Identifying Frail Patients by Using Electronic Health Records in Primary Care: Current Status and Future Directions

Examining South Tyrol's Experience: Digital Health Adoption and Workforce Issues in Implementing Italy's Primary Care Reform Under Ministerial Decree No. 77/2022

Background: Ministerial Decree (D.M.) 77/2022 aims to reform Italy's primary care system by establishing community health centres and integrating digital tools to address healthcare access disparities and workforce shortages. This review focuses on frailty assessment tools, digital health innovations, and workforce challenges in the Autonomous Province of Bolzano, South Tyrol, emphasising interprofessional trust and collaboration issues. Methods: Using a narrative custom review approach guided by the SANRA checklist, this study synthesised findings from PubMed, official health websites, and regional surveys on frailty, workforce dynamics, interprofessional collaboration, and digital infrastructure in South Tyrol. Results: General practitioners (GPs) exhibited high professional motivation but expressed concerns about autonomy and administrative burdens in collaborative care models. Trust issues between GPs and specialists hinder workforce cohesion and care coordination, highlighting the need for structured inter-professional communication. Frailty assessments, such as the PRISMA-7 tool, identify over 33% of community-dwelling individuals aged 75 years and older as frail, necessitating targeted interventions. Digital health adoption, particularly electronic health records and telemedicine, is slow because of workforce shortages and infrastructure limitations. Conclusions: The successful implementation of D.M. 77/2022 in South Tyrol requires addressing workforce challenges, improving interprofessional trust, expanding digital infrastructure, and integrating frailty assessment findings into care strategies. These measures are critical for achieving a more resilient, equitable, and effective primary healthcare system.

Unleashing frailty from laboratory into real world: A critical step toward frailty-guided clinical care of older adults

Understanding patients' degree of frailty is crucial for tailoring clinical care for older adults based on their physiologic reserve and health needs ("frailty-guided clinical care"). Two prerequisites for frailty-guided clinical care are: (1) access to frailty information at the point of care and (2) evidence to inform decisions based on frailty information. Recent advancements include web-based frailty assessment tools and their electronic health records integration for time-efficient, standardized assessments in clinical practice. Additionally, database frailty scores from administrative claims and electronic health records data enable scalable assessments and evaluation of the effectiveness and safety of medical interventions across different frailty levels using real-world data. Given limited evidence from clinical trials, real-world database studies can complement trial results and help treatment decisions for individuals with frailty. This article, based on the Thomas and Catherine Yoshikawa Award lecture I gave at the American Geriatrics Society Annual Meeting in Long Beach, California, on May 5, 2023, outlines our group's contributions: (1) developing and integrating a frailty index calculator (Senior Health Calculator) into the electronic health records at an academic medical center; (2) developing a claims-based frailty index for Medicare claims; (3) applying this index to evaluate the effect of medical interventions for patients with and without frailty; and (4) efforts to disseminate frailty assessment tools through the launch of the eFrailty website and the forthcoming addition of the claims-based frailty index to the Centers for Medicare and Medicaid Services Chronic Conditions Data Warehouse. This article concludes with future directions for frailty-guided clinical care.

Using Existing Clinical Data to Measure Older Adult Inpatients' Frailty at Admission and Discharge: Hospital Patient Register Study

BACKGROUND

Frailty is a widespread geriatric syndrome among older adults, including hospitalized older inpatients. Some countries use electronic frailty measurement tools to identify frailty at the primary care level, but this method has rarely been investigated during hospitalization in acute care hospitals. An electronic frailty measurement instrument based on population-based hospital electronic health records could effectively detect frailty, frailty-related problems, and complications as well be a clinical alert. Identifying frailty among older adults using existing patient health data would greatly aid the management and support of frailty identification and could provide a valuable public health instrument without additional costs.

OBJECTIVE

We aim to explore a data-driven frailty measurement instrument for older adult inpatients using data routinely collected at hospital admission and discharge.

