delayed treatment has unfavourable consequences. 1,3We report how a GP, with no clinical ultrasound experience, recorded images with a pocket-sized ultrasound device (PSUD) under supervision to confirm a complete Achilles tendon rupture.This could present a new indication for GP ultrasound.

Case report
A 36-year-old man experienced acute pain above the right heel accompanied by an audible snap while sprinting.He immediately had difficulty walking and 3 hours later consulted an on-call GP.Posterior ankle swelling with a tender depression 3 cm proximal to the calcaneum was found.Active plantar flexion against resistance was weak and Simmonds-Thompson test was 'partially positive' on applying a strong calf-squeeze.Based on these findings, calf muscle rupture was diagnosed as the Achilles tendon was thought to be intact.The patient was advised to elevate the foot and wait 2 weeks for improvement.Two days later a second GP, who was aware of a history of an audible snap, considered complete tendon rupture and reexamined the patient.Findings included an absent right heel raise due to weakness, minimal active plantar flexion against gravity and lying prone, significant right ankle swelling without bruising, and an altered angle of declination.Palpation elicited no ankle bony tenderness, yet a painful gap was identified 6 cm proximal from the calcaneal attachment, along the line of the Achilles tendon.Simmonds-Thompson's test was clearly positive.The positive Simmond's triad indicated a clinical diagnosis of complete rupture of the Achilles tendon.
A 3.4-8 MHz linear array probe PSUD (VScanÔ dual probe, GE Healthcare), set at a depth of 3.5 cm, was used under the supervision of a rheumatologist experienced in ultrasound.The tendon was enlarged from 1 cm to 6 cm above the calcaneal insertion, where a clear gap was seen (Figure 1).Two hours later a radiologist-performed ultrasound (LOGIQ E9Ô, GE Healthcare) and reported an enlarged distal tendon and a complete rupture at 5-6 cm from the calcaneal attachment, creating a 2.7 cm blood-filled gap (Figure 2).Surgical exploration 8 days post-injury found a complete Achilles tendon rupture '5-10 cm above the ankle joint'.

Discussion
Tromsø Hospital serves a large area with a population of approximately 160 000.Between 2010-2014 an average of 21 patients per year were referred by their GP for suspected Achilles rupture.

Introduction
Last summer our small medical team visited the Calais 'Jungle'.Since that time much has changed and the camp is being demolished and by the time this article is read, it will probably be long gone.Some youngsters are finally being brought to the UK under the 'Dubs' amendment.However, once this camp is cleared it will not solve the ongoing flight of refugees from war torn areas: other camps are already appearing.

July 2016
A young Afghan man caught his finger on a sharp point while trying to cross a barbed wire fence.The finger was partially degloved.He attended the local hospital, where they placed a few sutures, but now, 2 weeks later, the skin is necrotic and the underlying tissue looks infected.He is in danger of losing his finger.
A middle-aged Sudanese man has been having rigors and is generally unwell.He says it is similar to when he last had malaria.
A young Ukrainian woman complains of lower back pain and urinary frequency.The paths of these three people may never have crossed; yet here they are, denizens of the Calais Jungle.They turn up to a makeshift primary care 'clinic' that we set up in the heart of the unofficial refugee camp one weekend in July 2016.
With only basic medical supplies, we are immediately challenged by what we see.How can we arrange secondary care for the young Afghan in danger of losing his finger?We try to persuade him to return to the original local hospital, but he is reluctant.It was not a good experience for him the first time round.
With the other two patients, it is easier.They can attend the Salam clinic run by a local association during weekdays.Later, we receive word that malaria has been confirmed in our Sudanese patient.
More people arrive, presenting with scabies, rat bites, tinea, chest infections, and wheezing from inhaling smoke from fires lit to cook and keep warm in their tents at night.We examine a severely malnourished 2-year-old boy.We meet several of the camp's 600 unaccompanied children, at grave risk of sexual exploitation.We learn that there is inadequate safeguarding in place to protect them.A young Eritrean man comes in worried about his eye.He has sustained direct ocular trauma from a rubber bullet, and will never see normally again out of that eye.We see haematomas from police batons, and hear about children being exposed to tear gas again and again (Figure 1).

