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Safari R, Jackson J, Boole L. Comprehensive geriatric assessment delivered by advanced nursing practitioners within primary care setting: a mixed-methods pilot feasibility randomised controlled trial. BMC Geriatr 2023; 23:513. [PMID: 37620760 PMCID: PMC10463370 DOI: 10.1186/s12877-023-04218-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 08/04/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Comprehensive Geriatric Assessment (CGA)is a widely accepted intervention for frailty and can be cost-effective within a primary care setting. OBJECTIVE To explore the feasibility of identifying older adults with frailty and assess the subsequent implementation of a tailored CGA with care and support plan by Advanced Nursing Practitioners (ANPs). METHODS A mixed-method parallel randomised controlled trial was conducted. Participants were recruited from two General Practice (GP) centres between January and June 2019. Older adults with confirmed frailty, as assessed by practice nurses, were randomised, using a web service, to the intervention or treatment-as-usual (TAU) groups for six months with an interim and a final review. Data were collected on feasibility, health service usage, function, quality of life, loneliness, and participants' experience and perception of the intervention. Non-parametric tests were used to analyse within and between-group differences. P-values were adjusted to account for type I error. Thematic analysis of qualitative data was conducted. RESULTS One hundred sixty four older adults were invited to participate, of which 44.5% (n = 72) were randomised to either the TAU (n = 37) or intervention (n = 35) groups. All participants in the intervention group were given the baseline, interim and final reviews. Eight participants in each group were lost to post-intervention outcome assessment. The health service use (i.e. hospital admissions, GP/emergency calls and GP/Accident Emergency attendance) was slightly higher in the TAU group; however, none of the outcome data showed statistical significance between-group differences. The TAU group showed a deterioration in the total functional independence and its motor and cognition components post-intervention (p < .05), though the role limitation due to physical function and pain outcomes improved (p < .05). The qualitative findings indicate that participants appreciated the consistency of care provided by ANPs, experienced positive therapeutic relationship and were connected to wider services. DISCUSSION Frailty identification and intervention delivery in the community by ANPs were feasible. The study shows that older adults with frailty living in the community might benefit from intervention delivered by ANPs. It is suggested to examine the cost-effectiveness of the intervention in sufficiently powered future research. TRIAL REGISTRATIONS The protocol is available at clinicaltirals.gov, ID: NCT03394534; 09/01/2018.
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Affiliation(s)
- Reza Safari
- College of Health, Psychology and Social Care, University of Derby, Kedleston Rd, Derby, DE22 1GB, Derbyshire, UK.
| | - Jessica Jackson
- College of Health, Psychology and Social Care, University of Derby, Kedleston Rd, Derby, DE22 1GB, Derbyshire, UK
| | - Louise Boole
- College of Health, Psychology and Social Care, University of Derby, Kedleston Rd, Derby, DE22 1GB, Derbyshire, UK
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Luo J, Liao X, Zou C, Zhao Q, Yao Y, Fang X, Spicer J. Identifying Frail Patients by Using Electronic Health Records in Primary Care: Current Status and Future Directions. Front Public Health 2022; 10:901068. [PMID: 35812471 PMCID: PMC9256951 DOI: 10.3389/fpubh.2022.901068] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/31/2022] [Indexed: 11/21/2022] Open
Abstract
With the rapidly aging population, frailty, characterized by an increased risk of adverse outcomes, has become a major public health problem globally. Several frailty guidelines or consensuses recommend screening for frailty, especially in primary care settings. However, most of the frailty assessment tools are based on questionnaires or physical examinations, adding to the clinical workload, which is the major obstacle to converting frailty research into clinical practice. Medical data naturally generated by routine clinical work containing frailty indicators are stored in electronic health records (EHRs) (also called electronic health record (EHR) data), which provide resources and possibilities for frailty assessment. We reviewed several frailty assessment tools based on primary care EHRs and summarized the features and novel usage of these tools, as well as challenges and trends. Further research is needed to develop and validate frailty assessment tools based on EHRs in primary care in other parts of the world.