METHODS

A retrospective electronic patient register study included inpatients aged ≥65 years admitted to and discharged from a public hospital between 2015 and 2017. A dataset of 53,690 hospitalizations was used to customize this data-driven frailty measurement instrument inspired by the Edmonton Frailty Scale developed by Rolfson et al. A 2-step hierarchical cluster procedure was applied to compute e-Frail-CH (Switzerland) scores at hospital admission and discharge. Prevalence, central tendency, comparative, and validation statistics were computed.

RESULTS

Mean patient age at admission was 78.4 (SD 7.9) years, with more women admitted (28,018/53,690, 52.18%) than men (25,672/53,690, 47.81%). Our 2-step hierarchical clustering approach computed 46,743 inputs of hospital admissions and 47,361 for discharges. Clustering solutions scored from 0.5 to 0.8 on a scale from 0 to 1. Patients considered frail comprised 42.02% (n=19,643) of admissions and 48.23% (n=22,845) of discharges. Within e-Frail-CH's 0-12 range, a score ≥6 indicated frailty. We found a statistically significant mean e-Frail-CH score change between hospital admission (5.3, SD 2.6) and discharge (5.75, SD 2.7; P<.001). Sensitivity and specificity cut point values were 0.82 and 0.88, respectively. The area under the receiver operating characteristic curve was 0.85. Comparing the e-Frail-CH instrument to the existing Functional Independence Measure (FIM) instrument, FIM scores indicating severe dependence equated to e-Frail-CH scores of ≥9, with a sensitivity and specificity of 0.97 and 0.88, respectively. The area under the receiver operating characteristic curve was 0.92. There was a strong negative association between e-Frail-CH scores at hospital discharge and FIM scores (rs=-0.844; P<.001).

CONCLUSIONS

An electronic frailty measurement instrument was constructed and validated using patient data routinely collected during hospitalization, especially at admission and discharge. The mean e-Frail-CH score was higher at discharge than at admission. The routine calculation of e-Frail-CH scores during hospitalization could provide very useful clinical alerts on the health trajectories of older adults and help select interventions for preventing or mitigating frailty.

Intestinal barrier damage contributes to a higher prevalence of frailty in aging people living with HIV: a retrospective case control study in a Chinese cohort

Background

It has been previously demonstrated that intestinal barrier damage is one of the underlying mechanisms leading to frailty in non-HIV-infected aging populations. However, there is a paucity of direct evidence which demonstrates the association between intestinal barrier damage and frailty in people living with HIV (PLWH).

Methods

The present study is a retrospective case control study. Participants older than 50 years old were stratified into a frail/pre-frail group (case group) and non-frail group (control group) according to the Fried frailty phenotype. We collected and curated data concerning socio-demographic variables, psychological states and social functioning, and clinical information associated with the identification of biomarkers of intestinal barrier damage, microbial translocation, and levels of inflammatory cytokines of participants.

Results

The case group had significantly higher levels of Reg-3α (p=0.042) and I-FABP (p=0.045) compared to the control group. We further observed, after adjusting for confounding factors by logistic regression analysis, that I-FABP levels remained significantly higher in the case group compared to the control group (p=0.033). Also, Fried Phenotype scores positively correlated with I-FABP levels (rs=0.21, p=0.01), LPS levels (rs=0.20, p=0.02), and sCD14 levels (rs=0.18, p=0.04). Moreover, the study confirmed both the positive correlation between inflammatory cytokines (IL-6 and IP-10) with frailty in aging PLWH, and between inflammatory cytokines (IL-6, IL-8 and IP-10) with biomarkers of intestinal barrier dysfunction in older PLWH.

Conclusion

The present study indicates that the inflammation induced by intestinal barrier damage/dysfunction is likely to contribute to frailty in aging PLWH.

Development and validation of an electronic frailty index in a national health maintenance organization

BACKGROUND

Frailty constitutes a major factor that puts the elderly at risk of health and functional deterioration.

