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Identification and management of frailty in English primary care: a qualitative study of national policy. BJGP Open 2020; 4:bjgpopen20X101019. [PMID: 32184213 PMCID: PMC7330193 DOI: 10.3399/bjgpopen20x101019] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 07/08/2019] [Indexed: 01/03/2023] Open
Abstract
Background Policymakers are directing attention to addressing the needs of an ageing population. Since 2017, general practices in England have been contractually required to identify and code ‘frailty’ as a new clinical concept and, in doing so, support targeted management for this population with the aim of improving outcomes. However, embedding frailty policies into routine practice is not without challenges and little is currently known about the success of the programme. Aim To explore the implementation of a national policy on frailty identification and management in English primary care. Design & setting Qualitative study entailing interviews with primary care professionals in the North of England. Method Semi-structured interviews were conducted with GPs (n = 10), nurses (n = 6), practice managers (n = 3), and health advisors (n = 3). Normalisation process theory (NPT) and ‘system thinking’ provided sensitising frameworks to support data collection and analysis. Results Primary care professionals were starting to use the concept of frailty to structure care within practices and across organisations; however, there was widespread concern about the challenge of providing expanded care for the identified needs with existing resources. Concerns were also expressed around how best to identify the frail subpopulation and the limitations of current tools for this, and there was a professional reticence to use the term ‘frailty’ with patients. Conclusion Findings suggests that additional, focused resources and the development of a stronger evidence base are essential to facilitate professional engagement in policies to improve the targeted coding and management of frailty in primary care.
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Ambagtsheer RC, Archibald MM, Lawless M, Kitson A, Beilby J. Feasibility and acceptability of commonly used screening instruments to identify frailty among community-dwelling older people: a mixed methods study. BMC Geriatr 2020; 20:152. [PMID: 32321431 PMCID: PMC7178952 DOI: 10.1186/s12877-020-01551-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 04/05/2020] [Indexed: 12/04/2022] Open
Abstract
Background Frailty exposes older people to an elevated risk of a range of negative outcomes. Emerging evidence that frailty can be effectively treated within community settings has stimulated calls for more proactive screening within primary care. Assessing feasibility is a critical preliminary step in assessing the efficacy of interventions such as screening. However, few studies have explored the feasibility and acceptability of administering frailty screening instruments within general practice, and even fewer have incorporated patient perspectives. Our study had three objectives: To 1) assess overall feasibility of the instruments (completion time and rate); 2) assess patient acceptability towards the instruments; and 3) assess the feasibility and acceptability of the instruments to administering nurses. Methods The feasibility and acceptability of several frailty screening instruments (PRISMA-7, Edmonton Frail Scale, FRAIL Scale Questionnaire, Gait Speed, Groningen Frailty Indicator, Reported Edmonton Frail Scale and Kihon Checklist) was explored within the context of a larger diagnostic test accuracy (DTA) study. Completion time and rate was collected for all participants (N = 243). A sub-sample of patients (n = 30) rated each instrument for ease of completion and provided comment on perceived acceptability. Lastly, five of six administering nurses involved in the DTA study participated in semi-structured face-to-face interviews, rating the instruments against several feasibility and acceptability criteria (time, space, equipment, skill required to implement, acceptability to patients and nurses, ease of scoring) and providing comment on their responses. Results The PRISMA-7 returned the highest overall feasibility and acceptability, requiring minimal space, equipment, skills and time to implement, and returning the fastest completion rate and highest patient and nurse acceptability rating. All screening instruments were faster to implement than the two reference standards (Fried’s Frailty Phenotype and Frailty Index). Self-administered instruments were subject to lower rates of completion than nurse-administered instruments. Conclusions This study has demonstrated that a number of commonly used frailty screening instruments are potentially feasible for implementation within general practice. Ultimately, more research is needed to determine how contextual factors, such as differences in individual patient and clinician preferences, setting and system factors, impact on the feasibility of screening in practice.
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Affiliation(s)
- Rachel C Ambagtsheer
- National Health and Medical Research Council Centre of Research Excellence in Trans-Disciplinary Frailty Research to Achieve Healthy Ageing, Adelaide, Australia. .,Torrens University Australia, GPO Box 2025, Adelaide, SA, 5000, Australia.