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Affiliation(s)
- Jianzhao Luo
- International Medical Centre/Ward of General Practice and National Clinical Research Centre for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoyang Liao
- International Medical Centre/Ward of General Practice and National Clinical Research Centre for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Xiaoyang Liao ; orcid.org/0000000344099674
| | - Chuan Zou
- Department of General Practice, Chengdu Fifth People's Hospital, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Qian Zhao
- International Medical Centre/Ward of General Practice and National Clinical Research Centre for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
- Qian Zhao ; orcid.org/0000000295405726
| | - Yi Yao
- International Medical Centre/Ward of General Practice and National Clinical Research Centre for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Xiang Fang
- International Medical Centre/Ward of General Practice and National Clinical Research Centre for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - John Spicer
- GP and Senior Lecturer in Medical Law and Clinical Ethics, Institute of Medical and Biomedical Education, St George's University of London, London, United Kingdom
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3
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Sepehri K, Low H, Hoang J, Park G, Song X. Promoting early management of frailty in the new normal: An updated software tool in addressing the need of virtual assessment of frailty at points of care. Aging Med (Milton) 2022; 5:4-9. [PMID: 35309154 PMCID: PMC8917261 DOI: 10.1002/agm2.12198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 01/27/2022] [Indexed: 12/12/2022] Open
Abstract
Introduction Frailty is a state of diminished physiological reserve and can be assessed using the frailty index. Early management of frailty is crucial for preventing adverse outcomes. Intended for assessing home‐living older adults, the initial release of the eFI‐CGA software was prior to the coronavirus disease 2019 (COVID‐19) pandemic. Methods In addressing the increased need of virtual assessment, the eFI‐CGA was upgraded to version 3.0. In this paper, we introduce the updated electronic frailty assessment tool, reporting the newly developed features and validating its use. Results End‐user experiences with the previous versions are discussed. The updated features include a search function to resume disrupted assessments. The improved user interface enabled clinicians to record care management details. Conclusion This study represents an example of software solutions in moving from disruption to transformation, benefiting healthcare for older adults during this challenging time.
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Affiliation(s)
- Katayoun Sepehri
- Clinical Research and Evaluation Surrey Memorial Hospital Surrey British Columbia Canada
| | - Hilary Low
- Clinical Research and Evaluation Surrey Memorial Hospital Surrey British Columbia Canada
| | - Jenny Hoang
- Clinical Research and Evaluation Surrey Memorial Hospital Surrey British Columbia Canada
| | - Grace Park
- Primary and Family Care Fraser Health Surrey British Columbia Canada
| | - Xiaowei Song
- Clinical Research and Evaluation Surrey Memorial Hospital Surrey British Columbia Canada.,Department of Biomedical Physiology & Kinesiology Simon Fraser University Burnaby British Columbia Canada
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4
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Kim DH. Measuring Frailty in Health Care Databases for Clinical Care and Research. Ann Geriatr Med Res 2020; 24:62-74. [PMID: 32743326 PMCID: PMC7370795 DOI: 10.4235/agmr.20.0002] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 02/10/2020] [Indexed: 12/23/2022] Open
Abstract
Considering the increasing burden and serious consequences of frailty in aging populations, there is increasing interest in measuring frailty in health care databases for clinical care and research. This review synthesizes the latest research on the development and application of 21 frailty measures for health care databases. Frailty measures varied widely in terms of target population (16 ambulatory, 1 long-term care, and 4 inpatient), data source (16 claims-based and 5 electronic health records [EHR]-based measures), assessment period (6 months to 36 months), data types (diagnosis codes required for 17 measures, health service codes for 7 measures, pharmacy data for 4 measures, and other information for 9 measures), and outcomes for validation (clinical frailty for 7 measures, disability for 7 measures, and mortality for 16 measures). These frailty measures may be useful to facilitate frailty screening in clinical care and quantify frailty for large database research in which clinical assessment is not feasible.