OBJECTIVES

To develop and validate an Electronic Frailty Index based on electronic data routinely collected in the HMO.

STUDY DESIGN AND SETTING

A retrospective cohort of the HMO members.

PARTICIPANTS

120,986 patients, aged 65 years and over at the beginning of 2023.

PREDICTORS

A cumulative frailty index including 36 medical, functional, and social deficits.

OUTCOMES

One-year all-cause mortality or hospitalization.

STATISTICAL ANALYSIS

One-year hazard ratios were estimated for composite outcome of mortality or hospitalization using multivariable hierarchical Cox regression.

RESULTS

The mean EFI score increased with the Social Security Nursing Benefit. Compared to fit patients, mild, moderate, and severe frailty patients had 2.07, 3.35, and 4.4-fold increased risks of mortality or hospitalization, after controlling for covariates.

CONCLUSIONS

The findings showed that the Electronic Frailty Index version we created is valid in predicting mortality or hospitalization. In addition, the Electronic Frailty Index converged with an independent measurement produced by National Social Security.

Progression of frailty and cardiovascular outcomes among Medicare beneficiaries

BACKGROUND

Frailty is associated with adverse cardiovascular outcomes independent of age and comorbidities, yet the independent influence of frailty progression on cardiovascular outcomes remains uncertain.

METHODS

To determine whether frailty progression is associated with adverse cardiovascular outcomes, independent of baseline frailty and age, we evaluated all Medicare Fee-for-Service beneficiaries ≥65 years at cohort inception with continuous enrollment from 2003 to 2015. Linear mixed effects models, adjusted for baseline frailty and age, were used to estimate change in a validated claims-based frailty index (CFI) over a 5-year period. Survival analysis was used to examine frailty progression and risk of adverse health outcomes.

RESULTS

There were 8.9 million unique patients identified, mean age 77.3 ± 7.2 years, 58.7% female, 10.9% non-White race. In total, 60% had frailty progression and 40% frailty regression over median follow-up of 2.4 years. Compared to those with frailty regression, when adjusting for age and baseline CFI, those with frailty progression had a significantly greater risk of incident major adverse cardiovascular and cerebrovascular events (MACCE) (hazard ratio [HR] 1.31, 95% confidence interval [CI] 1.31-1.31), all-cause mortality (HR 1.34, 95% CI 1.34-1.34), acute myocardial infarction (HR 1.08, 95% CI 1.07-1.09), heart failure exacerbation (HR 1.30, 95% CI 1.29-1.30), ischemic stroke (HR 1.14, 95% CI 1.14-1.15). There was also a graded increase in risk of each outcome with more rapid progression, as well as significantly fewer days alive at home (DAH) with more rapid progression compared to the slowest progression group (270.4 ± 112.3 vs. 308.6 ± 93.0 days, rate ratio 0.88, 95% CI 0.87-0.88, p < 0.001).

CONCLUSIONS

In this large, nationwide sample of older Medicare beneficiaries, frailty progression, independent of age and baseline frailty, was associated with fewer DAH and a graded risk of MACCE, all-cause mortality, myocardial infarction, heart failure, and ischemic stroke compared to those with frailty regression.

Assessing the Benefits and Harms of Pharmacotherapy in Older Adults with Frailty: Insights from Pharmacoepidemiologic Studies of Routine Health Care Data