| | - Mandy M Archibald
- National Health and Medical Research Council Centre of Research Excellence in Trans-Disciplinary Frailty Research to Achieve Healthy Ageing, Adelaide, Australia.,College of Nursing and Health Sciences, Flinders University, Adelaide, Australia.,College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Michael Lawless
- National Health and Medical Research Council Centre of Research Excellence in Trans-Disciplinary Frailty Research to Achieve Healthy Ageing, Adelaide, Australia.,College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Alison Kitson
- National Health and Medical Research Council Centre of Research Excellence in Trans-Disciplinary Frailty Research to Achieve Healthy Ageing, Adelaide, Australia.,College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Justin Beilby
- National Health and Medical Research Council Centre of Research Excellence in Trans-Disciplinary Frailty Research to Achieve Healthy Ageing, Adelaide, Australia.,Torrens University Australia, GPO Box 2025, Adelaide, SA, 5000, Australia
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Archibald M, Lawless M, Ambagtsheer RC, Kitson A. Older adults' understandings and perspectives on frailty in community and residential aged care: an interpretive description. BMJ Open 2020; 10:e035339. [PMID: 32193272 PMCID: PMC7150596 DOI: 10.1136/bmjopen-2019-035339] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Despite growing interest in frailty as a significant public health challenge, comparatively little is known about how older adults perceive and experience frailty, limiting the effectiveness of strategies to improve frailty management and prevention. The objective of this study was to understand how older people, including frail older persons in residential aged care, perceive and understand frailty through an interpretive-descriptive qualitative study. SETTING Aged care facility, community-based university for older persons and an aged care auxiliary care group in a large metropolitan centre in South Australia. PARTICIPANTS 39 non-frail, prefrail, frail and very frail South Australian older adults. METHODS Seven focus groups were conducted. Participants completed one of two frailty instruments depending on setting and indicated whether they self-identified as frail. Data were analysed inductively and thematically by two independent investigators. RESULTS Frailty was described according to three schemas of (1) the old and frail: a static state near the end of life; (2) frailty at any age: a disability model; and (3) frailty as a loss of independence: control, actions and identity. In addition, a theme was identifying linking mindset, cognition and emotion to frailty. The term frailty was viewed negatively and was often implicated with personal choice. There was little correlation between frailty assessments and whether participants self-identified as frail. CONCLUSIONS Aside from a disability model, views of frailty as unmodifiable permeated older persons' diverse perspectives on frailty and are likely to impact health behaviours. To our knowledge, this is among the largest qualitative studies examining consumer perceptions of frailty and contributes a clinically relevant schema linking age, prevention and modifiability from a consumer perspective.
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Affiliation(s)
- Mandy Archibald
- College of Nursing and Health Sciences, Flinders University, Bedford Park, South Australia, Australia
- College of Nursing, University of Manitoba, Winnipeg, Manitoba, Canada
- Centre of Research Excellence in Frailty and Healthy Ageing, Adelaide, South Australia, Australia
| | - Michael Lawless
- College of Nursing and Health Sciences, Flinders University, Bedford Park, South Australia, Australia
- Centre of Research Excellence in Frailty and Healthy Ageing, Adelaide, South Australia, Australia
| | - Rachel C Ambagtsheer
- Centre of Research Excellence in Frailty and Healthy Ageing, Adelaide, South Australia, Australia
- Health, Torrens University Australia, Adelaide, South Australia, Australia
| | - Alison Kitson
- College of Nursing and Health Sciences, Flinders University, Bedford Park, South Australia, Australia
- Centre of Research Excellence in Frailty and Healthy Ageing, Adelaide, South Australia, Australia
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Lawless MT, Archibald MM, Ambagtsheer RC, Kitson AL. Factors influencing communication about frailty in primary care: A scoping review. PATIENT EDUCATION AND COUNSELING 2020; 103:436-450. [PMID: 31551158 DOI: 10.1016/j.pec.2019.09.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 08/14/2019] [Accepted: 09/12/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To summarise the available evidence on the factors influencing communication about frailty in the primary care setting. METHODS We conducted a scoping review, searching five electronic databases (PubMed, Scopus, CINAHL, PsycINFO, and ProQuest) for studies addressing communication about frailty in primary care practice. Reference list and grey literature searching was conducted to identify additional articles. A narrative descriptive method was used to synthesise the findings. RESULTS The search identified 3185 articles and 37 were included in the review. We identified five categories of factors influencing communication about frailty at the consumer, healthcare provider, and system levels: (1) consumer perceptions, information needs, and communication preferences; (2) healthcare providers' knowledge, capacities, and attitudes; (3) clinical communication skills and training; (4) availability of information and communication technologies; and (5) care coordination, collaboration, and case management. CONCLUSION Findings offer considerations for the design and delivery of initiatives to improve communication about frailty in primary care both at the local clinical level and at the broader level of healthcare service delivery. PRACTICE IMPLICATIONS Healthcare providers and systems require practical, evidence-informed guidance regarding the development of a systematic approach to the quality and timing of communication about frailty in healthcare encounters.