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Affiliation(s)
- Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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5
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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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6
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Sepehri K, Braley MS, Chinda B, Zou M, Tang B, Park G, Garm A, McDermid R, Rockwood K, Song X. A Computerized Frailty Assessment Tool at Points-of-Care: Development of a Standalone Electronic Comprehensive Geriatric Assessment/Frailty Index (eFI-CGA). Front Public Health 2020; 8:89. [PMID: 32296673 PMCID: PMC7137764 DOI: 10.3389/fpubh.2020.00089] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 03/04/2020] [Indexed: 02/05/2023] Open
Abstract
Background: Frailty is characterized by loss of biological reserves and is associated with an increased risk of adverse health outcomes. Frailty can be operationalized using a Frailty Index (FI) based on the accumulation of health deficits; items under health evaluation in the well-established Comprehensive Geriatric Assessment (CGA) have been used to generate an FI-CGA. Traditionally, constructing the FI-CGA has relied on paper-based recording and manual data processing. As this can be time-consuming and error-prone, it limits widespread uptake of this proven type of frailty assessment. Here, we report the development of an electronic tool, the eFI-CGA, for use on personal computers by frontline healthcare providers, to collect CGA data and automate FI-CFA calculation. The ultimate goal is to support early identification and management of frailty at points-of-care, and make uptake in Electronic Medical Records (EMR) feasible and transparent. Methods: An electronic CGA (eCGA) form was implemented to operate on Microsoft's WinForms platform and coded using C# programming language. Users complete the eCGA form, from which items under the CGA evaluation are automatically retrieved and processed to output an eFI-CGA score. A user-friendly interface and secured data saving methods were implemented. The software was debugged and tested using systematically designed simulation data, addressing different logic, syntax, and application errors, and then tested with clinical assessment. The user manual and manual scoring were used as ground truth to compare eFI-CGA input and automated eFI score calculations. Frontline health-provider user feedback was incorporated to improve the end-user experience. Results: The Standalone eFI-CGA software tool was developed and optimized for use on personal computers. The user interface adapted the design of paper-based CGA form to facilitate familiarity for clinical users. Compared to known scores, the software tool generated eFI-CGA scores with 100% accuracy to four decimal places. The eFI-CGA allowed secure data storage and retrieval of multiple types, including user input, completed eCGA form, coded items, and calculated eFI-CGA scores. It also permitted recording of actions requiring clinical follow-up, facilitating care planning. Application bugs were identified and resolved at various stages of the implementation, resulting in efficient system performance. Discussion: Accurate, robust, and reliable computerized frailty assessments are needed to promote effective frailty assessment and management, as a key tool in health care systems facing up to frailty. Our research has enabled the delivery of the standalone eFI-CGA software technology to empower effective frailty assessment and management by various healthcare providers at points-of-care, facilitating integrated care of older adults.
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Affiliation(s)
- Katayoun Sepehri
- Health Sciences and Innovation, Surrey Memorial Hospital, Surrey, BC, Canada
- Department of Computing Science, Simon Fraser University, Burnaby, BC, Canada
| | | | - Betty Chinda
- Health Sciences and Innovation, Surrey Memorial Hospital, Surrey, BC, Canada
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada
| | - Macy Zou
- Health Sciences and Innovation, Surrey Memorial Hospital, Surrey, BC, Canada
| | - Brandon Tang
- Health Sciences and Innovation, Surrey Memorial Hospital, Surrey, BC, Canada
| | - Grace Park
- Primary and Family Care, Fraser Health, Surrey, BC, Canada
| | - Antonina Garm
- Community Actions and Resources Empowering Seniors, Fraser Health Authority, Surrey, BC, Canada
| | - Robert McDermid
- Emergency Medicine, Surrey Memorial Hospital, Surrey, BC, Canada
| | - Kenneth Rockwood
- Division of Geriatric Medicine, Dalhousie University, Halifax, BC, Canada
- Centre for Healthcare of the Elderly, QEII Health Sciences Center, Halifax, NS, Canada
| | - Xiaowei Song
- Health Sciences and Innovation, Surrey Memorial Hospital, Surrey, BC, Canada
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada
- Division of Geriatric Medicine, Dalhousie University, Halifax, BC, Canada
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7
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Hu YL, Patel P, Fritz H. Detecting Prefrailty: Comparing Subjective Frailty Assessment and the Paulson-Lichtenberg Frailty Index. Gerontol Geriatr Med 2020; 6:2333721420904234. [PMID: 32076629 PMCID: PMC7003161 DOI: 10.1177/2333721420904234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/27/2019] [Accepted: 01/08/2020] [Indexed: 11/17/2022] Open
Abstract
We examined the level of agreement between subjective frailty assessments (SFA) and frailty classifications derived from the validated Paulson-Lichtenberg Frailty Index (PLFI). Clinic patients (n = 202) were classified as healthy, prefrail, or frail first by screening using the PLFI and later by two geriatric nurses and two geriatricians according to SFA. Of the 202 participants (mean age = 76.7 ± 8.6), 52 (26%) were prefrail and 57 (28%) were frail based on the PLFI. Geriatrician SFA aligned with the PLFI in 43.0% of prefrail and 65.7% of frail cases. Nurse SFA aligned with the PLFI in 43.9% of prefrail and 17.0% of frail cases. There was slight-to-fair agreement between SFA and PLFI (geriatrician: Cohen's κ = .23; 95% confidence interval (CI) = [.11, .35], p < .001; nurse: Cohen's κ = .20; 95% CI = [.08, .33], p = .001). Clinician SFA did not align well with PLFI classifications.