The reality
These are no ordinary patients.They have travelled far from home to escape war, poverty, and misery.They have endured personal odysseys to get here, experienced untold hardships, and suffered unimaginable privations.Many have survived the loss of their families, torture, and rape.Their journeys over, for the moment at least, they must make their homes in the Calais Jungle.Their new shelters are in many cases mere tarpaulin covers, and their new beds just rugs on the ground.They own next to nothing.There is little for them to do, besides use their ingenuity to cross the English Channel in search of a better life.They are vulnerable to exploitation, crime, injury, and disease.Potentially violent clashes with local police, with other ethnic groups resident in the Jungle, or local far

Introduction
Frailty is a distinct health state associated with the ageing process; 1 it is characterised by a loss of biological reserves throughout multiple organ systems and susceptibility to physiological decompensation after a potentially minor health event. 2 Although a definitive operational definition of frailty is yet to be agreed on, two conceptual models dominate the field: The Frailty Index (FI) 3 and the Frailty Phenotype (FP). 4 The FI identifies frailty as a state, defined as an accumulation of deficits over time.The FI's deficits comprise an adaptable range of conditions and diseases, from physical to psychosocial. 3The FP distinguishes frailty as a syndrome identified by a pre-defined set of five criteria: involuntary weight loss; exhaustion; slow gait speed; poor handgrip strength; and sedentary behaviour. 4here is global concern that existing healthcare services cannot meet the demand of an increasing frail population. 5However, frailty is not an inevitable part of ageing and the condition can be improved through appropriate management. 1 One suggested approach to tackling the challenges of an ageing population is primary prevention. 5Conceptual models such as the FP and FI have led to the development of several frailty assessment instruments, which provide the opportunity to develop interventions against such age-related conditions.One such approach to manage frailty is the CGA, the purpose of which is to conduct a holistic, interdisciplinary, and multidimensional frailty assessment, 1 and subsequently develop a management plan, comprising treatment and follow-up, linking medical and social care. 6he British Geriatric Society (BGS) suggests that healthcare professionals assess frailty during routine primary healthcare encounters and then refer to a geriatrics team to perform a CGA. 1 There is evidence that the use of a CGA to guide treatment significantly improves the chances of a patient being alive and in their own home 12 months after an emergency hospital admission, 7 and this is of increasing interest to primary healthcare policy makers.A shortened form of the CGA has been developed for use in primary health care with the objective of identifying frail individuals most at risk of requiring secondary care admission.8 Despite there being some evidence for the effectiveness of conducting frailty assessments within primary health care and its role in reducing hospital admissions, there is no evidence to date supporting the specific use of a shortened CGA in that setting, as far as the authors are aware.
Considering this, a rapid review of the literature was conducted to identify if assessment of frailty and/or management of frailty, including CGA, in PHC lead to reductions in unplanned secondary care use.

Method
The literature search followed standard methodology informed by the latest Cochrane systematic review guidance. 9The authors searched Medline and Medline In-Process from 1 January 2005-8 June 2016, and identified 984 entries.The search structure is available from the authors on request.

Eligibility criteria
The search strategy sought studies meeting the following criteria: . Population/intervention: the population included frail adults receiving an intervention involving any type of frailty assessment conducted by primary or community healthcare professionals.
. Control: any type of control group.
. Outcome: any measurement assessing the effect of frailty on unplanned secondary care use.
. Design: quantitative and qualitative studies.
Non-English language studies were considered if they had an English abstract on which to assess their eligibility.