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Affiliation(s)
- Michael T Lawless
- College of Nursing and Health Sciences, Flinders University, Adelaide, Australia; National Health and Medical Research Council Centre of Research Excellence in Transdisciplinary Frailty Research to Achieve Healthy Ageing, Adelaide, Australia.
| | - Mandy M Archibald
- College of Nursing and Health Sciences, Flinders University, Adelaide, Australia; National Health and Medical Research Council Centre of Research Excellence in Transdisciplinary Frailty Research to Achieve Healthy Ageing, Adelaide, Australia
| | | | - Alison L Kitson
- College of Nursing and Health Sciences, Flinders University, Adelaide, Australia; National Health and Medical Research Council Centre of Research Excellence in Transdisciplinary Frailty Research to Achieve Healthy Ageing, Adelaide, Australia
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Schulz M, Czwikla J, Tsiasioti C, Schwinger A, Gand D, Schmiemann G, Schmidt A, Wolf-Ostermann K, Kloep S, Heinze F, Rothgang H. Differences in medical specialist utilization among older people in need of long-term care - results from German health claims data. Int J Equity Health 2020; 19:22. [PMID: 32033606 PMCID: PMC7006141 DOI: 10.1186/s12939-020-1130-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 01/16/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Elderly in need of long-term care tend to have worse health and have higher need of medical care than elderly without need for long-term care. Yet, characteristics associated with long-term care need can impede health care access: Higher levels of long-term care need come with physical and cognitive decline such as frailty and memory loss. Yet, it has not been investigated whether level of long-term care need is related to medical care utilization. METHODS We investigated the association between the level of long-term care and medical specialist utilization among nursing home residents and home care recipients. We applied zero-inflated Poisson regression with robust standard errors based on a sample of statutory health insurance members. The sample consisted of 100.000 elderly over age 60. We controlled for age, gender, morbidity and mortality, residential density, and general practitioner utilization. RESULTS We found a strong gradient effect of the level of long-term care for 9 out of 12 medical specialties: A higher level of long-term care need was associated with a lower probability of having a medical specialist visit. Yet, we did not find clear effects of the level of long-term care need on the intensity of medical specialist care. These findings were similar for both the nursing home and home care setting. CONCLUSION The findings indicate that inequalities in medical specialist utilization exist between elderly with differing levels of long-term care need because differences in morbidity were controlled for. Elderly with higher need of long-term care might face more access barriers to specialist medical care.
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Affiliation(s)
- Maike Schulz
- University of Bremen, SOCIUM Research Center on Inequality and Social Policy, Mary-Somerville-Straße 5, 28359 Bremen, Germany
- University of Bremen, Institute for Public Health and Nursing Research (IPP), Grazer Straße 4, 28359 Bremen, Germany
| | - Jonas Czwikla
- University of Bremen, SOCIUM Research Center on Inequality and Social Policy, Mary-Somerville-Straße 5, 28359 Bremen, Germany
- University of Bremen, Institute for Public Health and Nursing Research (IPP), Grazer Straße 4, 28359 Bremen, Germany
| | - Chrysanthi Tsiasioti
- Research Institute of the Local Health Care Funds (WIdO), P.O. Box 11 02 46, 10832 Berlin, Germany
| | - Antje Schwinger
- Research Institute of the Local Health Care Funds (WIdO), P.O. Box 11 02 46, 10832 Berlin, Germany
| | - Daniel Gand
- University of Bremen, Institute for Public Health and Nursing Research (IPP), Grazer Straße 4, 28359 Bremen, Germany
- University of Bremen, Competence Center for Clinical Trials (KKSB), Linzer Straße 4, 28359 Bremen, Germany
| | - Guido Schmiemann
- University of Bremen, Institute for Public Health and Nursing Research (IPP), Grazer Straße 4, 28359 Bremen, Germany
- University of Bremen, Competence Center for Clinical Trials (KKSB), Linzer Straße 4, 28359 Bremen, Germany
| | - Annika Schmidt
- University of Bremen, Institute for Public Health and Nursing Research (IPP), Grazer Straße 4, 28359 Bremen, Germany
- University of Bremen, Competence Center for Clinical Trials (KKSB), Linzer Straße 4, 28359 Bremen, Germany
| | - Karin Wolf-Ostermann
- University of Bremen, Institute for Public Health and Nursing Research (IPP), Grazer Straße 4, 28359 Bremen, Germany
- University of Bremen, Competence Center for Clinical Trials (KKSB), Linzer Straße 4, 28359 Bremen, Germany
| | - Stephan Kloep
- University of Bremen, Institute for Public Health and Nursing Research (IPP), Grazer Straße 4, 28359 Bremen, Germany