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Affiliation(s)
- Yi-Ling Hu
- Wayne State University, Detroit, MI, USA
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8
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Fillion V, Sirois MJ, Gamache P, Guertin JR, Morin SN, Jean S. Frailty and health services use among Quebec seniors with non-hip fractures: a population-based study using adminsitrative databases. BMC Health Serv Res 2019; 19:70. [PMID: 30683094 PMCID: PMC6347825 DOI: 10.1186/s12913-019-3865-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 01/02/2019] [Indexed: 01/12/2023] Open
Abstract
Background The number of frail elderly will increase as the world population ageing accelerates. Since frail elders are at risk of falls, hospitalizations and disabilities, they will require more health care and services. To assess frailty prevalence using health administrative databases, to examine the association between frailty and the use of medical services and to measure the excess use of health services following a non-hip fracture across frailty levels among community-dwelling seniors. Methods A population-based cohort study was built from the Quebec Integrated Chronic Disease Surveillance System, including men and women ≥65 years old, non-institutionalized in the pre-fracture year. Frailty was measured using the Elders Risk Assessment (ERA) index. Multivariate Generalized Estimating Equation models were used to examine the relationship between frailty levels and health services while adjusting for covariates. The excess numbers of visits to Emergency Departments (ED) and to Primary Care Practitioners (PCP) as well as hospitalizations were also estimated. Results The cohort included 178,304 fractures. There were 13.6 and 5.2% frail and robust seniors, respectively. In the post-fracture year, the risks of ED visits, PCP visits and hospitalizations, were significantly higher in frail vs. non-frail seniors: adjusted relative risk (RR) = 2.69 [95% CI: 2.50–2.90] for ED visits, RR = 1.28 [95% CI: 1.23–1.32] for PCP visits and RR = 2.34 [95% CI: 2.14–2.55] for hospitalizations. Conclusion Our results suggest that it is possible to characterize seniors’ frailty status at a population level using health administrative databases. Furthermore, this study shows that non-institutionalized frail seniors require more health services after an incident fracture. Screening for frailty in seniors should be part of clinical management in order to identify those at a higher risk of needing health services. Electronic supplementary material The online version of this article (10.1186/s12913-019-3865-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Vanessa Fillion
- Centre d'Excellence sur le Vieillissement de Québec (CEVQ), Québec, Canada. .,Centre de recherche du CHU de Québec, Québec, Canada. .,The Canadian Emergency Team Initiative (CETI), Québec, Canada. .,Bureau d'information et d'études en santé des populations, Institut national de santé publique du Québec (INSPQ), 945, avenue Wolfe, Québec, QC, G1V 5B3, Canada.