Research
References were managed using EndNote software and screened by two authors using the above eligibility criteria.Abstracts were initially screened and then full papers of potential studies were screened to produce the final inclusion list.Any disagreements at either stage were resolved using a third reviewer.
Data were extracted into a custom-designed table to capture all relevant information.The Cochrane Collaboration's tool for assessing risk of bias was used to assess risk of bias for trials identified in the rapid review. 10

Results
The review identified 11 primary studies: nine observational studies; one RCT; and one nRCT.More study detail is provided in a brief summary of the observational and trial evidence (Table 1).Seven studies were conducted in Western Europe, including the Republic of Ireland and Northern Ireland, 11 Spain, 12 the Netherlands, 13,14 Switzerland, 15 Portugal, 16 and the UK. 2 Two studies were conducted in Australia, 17,18 one in Singapore, 19 and one in the US. 20Risk of bias was generally low for both RCTs and high for the nRCT, due to its lack of randomisation.No relevant qualitative studies were identified.
Of the nine observational studies identified, eight reported a positive association between frailty and secondary care utilisation.The review identified only one RCT and one nRCT; in these trials frailty assessment preceded an intervention. 11,12Both trials, however, were considered relevant given the application of the frailty assessment to the care received by intervention participants.

Retrospective studies
The electronic health record data of individuals aged 65-95 years from the UK was used to develop and validate the electronic Frailty Index (eFI). 2 The eFI was externally validated in 516 007 primary healthcare patients (mean age 75 ± 7.3 years) over a 3-year period.At the 3-year time point, hazard ratios demonstrated that patients with 'severe' frailty were at 4.66 (95% confidence interval [CI] = 4.51 to 4.80) times greater risk of an unplanned secondary care admission than those identified as 'fit'.The eFI predicted secondary care utilisation with fair predictive validity at year 1 (cStatistic 0.71), although the calibration estimate (variance explained by eFI) for the hospital admissions outcome was low.The eFI algorithm was incorporated into the System One GP health record system for feasibility testing in 2014, and in 2016 was introduced via the EMISWEB and Vision clinical systems. 21 Community Assessment Risk Screen (CARS) and the Probability of Repeated Admission (Pra) tool was used to detect hospital admission risk of 500 community-dwelling patients in Spain aged 65 years.12 Those classified at higher risk of admission by both the CARS and Pra tools reported more per-patient hospital admissions (P0.001) and greater lengths of hospital stay (P0.001) in the subsequent 12 months.However, poor predictive values (area under the curve [AUC] and positive predictive values [PPV]) suggest neither tool efficiently identifies risk of secondary care utilisation.

Cross-sectional studies
An Australian study utilised the data of 1501 individuals aged 65 years to identify frailty by applying the FI model. 17Participants classed as frail by the FI were 2.39 (95% CI = 1.74 to 3.29) times more likely to be admitted to hospital compared to non-frail participants during the previous 12 months (n = 1490 for participants with hospital admissions data).
The Cardiovascular Health Study (CHS) criteria (weight loss or shrinking, weakness, exhaustion, slowness, and low activity) were used to identify frailty in 1674 men aged 70 years, living in Sydney, Australia. 18Compared to 'robust' men (0 frailty criteria), 'frail' men (3 frailty criteria) were 3.29 (95% CI = 2.18 to 4.96) times more likely to spend 1 night admitted to hospital during the previous 12 months.
Data from the Singapore Longitudinal Ageing Study was used for the development of a primary healthcare clinical frailty risk indicator (FRI) in 1685 patients (mean age 67 ± 8 years). 19The development study evaluated how frailty risk factors predict frailty, as defined by five criteria validated in the CHS. 4 In the validation cohort (n = 2478), participants were 1.14 (95% CI = 1.05 to 1.24; P = 0.002) times more likely to be admitted to hospital during the 2-year follow-up period per unit increase in Individuals aged 60 years completing a screening for selfreported 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).

Longitudinal studies
In a longitudinal study from the Netherlands, 520 patients (mean age 77 ± 5 years) were assessed for frailty by their GP at baseline, using the EASY-Care Two step Older persons Screening (EASY-Care TOS) tool. 13During the 12-month those classed as 'frail' reported a greater proportion of hospital admissions than their 'non-frail' counterparts (39 [22%] versus 41 [12.9%],P = 0.01).
The PRIME-MD (primary healthcare evaluation of mental disorders) screening instrument was employed in a study from the US exploring the validity of physical symptoms identified during routine primary healthcare visits for predicting hospitalisations in 3498 adults (mean age 69 ± 7 years). 20Compared to those with 0-2 symptoms, participants with 8-12 symptoms were 1.4 times more likely to be admitted to secondary care, (95% CI = 1.0 to 1.9, P0.05).
However, in a study of 252 community-based participants aged 60 years there was no evidenced association between frailty and secondary care utilisation. 16The authors compared three frailty measures: the FP, Groningen Frailty Indicator, and Tilburg Frailty Indicator for the prediction of secondary care utilisation over the previous 12 months.Given the small sample size at follow-up (n = 95), the authors highlight their study's lack of statistical power.