- University of Bremen, High-Profile Area Health Sciences, Bremen, Germany
| | - Franziska Heinze
- University of Bremen, SOCIUM Research Center on Inequality and Social Policy, Mary-Somerville-Straße 5, 28359 Bremen, Germany
- University of Bremen, Institute for Public Health and Nursing Research (IPP), Grazer Straße 4, 28359 Bremen, Germany
| | - Heinz Rothgang
- University of Bremen, SOCIUM Research Center on Inequality and Social Policy, Mary-Somerville-Straße 5, 28359 Bremen, Germany
- University of Bremen, Institute for Public Health and Nursing Research (IPP), Grazer Straße 4, 28359 Bremen, Germany
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Lim YJ, Ng YS, Sultana R, Tay EL, Mah SM, Chan CHN, Latib AB, Abu-Bakar HM, Ho JCY, Kwek THH, Tay L. Frailty Assessment in Community-Dwelling Older Adults: A Comparison of 3 Diagnostic Instruments. J Nutr Health Aging 2020; 24:582-590. [PMID: 32510110 DOI: 10.1007/s12603-020-1396-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Compare the diagnostic performance of FRAIL against Fried Phenotype and Frailty Index (FI), and identify clinical factors associated with pre-frailty/frailty. DESIGN Cross-sectional analysis. SETTING Community-based screenings in Senior Activity Centres, Residents' Corners and Community Centres in northeast Singapore. PARTICIPANTS 517 community dwelling participants aged >55 years and ambulant independently (with/ without walking aids) were included in this study. Residents of sheltered or nursing homes, and seniors unable to ambulate at least four meters independently were excluded. MEASUREMENTS The multidomain geriatric screen included assessments for social vulnerability, mood, cognition, sarcopenia and nutrition. Participants completed a battery of physical fitness tests for grip strength, gait speed, lower limb strength and power, flexibility, balance and endurance, with overall physical performance represented by Short Physical Performance Battery (SPPB). Frailty status was assigned on FRAIL, Fried and 35-item FI. RESULTS Prevalence of frailty was 1.3% (FRAIL) to 3.1% (FI). Pre-frailty prevalence ranged from 17.0% (FRAIL) to 51.2% (FI). FRAIL demonstrated poor agreement with FI (kappa=0.171, p<0.0001), and Fried (kappa=0.194, p<0.0001). A lower FRAIL cut-off ≥1 yielded significantly improved AUC of 0.70 (95%CI 0.55 to 0.86, p=0.009) against Fried, and 0.71 (95%CI 0.55 to 0.86, p=0.008) against FI. All 3 frailty measures were diagnostic of impaired physical performance on SPPB, with AUCs ranging from 0.69 on FRAIL to 0.77 on Fried (all p values <0.01). Prevalence of low socio-economic status, depression, malnutrition and sarcopenia increased significantly, while fitness measures of gait speed, balance, and endurance declined progressively across robust, pre-frail and frail on all 3 frailty instruments (p <0.05). CONCLUSIONS Our results suggest that different frailty instruments may capture over-lapping albeit distinct constructs, and thus may not be used interchangeably. FRAIL has utility for quick screening, and any positive response should trigger further assessment, including evaluation for depression, social vulnerability and malnutrition.
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Affiliation(s)
- Y J Lim
- Laura Tay, Sengkang General Hospital, Singapore,
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McMillan JM, Krentz HB, Gill MJ, Hogan DB. An Emerging Concern-High Rates of Frailty among Middle-aged and Older Individuals Living with HIV. Can Geriatr J 2019; 22:190-198. [PMID: 31885759 PMCID: PMC6887139 DOI: 10.5770/cgj.22.387] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background The aim of the present study was to calculate a frailty index (FI) in older adults (≥50) living with HIV, search for cross-sectional associations with the FI, and investigate the association between the FI score and two-year mortality. Methods Cross-sectional study with a short-term prospective component for the determination of two-year mortality was performed. The study took place in an HIV outpatient clinic in Calgary, Canada between November 1, 2016 and December 31, 2018. Over 700 patients 50 years of age or older took part. We calculated a FI for each patient, examined associations between FI and select patient characteristics, and evaluated the association between FI value and two-year mortality. Results The mean FI was 0.303 (± 0.128). Mean FI did not differ between males and females, nor was it associated with either nadir or current CD4 cell count. It did increase with age, duration of ART, and duration of diagnosed HIV infection. Mean FI was higher among those who died compared to survivors (0.351 vs. 0.301; p=.033). Conclusions Frailty is highly prevalent in persons living with HIV and associated with a higher mortality rate. Health-care providers should be aware of the earlier occurrence of frailty in adults living with HIV.