| | - Marie-Josée Sirois
- Centre d'Excellence sur le Vieillissement de Québec (CEVQ), Québec, Canada.,Centre de recherche du CHU de Québec, Québec, Canada.,The Canadian Emergency Team Initiative (CETI), Québec, Canada.,Université Laval, Québec, Canada.,Hôpital de l'Enfant-Jésus, 1401 18e rue, H-602, Québec, QC, G1J 1Z4, Canada
| | - Philippe Gamache
- Bureau d'information et d'études en santé des populations, Institut national de santé publique du Québec (INSPQ), 945, avenue Wolfe, Québec, QC, G1V 5B3, Canada
| | - Jason Robert Guertin
- Centre de recherche du CHU de Québec, Québec, Canada.,Université Laval, Québec, Canada.,Hôpital Saint-Sacrement, 1050 Chemin Sainte-Foy, Bureau J0-01, Québec, QC, G1S 4L8, Canada
| | - Suzanne N Morin
- Université McGill, Québec, Canada.,Montreal General Hospital, 1650 Cedar Avenue, Room B2.118, Montréal, QC, H3G 1A4, Canada
| | - Sonia Jean
- Bureau d'information et d'études en santé des populations, Institut national de santé publique du Québec (INSPQ), 945, avenue Wolfe, Québec, QC, G1V 5B3, Canada.,Université Laval, Québec, Canada
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9
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Kinosian B, Wieland D, Gu X, Stallard E, Phibbs CS, Intrator O. Validation of the JEN frailty index in the National Long-Term Care Survey community population: identifying functionally impaired older adults from claims data. BMC Health Serv Res 2018; 18:908. [PMID: 30497450 PMCID: PMC6267903 DOI: 10.1186/s12913-018-3689-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 11/05/2018] [Indexed: 11/16/2022] Open
Abstract
Background Use of a claims-based index to identify persons with physical function impairment and at risk for long-term institutionalization would facilitate population health and comparative effectiveness research. The JEN Frailty Index [JFI] is comprised of diagnosis domains representing impairments and multimorbid clusters with high long-term institutionalization [LTI] risk. We test the index’s discrimination of activities-of-daily-living [ADL] dependency and 1-year LTI and mortality in a nationally representative sample of over 12,000 Medicare beneficiaries, and compare long-term community survival stratified by ADL and JFI. Methods 2004 U.S. National Long-Term Care Survey data were linked to Medicare, Minimum Data Set, Veterans Health Administration files and vital statistics. ADL dependencies, JFI score, age and sex were measured at baseline survey. ADL and JFI groups were cross-tabulated generating likelihood ratios and classification statistics. Logistic regression compared discrimination (areas under receiver operating characteristic curves), multivariable calibration and accuracy of the JFI and, separately, ADLs, in predicting 1-year outcomes. Hall-Wellner bands facilitated contrasts of JFI- and ADL-stratified 5-year community survival. Results Likelihood ratios rose evenly across JFI risk categories. Areas under the curves of functional dependency at ≥3 and ≥ 2 for JFI, age and sex models were 0.807 [95% c.i.: 0.795, 0.819] and 0.812 [0.801, 0.822], respectively. The area under the LTI curve for JFI and age (0.781 [0.747, 0.815]) discriminated less well than the ADL-based model (0.829 [0.799, 0.860]). Community survival separated by JFI strata was comparable to ADL strata. Conclusions The JEN Frailty Index with demographic covariates is a valid claims-based measure of concurrent activities-of-daily-living impairments and future long-term institutionalization risk in older populations lacking functional information. Electronic supplementary material The online version of this article (10.1186/s12913-018-3689-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bruce Kinosian
- Center for Health Equity Research and Promotion, Cpl Michael J Crescenz VA Medical Center, Philadelphia, USA. .,Geriatrics and Extended Care Data Analysis Center, Cpl. Michael J Crescenz VA Medical Center, Philadelphia, USA. .,Department of Medicine, University of Pennsylvania, Philadelphia, USA.