Controlled trials
An nRCT of The Care Well primary healthcare programme based in the Netherlands found no evidence of effect in moderating hospital admission rates in the intervention compared to control group. 14This 12-month intervention was conducted in 536 participants (intervention n = 287, control n =249) aged 70 years who were identified as frail using the Easy-Care TOS tool.The trial was non- Research randomised and lasted 12 months, which may have been insufficient for establishing effective multidisciplinary collaborations.
In Switzerland, an in-home health consultation programme was delivered by advanced practice nurses (APNs) to 461 (intervention n = 231, control n = 230) German-speaking, community-dwelling individuals aged 80 years, and was evaluated over 9 months. 15Multilevel analysis showed no evidence of effect, although group comparisons showed overall secondary care admission rates were lower in the intervention compared to control group (47 [23%] versus 68 [33%], P = 0.03, relative risk ratio = 0.70).The lack of change in other healthcare services suggested the intervention did not replace existing services but was complementary to them.The study employed un-blinded data collection and self-reported measures over 3-month periods, and thus reporting bias and misreporting is a possibility.

Reviews
An International Academy of Nutrition and Aging taskforce reviewed the evidence for gait speed assessed at usual pace to identify risk of adverse outcomes in community-dwelling older people. 22Twenty-seven articles were identified, five of which assessed hospitalisations as an outcome.The review reported that lower gait speed was associated with higher likelihood of secondary care utilisation.

Discussion Summary
This review identified that the majority of evidence for the effect of frailty assessment in primary health care on unplanned secondary care is observational, with eight of the nine observational studies included suggesting a positive association between the identification of frailty and secondary care utilisation.Of the trial evidence, one RCT presented reduced admission rates following a health consultation programme in the home and one nRCT was ineffective in moderating hospital admissions.The reduced secondary care admission rates in the RCT suggest that its interventional care package, which incorporated frailty assessments in addition to usual care, is effective. 15In contrast, a multicomponent, multidisciplinary programme was ineffective at reducing admissions. 14

Strengths and limitations
To the best of the authors' knowledge, this is the first review to explore frailty assessment in primary health care and its association with unplanned secondary care use.However, due to the lack of related research including secondary care use as an outcome, this focused review yielded a limited number of eligible studies.Additionally, due to time constraints, this rapid review searched only Medline and Medline In-Process, which may have restricted the number of eligible studies identified.
The three trials included in this review had methodological issues that reflect the limited quality of evidence in this area.

Comparison with existing literature
The latest best practice guideline by the BGS, recommends the following tools for triaging individuals for a CGA: gait speed and the timed-up-and-go test for clinical staff during routine assessment; and the PRISMA-7 questionnaire for self-assessment tests. 1 However, this recommendation is based on a review exploring test characteristics of tools for identifying frailty 23 but which did not explore association with hospital admission.
A 2006 systematic review 24 explored the characteristics of published CGA interventions across a variety of settings and the association with emergency department utilisation, as opposed to hospital admissions.Interventions within secondary care were mostly short-term and had little effect, whereas most interventions in primary care, outpatient, and home-care settings reduced emergency department utilisation.Like in the current review, there was heterogeneity among the included interventions; this precluded the use of meta-analysis.

Table 1 .
Summary of evidence for included studies

Table 1 continued
Study design and aimsEligibility criteria or population Frailty assessment Secondary care use Table 1 continued on next page FRI score.However, the predictive validity of the FRI with regards secondary care utilisation was poor (AUC = 0.63).