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Affiliation(s)
- Jacqueline M McMillan
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Southern Alberta Clinic, Calgary, AB, Canada
| | - Hartmut B Krentz
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Southern Alberta Clinic, Calgary, AB, Canada
| | - M John Gill
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Southern Alberta Clinic, Calgary, AB, Canada
| | - David B Hogan
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Rosenberg T, Montgomery P, Hay V, Lattimer R. Using frailty and quality of life measures in clinical care of the elderly in Canada to predict death, nursing home transfer and hospitalisation - the frailty and ageing cohort study. BMJ Open 2019; 9:e032712. [PMID: 31722953 PMCID: PMC6858169 DOI: 10.1136/bmjopen-2019-032712] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To assess the value of using frailty measures in primary care for predicting death, nursing home transfer (NHT) and hospital admission. DESIGN Cohort study. SETTING AND PARTICIPANTS All 380 people, mean age 88.4, living in the community and receiving home-based primary geriatric care from one practice in Victoria, Canada. INTERVENTIONS/MEASUREMENTS A 60 min baseline assessment which included: Clinical Frailty Scale (CFS), EuroQol EQ-5D-5L (EQ-5D), EuroQol Visual Analogue Scale (EQ-VAS) and Gait Speed (Gaitspeed). OUTCOMES Death, NHT and hospital admission. RESULTS During 18 months of follow-up, there were 39 (10.3%) deaths, 48 (12.6%) NHTs and 93 (24.5%) individuals admitted to hospital. All three outcomes were predicted by: CFS Level 6+7/4+5 (HR death 5.92, 95% CI 3.12 to 11.22, NHT 6.00, 95% CI 3.37 to 10.66 and hospital admission 2.92, 95% CI 1.93 to 4.40); EQ-5D Quintile 1/Quintile 5 (death 6.26, 95% CI 2.11 to 18.62; NHT 3.18, 95% CI 1.29 to 7.82 and hospital admission 2.94, 95% CI 1.47 to 5.87); EQ-VAS Q1/Q5 (death 7.0, 95% CI 2.34 to 20.93; NHT 3.38, 95% CI 1.22 to 9.35 and hospital admission 6.69, 95% CI 3.20 to 13.99) and Gaitspeed (death 5.87, 95% CI 1.78 to 19.34; NHT 8.51, 95% CI 3.18 to 22.79 and hospital admission 11.05, 95% CI 5.45 to 22.40). Medical diagnoses, multiple comorbidities and polypharmacy were weaker predictors of these outcomes. Cox regression analyses showed CFS (adjusted HR 2.88, 95% CI 1.23 to 6.68), EQ-VAS (0.96, 95% CI 0.93 to 0.98), estimated glomerular filtration rate (0.97, 95% CI 0.95 to 1.00) and haemoglobin (0.97, 95% CI 0.94 to 0.99) were independently associated with death. Gaitspeed (0.13, 95% CI 0.03 to 0.57), Geriatric Depression Scale (1.39, 95% CI 1.07 to 1.82) and dementia diagnosis (4.61, 95% CI 1.86 to 11.44) were associated with NHT. Only CFS (1.75, 95% CI 1.21 to 2.51) and EQ-VAS (0.98, 95% CI 0.96 to 0.99) were associated with hospital admission. No other diagnoses, polypharmacy nor multiple comorbidities predicted these outcomes. CONCLUSIONS For elderly people, standardised simple measures of frailty and health status were stronger predictors of death, NHT and hospital admission than medical diagnoses. Consideration should be given to adding these measures into usual medical care for this age group.
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Affiliation(s)
- Ted Rosenberg
- Family Practice, The University of British Columbia Faculty of Medicine, Victoria, British Columbia, Canada
| | - Patrick Montgomery
- Geriatriac Medicine (Retired), The University of British Columbia Faculty of Medicine, Victoria, British Columbia, Canada
| | - Vikki Hay
- Home Team Medical Services, Victoria, British Columbia, Canada
| | - Rory Lattimer
- Home Team Medical Services, Victoria, British Columbia, Canada
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van der Kleij RMJJ, Kasteleyn MJ, Meijer E, Bonten TN, Houwink EJF, Teichert M, van Luenen S, Vedanthan R, Evers A, Car J, Pinnock H, Chavannes NH. SERIES: eHealth in primary care. Part 1: Concepts, conditions and challenges. Eur J Gen Pract 2019; 25:179-189. [PMID: 31597502 PMCID: PMC6853224 DOI: 10.1080/13814788.2019.1658190] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Primary care is challenged to provide high quality, accessible and affordable care for an increasingly ageing, complex, and multimorbid population. To counter these challenges, primary care professionals need to take up new and innovative practices, including eHealth. eHealth applications hold the promise to overcome some difficulties encountered in the care of people with complex medical and social needs in primary care. However, many unanswered questions regarding (cost) effectiveness, integration with healthcare, and acceptability to patients, caregivers, and professionals remain to be elucidated. What conditions need to be met? What challenges need to be overcome? What downsides must be dealt with? This first paper in a series on eHealth in primary care introduces basic concepts and examines opportunities for the uptake of eHealth in primary care. We illustrate that although the potential of eHealth in primary care is high, several conditions need to be met to ensure that safe and high-quality eHealth is developed for and implemented in primary care. eHealth research needs to be optimized; ensuring evidence-based eHealth is available. Blended care, i.e. combining face-to-face care with remote options, personalized to the individual patient should be considered. Stakeholders need to be involved in the development and implementation of eHealth via co-creation processes, and design should be mindful of vulnerable groups and eHealth illiteracy. Furthermore, a global perspective on eHealth should be adopted, and eHealth ethics, patients’ safety and privacy considered.