| | - Darryl Wieland
- Biodemography of Aging Research Unit, Center for Population Health and Aging, Duke University, Durham, NC, USA.,Geriatric Research, Education and Clinical Center, VA Medical Center, Durham, NC, USA
| | - Xiliang Gu
- Biodemography of Aging Research Unit, Center for Population Health and Aging, Duke University, Durham, NC, USA
| | - Eric Stallard
- Biodemography of Aging Research Unit, Center for Population Health and Aging, Duke University, Durham, NC, USA
| | - Ciaran S Phibbs
- Health Economics Resource Center, Palo Alto VA Health Care System, Palo Alto, CA, USA.,Center for Innovation to Implementation, Stanford University School of Medicine, Palo Alto, CA, USA.,Geriatrics and Extended Care Data and Analysis Center, Palo Alto VA Health Care System, Palo Alto, CA, USA
| | - Orna Intrator
- Geriatrics and Extended Care Data and Analysis Center, Canandaigua VA Medical Center, Canandaigua, NY, USA.,Department of Public Health Sciences, University of Rochester, Rochester, NY, USA
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10
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The emergence and utilisation of frailty in the United Kingdom: a contemporary biopolitical practice. AGEING & SOCIETY 2018. [DOI: 10.1017/s0144686x18001319] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
AbstractFrailty has recently emerged as a dominant concept against a backdrop of media and governmental narratives that frame the growing ageing population as an economic threat to the current configuration of health care in the United Kingdom (UK). Despite frailty's popularity amongst geriatricians and policy makers, the concept faces resistance from other health-care professionals and older people themselves. This paper draws on the Foucauldian idea of biopower; by suggesting that the contemporary emergence and utilisation of frailty represents a biopolitical practice a number or critical observations are made. First, despite biomedical experts acknowledging ambiguities in the definition of frailty, the concept is presented as a truth discourse. This is driven by the ability of frailty measurements to predict risk of costly adverse outcomes; the capability of frailty scores to enumerate complex needs; and the scientific legitimacy frailty affords to geriatric medicine. Consequently, frailty has become pervasive, knowable and measurable. Second, the routine delineation between frail and robust objectifies older people, and can be said to benefit those making the diagnosis over those being labelled frail, with the latter becoming disempowered. Last, studies show that frailty is associated with increasing wealth inequalities in the UK; however, experts’ suggested management of frailty shifts the focus of responsibility away from ideologically driven structural inequalities towards the frail older person, attempting to encourage individuals to modify lifestyle choices. This neglects the association between lifestyle opportunities and socio-economic deprivation, and the impact of long-term poverty on health. These observations, set against the contemporary political climate of economic austerity, cuts to public services and rationalisation of health resources, bring the urgency of a critical consideration of frailty to the fore.
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11
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Rahman S. The two cultures of health and social care might perhaps be brought together by assets. Aging Med (Milton) 2018; 1:117-119. [PMID: 31942487 PMCID: PMC6880737 DOI: 10.1002/agm2.12035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 08/09/2018] [Accepted: 08/10/2018] [Indexed: 11/07/2022] Open
Abstract
Arguably, there are two sides to the frailty "coin," with only one culture dominated by deficits. Certainly, as cells age, they develop deficits as a result of the accumulation of unrepaired cellular and molecular damage; however, the factors that make people well or healthy are important in defending against deficits and building up resilience, and need to be routinely discussed with patients. I argue that all health and social care professionals should feel confident in exploring assets or more "positive aspects" of living, and this common language could even drive integration between person-centered services.
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Affiliation(s)
- Shibley Rahman
- England Centre for Practice DevelopmentFaculty of Health and WellbeingCanterbury Christ Church UniversityCanterburyUK
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12
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Kharrazi H, Anzaldi LJ, Hernandez L, Davison A, Boyd CM, Leff B, Kimura J, Weiner JP. The Value of Unstructured Electronic Health Record Data in Geriatric Syndrome Case Identification. J Am Geriatr Soc 2018; 66:1499-1507. [PMID: 29972595 DOI: 10.1111/jgs.15411] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 03/26/2018] [Accepted: 03/28/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To examine the value of unstructured electronic health record (EHR) data (free-text notes) in identifying a set of geriatric syndromes. DESIGN Retrospective analysis of unstructured EHR notes using a natural language processing (NLP) algorithm. SETTING Large multispecialty group. PARTICIPANTS Older adults (N=18,341; average age 75.9, 58.9% female). MEASUREMENTS We compared the number of geriatric syndrome cases identified using structured claims and structured and unstructured EHR data. We also calculated these rates using a population-level claims database as a reference and identified comparable epidemiological rates in peer-reviewed literature as a benchmark. RESULTS Using insurance claims data resulted in a geriatric syndrome prevalence ranging from 0.03% for lack of social support to 8.3% for walking difficulty. Using structured EHR data resulted in similar prevalence rates, ranging from 0.03% for malnutrition to 7.85% for walking difficulty. Incorporating unstructured EHR notes, enabled by applying the NLP algorithm, identified considerably higher rates of geriatric syndromes: absence of fecal control (2.1%, 2.3 times as much as structured claims and EHR data combined), decubitus ulcer (1.4%, 1.7 times as much), dementia (6.7%, 1.5 times as much), falls (23.6%, 3.2 times as much), malnutrition (2.5%, 18.0 times as much), lack of social support (29.8%, 455.9 times as much), urinary retention (4.2%, 3.9 times as much), vision impairment (6.2%, 7.4 times as much), weight loss (19.2%, 2.9 as much), and walking difficulty (36.34%, 3.4 as much). The geriatric syndrome rates extracted from structured data were substantially lower than published epidemiological rates, although adding the NLP results considerably closed this gap. CONCLUSION Claims and structured EHR data give an incomplete picture of burden related to geriatric syndromes. Geriatric syndromes are likely to be missed if unstructured data are not analyzed. Pragmatic NLP algorithms can assist with identifying individuals at high risk of experiencing geriatric syndromes and improving coordination of care for older adults.