The objective of this review is to summarize and appraise the research methodology, emerging findings, and future directions in pharmacoepidemiologic studies assessing the benefits and harms of pharmacotherapies in older adults with different levels of frailty. Older adults living with frailty are at elevated risk for poor health outcomes and adverse effects from pharmacotherapy. However, current evidence is limited due to the under-enrollment of frail older adults and the lack of validated frailty assessments in clinical trials. Recent advancements in measuring frailty in administrative claims and electronic health records (database-derived frailty scores) have enabled researchers to identify patients with frailty and to evaluate the heterogeneity of treatment effects by patients' frailty levels using routine health care data. When selecting a database-derived frailty score, researchers must consider the type of data (e.g., different coding systems), the length of the predictor assessment period, the extent of validation against clinically validated frailty measures, and the possibility of surveillance bias arising from unequal access to care. We reviewed 13 pharmacoepidemiologic studies published on PubMed from 2013 to 2023 that evaluated the benefits and harms of cardiovascular medications, diabetes medications, anti-neoplastic agents, antipsychotic medications, and vaccines by frailty levels. These studies suggest that, while greater frailty is positively associated with adverse treatment outcomes, older adults with frailty can still benefit from pharmacotherapy. Therefore, we recommend routine frailty subgroup analyses in pharmacoepidemiologic studies. Despite data and design limitations, the findings from such studies may be informative to tailor pharmacotherapy for older adults across the frailty spectrum.

Progression of Frailty and Cardiovascular Outcomes Among Medicare Beneficiaries

Background

Frailty is associated with adverse cardiovascular outcomes independent of age and comorbidities, yet the independent influence of frailty progression remains uncertain.

Methods

Medicare Fee-for-service beneficiaries ≥ 65 years at cohort inception with continuous enrollment from 2003-2015 were included. Frailty trajectory was measured by annualized change in a validated claims-based frailty index (CFI) over a 5-year period. Linear mixed effects models, adjusting for baseline frailty, were used to estimate CFI change over a 5-year period. Survival analysis was used to evaluate associations of frailty progression and future health outcomes (major adverse cardiovascular and cerebrovascular events [MACCE], all-cause death, heart failure, myocardial infarction, ischemic stroke, and days alive at home [DAH] within the following calendar year).

Results

26.4 million unique beneficiaries were included (mean age 75.4 ± 7.0 years, 57% female, 13% non-White). In total, 20% had frailty progression, 66% had no change in frailty, and 14% frailty regression over median follow-up of 2.4 years. Compared to those without a change in CFI, when adjusting for baseline frailty, those with frailty progression had significantly greater risk of incident MACCE (hazard ratio [HR] 2.30, 95% confidence interval [CI] 2.30-2.31), all-cause mortality (HR 1.59, 95% CI 1.58-1.59), acute myocardial infarction (HR 1.78, 95% CI 1.77-1.79), heart failure (HR 2.78, 95% CI 2.77-2.79), and stroke (HR 1.78, 95% CI 1.77-1.79). There was also a graded increase in risk of each outcome with more rapid progression and significantly fewer DAH with the most rapid vs. the slowest progression group (270.4 ± 112.3 vs. 308.6 ± 93.0 days, rate ratio 0.88, 95% CI 0.87-0.88, p < 0.001).

Conclusions

In this large, nationwide sample of Medicare beneficiaries, frailty progression, independent of baseline frailty, was associated with fewer DAH and a graded risk of MACCE, all-cause mortality, myocardial infarction, heart failure, and stroke compared to those without progression.

Use of Electronic Medical Records (EMR) in Gerontology: Benefits, Considerations and a Promising Future

Electronic medical records (EMRs) have many benefits in clinical research in gerontology, enabling data analysis, development of prognostic tools and disease risk prediction. EMRs also offer a range of advantages in clinical practice, such as comprehensive medical records, streamlined communication with healthcare providers, remote data access, and rapid retrieval of test results, ultimately leading to increased efficiency, enhanced patient safety, and improved quality of care in gerontology, which includes benefits like reduced medication use and better patient history taking and physical examination assessments. The use of artificial intelligence (AI) and machine learning (ML) approaches on EMRs can further improve disease diagnosis, symptom classification, and support clinical decision-making. However, there are also challenges related to data quality, data entry errors, as well as the ethics and safety of using AI in healthcare. This article discusses the future of EMRs in gerontology and the application of AI and ML in clinical research. Ethical and legal issues surrounding data sharing and the need for healthcare professionals to critically evaluate and integrate these technologies are also emphasized. The article concludes by discussing the challenges related to the use of EMRs in research as well as in their primary intended use, the daily clinical practice.