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Affiliation(s)
| | - Marise J Kasteleyn
- Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Eline Meijer
- Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Tobias N Bonten
- Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Elisa J F Houwink
- Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Martine Teichert
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Sanne van Luenen
- Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, The Netherlands.,Department of Clinical Psychology, Faculty of Social Sciences, Institute of Psychology, Leiden University, Leiden, The Netherlands
| | - Rajesh Vedanthan
- Department of Population Health, Section for Global Health, NYU School of Medicine, New York, NY, USA
| | - Andrea Evers
- Department of Health, Medical and Neuropsychology, Faculty of Social Sciences, Institute of Psychology, Leiden University, Leiden, The Netherlands
| | - Josip Car
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Hilary Pinnock
- Allergy and Respiratory Research Group, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, Scotland
| | - Niels H Chavannes
- Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, The Netherlands
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60
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Affiliation(s)
- David Nunan
- Primary Care Health Sciences, University of Oxford, Oxford, UK
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Pradhananga S, Regmi K, Razzaq N, Ettefaghian A, Dey AB, Hewson D. Ethnic differences in the prevalence of frailty in the United Kingdom assessed using the electronic Frailty Index. Aging Med (Milton) 2019; 2:168-173. [PMID: 31942531 PMCID: PMC6880682 DOI: 10.1002/agm2.12083] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 07/05/2019] [Accepted: 08/02/2019] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE There have been few studies in which the prevalence of frailty of different ethnic groups has been assessed in multiethnic countries. The aim of this study was to evaluate the prevalence of frailty in different ethnic groups in the United Kingdom. METHODS Anonymized electronic health records (EHR) of 13 510 people aged 65 years and over were extracted from the database of a network of general practitioners, covering 16 clinical commissioning groups in London. Frailty was determined using the electronic Frailty Index (eFI), which was automatically calculated using EHR data. The eFI was used as a categorical variable with fit and mild frailty grouped together, and moderate and severe frailty grouped as frail. RESULTS The overall prevalence of frailty was 18.1% (95% confidence interval [CI], 17.4%-18.9%). The prevalence of frailty increased with age (odds ratio [OR], 1.11; 95% CI, 1.10-1.12) and body mass index (BMI; OR, 1.05; 95% CI, 1.04-1.06). The highest prevalence of frailty was observed for Bangladeshis, with 32.9% classified as frail (95% CI, 29.2-36.7); and the lowest prevalence of 14.0% (95% CI, 12.6-15.5) was observed for the Black ethnic group. Stepwise logistic regression retained ethnicity, age, and BMI as predictors of frailty. CONCLUSION This pilot study identified differences in the prevalence of frailty between ethnic groups in a sample of older people living in London. Additional studies are warranted to determine the causes of such differences, including migration and socioeconomic status. It would be worthwhile carrying out a validation study of the eFI in different ethnic populations.
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Affiliation(s)
| | - Krishna Regmi
- Institute for Health ResearchUniversity of BedfordshireLutonUK
| | - Nasrin Razzaq
- Business Intelligence DepartmentAT Medics LtdLondonUK
| | | | - Aparajit Ballav Dey
- Department of Geriatric MedicineAll India Institute of Medical SciencesNew DelhiIndia
| | - David Hewson
- Institute for Health ResearchUniversity of BedfordshireLutonUK
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Han L, Clegg A, Doran T, Fraser L. The impact of frailty on healthcare resource use: a longitudinal analysis using the Clinical Practice Research Datalink in England. Age Ageing 2019; 48:665-671. [PMID: 31297511 DOI: 10.1093/ageing/afz088] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 05/01/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND routine frailty identification and management is national policy in England, but there remains a lack of evidence on the impact of frailty on healthcare resource use. We evaluated the impact of frailty on the use and costs of general practice and hospital care. METHODS retrospective longitudinal analysis using linked routine primary care records for 95,863 patients aged 65-95 years registered with 125 UK general practices between 2003 and 2014. Baseline frailty was measured using the electronic Frailty Index (eFI) and classified in four categories (non, mild, moderate, severe). Negative binomial regressions and ordinary least squares regressions with multilevel mixed effects were applied on the use and costs of general practice and hospital care. RESULTS compared with non-frail status, annual general practitioner consultation incidence rate ratios (IRRs) were 1.24 (95% CI: 1.21-1.27) for mild, 1.41 (95% CI: 1.35-1.47) for moderate, and 1.52 (95% CI: 1.42-1.62) for severe frailty. For emergency hospital admissions, the respective IRRs were 1.64 (95% CI 1.60-1.68), 2.45 (95% CI 2.37-2.53) and 3.16 (95% CI: 3.00-3.33). Compared with non-frail people the IRR for inpatient days was 7.26 (95% CI 6.61-7.97) for severe frailty. Using 2013/14 reference costs, extra annual cost to the healthcare system per person was £561.05 for mild, £1,208.60 for moderate and £2,108.20 for severe frailty. This equates to a total additional cost of £5.8 billion per year across the UK. CONCLUSIONS increasing frailty is associated with substantial increases in healthcare costs, driven by increased hospital admissions, longer inpatient stay, and increased general practice consultations.