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Affiliation(s)
- Hadi Kharrazi
- Center for Population Health Information Technology, Department of Health Policy and Management, Bloomberg School of Public Health.,Division of Health Sciences and Informatics, Department of General Internal Medicine, University School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Laura J Anzaldi
- Center for Population Health Information Technology, Department of Health Policy and Management, Bloomberg School of Public Health
| | | | - Ashwini Davison
- Division of Health Sciences and Informatics, Department of General Internal Medicine, University School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Cynthia M Boyd
- Center for Transformative Geriatric Research, Division of Geriatric Medicine and Gerontology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Bruce Leff
- Center for Transformative Geriatric Research, Division of Geriatric Medicine and Gerontology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | - Jonathan P Weiner
- Center for Population Health Information Technology, Department of Health Policy and Management, Bloomberg School of Public Health
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Comparing clinician descriptions of frailty and geriatric syndromes using electronic health records: a retrospective cohort study. BMC Geriatr 2017; 17:248. [PMID: 29070036 PMCID: PMC5657074 DOI: 10.1186/s12877-017-0645-7] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 10/17/2017] [Indexed: 01/15/2023] Open
Abstract
Background Geriatric syndromes, including frailty, are common in older adults and associated with adverse outcomes. We compared patients described in clinical notes as “frail” to other older adults with respect to geriatric syndrome burden and healthcare utilization. Methods We conducted a retrospective cohort study on 18,341 Medicare Advantage enrollees aged 65+ (members of a large nonprofit medical group in Massachusetts), analyzing up to three years of administrative claims and structured and unstructured electronic health record (EHR) data. We determined the presence of ten geriatric syndromes (falls, malnutrition, dementia, severe urinary control issues, absence of fecal control, visual impairment, walking difficulty, pressure ulcers, lack of social support, and weight loss) from claims and EHR data, and the presence of frailty descriptions in clinical notes with a pattern-matching natural language processing (NLP) algorithm. Results Of the 18,341 patients, we found that 2202 (12%) were described as “frail” in clinical notes. “Frail” patients were older (82.3 ± 6.8 vs 75.9 ± 5.9, p < .001) and had higher rates of healthcare utilization, including number of inpatient hospitalizations and emergency department visits, than the rest of the population (p < .001). “Frail” patients had on average 4.85 ± 1.72 of the ten geriatric syndromes studied, while non-frail patients had 2.35 ± 1.71 (p = .013). Falls, walking difficulty, malnutrition, weight loss, lack of social support and dementia were more highly correlated with frailty descriptions. The most common geriatric syndrome pattern among “frail” patients was a combination of walking difficulty, lack of social support, falls, and weight loss. Conclusions Patients identified as “frail” by providers in clinical notes have higher rates of healthcare utilization and more geriatric syndromes than other patients. Certain geriatric syndromes were more highly correlated with descriptions of frailty than others. Electronic supplementary material The online version of this article (10.1186/s12877-017-0645-7) contains supplementary material, which is available to authorized users.
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