Retrospective Use of the Pictorial Fit-Frail Scale for Determination of Frailty Level in Hospitalized Older Adults with a Hip Fracture

The Pictorial Fit-Frail Scale (PFFS) is a frailty tool consisting of visual images to comprehensively assess frailty across 14 domains that can be completed by health professionals, patients, or caregivers. The objective of this study was to explore the feasibility of using the PFFS retrospectively to determine a patient's frailty level using data from the hospital electronic health records (EHRs) of older adults admitted with an isolated hip fracture. A random sample of 200 hip fracture patients admitted to a Level 1 Trauma Center hospital in New Brunswick was selected for review using the PFFS. The majority (94.5%) of hospital EHRs contained the clinical information needed to populate most of the 14 PFFS domains, allowing for determination of a frailty score. The mean raw PFFS frailty score was 9.7 (SD 6.6), consistent with moderate frailty. For all patients, a Frailty Index (FI) score was calculated, with the mean being 0.27 (SD 0.18), again consistent with moderate frailty. Comparing the PFFS score to the FI score, the percentage categorized as not frail or very mildly frail fell from 33.3% to 20.1%, and those considered severely frail rose from 30.7% to 34.9%. The PFFS can be successfully used retrospectively with hospital EHRs to determine the frailty level of older patients. When converted to the FI score, there was an increase in the frequency and severity of frailty. This tool may provide a useful way to stratify older adults by frailty that can be helpful in evaluating health outcomes based on frailty levels.

Higher Hospital Frailty Risk Score Is Associated With Increased Risk of Stroke: Observational and Genetic Analyses

BACKGROUND

Frailty is a prevalent state associated with several aging-related traits and conditions. The relationship between frailty and stroke remains understudied. Here we aim to investigate whether the hospital frailty risk score (HFRS) is associated with the risk of stroke and determine whether a significant association between genetically determined frailty and stroke exists.

DESIGN

Observational study using data from All of Us research program and Mendelian Randomization analyses.

METHODS

Participants from All of Us with available electronic health records were selected for analysis. All of Us began national enrollment in 2018 and is expected to continue for at least 10 years. All of Us is recruiting members of groups that have traditionally been underrepresented in research. All participants provided informed consent at the time of enrollment, and the date of consent was recorded for each participant. Incident stroke was defined as stroke event happening on or after the date of consent to the All of Us study HFRS was measured with a 3-year look-back period before the date of consent for stroke risk. The HFRS was stratified into 4 categories: no-frailty (HFRS=0), low (HFRS ≥1 and <5), intermediate (≥5 and <15), and high (HFRS ≥15). Last, we implemented Mendelian Randomization analyses to evaluate whether genetically determined frailty is associated with stroke risk.

RESULTS

Two hundred fifty-three thousand two hundred twenty-six participants were at risk of stroke. In multivariable analyses, frailty status was significantly associated with risk of any (ischemic or hemorrhagic) stroke following a dose-response way: not-frail versus low HFRS (HR, 4.9 [CI, 3.5-6.8]; P<0.001), not-frail versus intermediate HFRS (HR, 11.4 [CI, 8.3-15.7]; P<0.001) and not-frail versus high HFRS (HR, 42.8 [CI, 31.2-58.6]; P<0.001). We found similar associations when evaluating ischemic and hemorrhagic stroke separately (P value for all comparisons <0.05). Mendelian Randomization confirmed this association by indicating that genetically determined frailty was independently associated with risk of any stroke (OR, 1.45 [95% CI, 1.15-1.84]; P=0.002).

CONCLUSIONS

Frailty, based on the HFRS was associated with higher risk of any stroke. Mendelian Randomization analyses confirmed this association providing evidence to support a causal relationship.