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Affiliation(s)
- Lu Han
- Department of Health Sciences, University of York, Heslington, York, United Kingdom of Great Britain and Northern Ireland
| | - Andrew Clegg
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford Teaching Hospital NHS Foundation Trust, Bradford, West Yorkshire, United Kingdom of Great Britain and Northern Ireland
| | - Tim Doran
- Department of Health Sciences, University of York, Heslington, York, United Kingdom of Great Britain and Northern Ireland
| | - Lorna Fraser
- Department of Health Sciences, University of York, Heslington, York, United Kingdom of Great Britain and Northern Ireland
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63
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Kozakiewicz M, Kornatowski M, Krzywińska O, Kędziora-Kornatowska K. Changes in the blood antioxidant defense of advanced age people. Clin Interv Aging 2019; 14:763-771. [PMID: 31118597 PMCID: PMC6507109 DOI: 10.2147/cia.s201250] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 03/15/2019] [Indexed: 12/30/2022] Open
Abstract
Introduction: Since 1956 there have been numerous scientific articles about free radical theory of aging which both confirm and deny the theory. Due to oxygen metabolism, there are relatively high concentrations of molecular oxygen in human cells, especially in mitochondria. Under normal physiological conditions, a small fraction of oxygen is constantly converted to ROS, such as superoxide radical (O2-•), H2O2, and related metabolites. Aim of the study: The aim of this work was to show the relation between the activity of main antioxidative enzymes and the age of the examined patients. Materials and methods: The analysis of antioxidant defense was performed on the blood samples from 184 "aged" individuals aged 65-90+ years, and compared to the blood samples of 37 individuals just about at the beginning of aging, aged 55-59 years. Results: The statistically significant decreases of Zn,Cu-superoxide dismutase (SOD-1), catalase (CAT), and glutathione peroxidase (GSH-Px) activities were observed in elderly people in comparison with the control group. Moreover, an inverse correlation between the activities of SOD-1, CAT, and GSH-Px and the age of the examined persons was found. No age-related changes in glutathione reductase activities and malondialdehyde concentrations were observed. Conclusion: Lower activities of fundamental antioxidant enzymes in the erythrocytes of elderly people, which indicate the impairment of antioxidant defense in the aging organism and the intensity of peroxidative lipid structures, were observed.
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Affiliation(s)
- Mariusz Kozakiewicz
- Nicolaus Copernicus University in Torun Ludwig Rydygier Collegium Medicum in Bydgoszcz, Department of Food Chemistry, Bydgoszcz, Poland
| | - Maciej Kornatowski
- Nicolaus Copernicus University in Torun Ludwig Rydygier Collegium Medicum in Bydgoszcz, Department and Clinic of Geriatrics, Bydgoszcz, Poland
| | - Olga Krzywińska
- Nicolaus Copernicus University in Torun Ludwig Rydygier Collegium Medicum in Bydgoszcz, Department of Food Chemistry, Bydgoszcz, Poland
| | - Kornelia Kędziora-Kornatowska
- Nicolaus Copernicus University in Torun Ludwig Rydygier Collegium Medicum in Bydgoszcz, Department and Clinic of Geriatrics, Bydgoszcz, Poland
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Millares-Martin P. Large retrospective analysis on frailty assessment in primary care: electronic Frailty Index versus frailty coding. BMJ Health Care Inform 2019; 26:0. [PMID: 31039123 PMCID: PMC7062325 DOI: 10.1136/bmjhci-2019-000024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Primary care in UK is expected to use tools such as the electronic Frailty Index (eFI) to identify patients with frailty, which should be then validated and coded accordingly. Aim To assess the influence of organisation and software on how eFI score and direct clinical validation occurs across practices in Leeds. Method The ‘minimum necessary’ anonymised patient data required for the study (recorded eFI scores and frailty codes – mild, moderate or severe – with their dates of entry) was requested to the Health and Care Hub of the NHS Leeds Clinical Commissioning Group. Data from 44 185 patients from 104 practices using two different clinical software were collected. Descriptive statistics was carried out using SPSS software. Results 42 593 patients had a frailty code, 8881 had an eFI code. 7341 had both types of entry, and correlation between eFI and coded level of frailty was as expected high (85.3%), but there was statistically significant variation depending on practice and software used. When results did not match, there was a tendency to overstate, to code a level of frailty above the value to be assigned based on the numeric value of eFI, and it was more so on those practices using SystmOne software compared with those using EMIS Web. Conclusions Although correlation was generally good, the variability encountered would indicate the need for training and also for software improvements to reduce current disparity and facilitate validation, so frailty level is adequately recorded.
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Boyd PJ, Nevard M, Ford JA, Khondoker M, Cross JL, Fox C. The electronic frailty index as an indicator of community healthcare service utilisation in the older population. Age Ageing 2019; 48:273-277. [PMID: 30590413 DOI: 10.1093/ageing/afy181] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 09/25/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND older people with frailty are particularly high users of healthcare services, however a lack of standardised recording of frailty in different healthcare electronic datasets has limited investigations into healthcare service usage and demand of the older frail population. OBJECTIVES to investigate the community service demand of frail patients using the electronic frailty index (eFI) as a measure of frailty. STUDY DESIGN AND SETTING a retrospective cohort study using anonymised linked healthcare patient data from primary care, community services and acute hospitals in Norfolk. PARTICIPANTS patients aged 65 and over who had an eFI assessment score established in their primary care electronic patient record in Norwich based General Practices. RESULTS we include data from 22,859 patients with an eFI score. Frailty severity increased with age and was associated with increased acute hospital admission within a 6-month window. Patients with a frail eFI score were also more likely to have a community service referral within a 6-month window of frailty assessment, with a RR of 1.84 (1.76-1.93) for mild frailty, 1.96 (1.83-2.09) for moderate frailty and 2.95 (2.76-3.14) for severe frailty scores. We also found that frail patients had more community referrals per patient then those classified as fit and required more care plans per community referral. CONCLUSIONS eFI score was an indicator of community service use, with increasing severity of frailty being associated with higher community healthcare requirements. The eFI may help planning of community services for the frail population.
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Affiliation(s)
- Penelope J Boyd
- Faculty of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Matthew Nevard
- NHS North East London Commissioning Support Unit, Lakeside 400, Norwich, UK
| | - John A Ford
- Faculty of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Mizanur Khondoker
- Faculty of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Jane L Cross
- Faculty of Medicine and Health Sciences, School of Health Sciences, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Chris Fox
- Faculty of Medicine and Health Sciences, Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK
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Kojima G, Liljas AEM, Iliffe S. Frailty syndrome: implications and challenges for health care policy. Risk Manag Healthc Policy 2019; 12:23-30. [PMID: 30858741 PMCID: PMC6385767 DOI: 10.2147/rmhp.s168750] [Citation(s) in RCA: 188] [Impact Index Per Article: 37.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Older adults are a highly heterogeneous group with variable health and functional life courses. Frailty has received increasing scientific attention as a potential explanation of the health diversity of older adults. The frailty phenotype and the Frailty Index are the most frequently used frailty definitions, but recently new frailty definitions that are more practical have been advocated. Prevalence of frailty among the community-dwelling population aged 65 years and older is ~10% but varies depending on which frailty definitions are used. The mean prevalence of frailty gradually increases with age, but the individual's frailty level can be improved. Older adults, especially frail older adults, form the main users of medical and social care services. However, current health care systems are not well prepared to deal with the chronic and complex medical needs of frail older patients. In this context, frailty is potentially a perfect fit as a risk stratification paradigm. The evidence from frailty studies has not yet been fully translated into clinical practice and health care policy making. Successful implementation would improve quality of care and promote healthy aging as well as diminish the impact of aging on health care systems and strengthen their sustainability. At present, however, there is no effective treatment for frailty and the most effective intervention is not yet known. Based on currently available evidence, multi-domain intervention trials, including exercise component, especially multicomponent exercise, which includes resistance training, seem to be promising. The current challenges in frailty research include the lack of an international standard definition of frailty, further understanding of interventions to reverse frailty, the best timing for intervention, and education/training of health care professionals. The hazards of stigmatization should also be considered. If these concerns are properly addressed, widespread application of public health approaches will be possible, including screening, identification, and treatment of frailty, resulting in better care and healthier aging for older people.
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Affiliation(s)
- Gotaro Kojima
- Department of Primary Care and Population Health, University College London, London, UK,
| | - Ann E M Liljas
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Steve Iliffe
- Department of Primary Care and Population Health, University College London, London, UK,
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