www.clahrc-yh.nihr.ac.uk electronic frailty index (efi) john young geriatrician, bradford, uk...

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Electronic Frailty Index (eFI)

John Young

Geriatrician, Bradford, UK

National Clinical Director for Integration & Frail Elderly, NHS England

([email protected])


Mrs Greenaway was found on the floor (“FLOF”) with new confusion by the home care staff and taken to hospital where is was found to be poorly mobile.

Fall Delirium Immobility

“She was a fall waiting to happen.”

Home care staff

Frailty is ………………


The “new” narrative:Frailty as a long-term condition ?

A LTC is: “A condition that cannot, at present, be cured but is controlled by medication and/or other treatment/therapies” (DH 2012)

Frailty is:• Common (25-50% of people over 80 years)• Progressive (5 to 15 years)• Episodic deteriorations (delirium; falls; immobility)• Preventable components• Potential to impact on quality of life• Expensive

(Harrison, Young, Clegg, Conroy Age & Ageing 2015)


Increasing frailty

Fit Mild frailty Moderate frailty Severe frailty

Frailty as a trajectory


Diagnostic Test Accuracy (DTA) for simple frailty instruments (Systematic Review)

Sensitivity Specificity

Gait Speed <0.8m/s 99% 64%

Gait Speed <0.7m/s 93% 78%

TUGT >10s 93% 62%

PRISMA 7 83% 83% (wide CIs)

Self-reported Health 83% 72% (wide CIs)

Groningen Frailty Indicator 58% 72%

Polypharmacy (>5 meds) 67% 72%

GP clinical assessment 58% 72%

(Frailty instruments assessed against a reference standard)

(Clegg, Teale, Young. Age Ageing 2014)


Phenotype Frailty Model(Cardiovascular Health Study [n=5210] Fried et al 2001)

Weight loss: > 4.5kg or > 5% per year

Fatigue: US Centre for Epidemiological Studies Depression Scale

Sedentary Life: < 383 Kcal/week men< 270Kcal/week women

Slow gait speed: Standardised cut-off times to walk 4.57m stratified by sex & height

Weakness: Dynamometer measurement stratified by sex & BMI


Cumulative Deficit Model of Frailty: Frailty Index (Rockwood et al)

“The more things that are wrong with you, the more likely you are to be frail”

• Frailty Index counts “deficits”• A deficit is a thing that is wrong with you (symptom, sign,

disease or disability)

Frailty Index = the proportion of deficits accumulated over timeSimple calculation:• Zero deficits from list of 50: FI = 0/50 = 0• Ten deficits from list of 50: FI = 10/50 = 0.20• Frailty Index(s) based on deficit accumulation closely related to

risk of death (Mexico, China, Canada, Europe etc. …)


Development of the primary care eFI

Existing primary care EHR (“SystmOne”)

Read Codes (>80,000 8,000 2,200)

Read codes map onto 36 ‘DEFICITS’

Tested in “ResearchOne” (n=227,648 ≥65y)

Internal Validation Process (n=227,063 ≥ 65y)

External Validation Process (n=516,107 ≥ 65 y)


OutcomeMild frailty

(HR, 95% CI)Moderate frailty

(HR, 95% CI)Severe frailty(HR, 95% CI)

1 yr care home admission

2.00 (1.68 to 2.39) 2.70 (2.41 to 3.04) 5.94 (4.61 to 7.64)


1.52 (1.37 to 1.69) 2.70 (2.41 to 3.04) 3.42 (2.84 to 4.12)


1.56 (1.43 to 1.70) 2.34 (2.10 to 2.61) 3.00 (2.42 to 3.70)

1 yr hospitalisation 1.85 (1.81 to 1.88) 2.96 (2.90 to 3.02) 4.62 (4.50 to 4.74)



1 yr mortality 1.91 (1.78 to 2.04) 3.39 (3.15 to 3.65) 5.23 (4.73 to 5.79)



eFI outcomes


Proportion alive

Time

Primary care electronic Frailty Index (eFI): survival plots (n=227,648; >65y)

Fit

Mild frailty

Moderate frailty

Severe frailty

5 yrs

Supported self-management

Care & Support Planning

Comprehensive Geriatric Assessment


FIT32%

MILD41%

MOD20%

SEV7%


Frailty & Social Deprivation

eFI score

Social Deprivation (IMD rank group)


Partners Engagement Count

GP Practices 22

CCGs (n=211) 35

CSU 1

SCN 1

CLAHRC 1

Public Health (regional)

3

Industry Partners 2 (ACG Systems)

VCS 1 (Age UK Y&H)

National Spread of eFI (Year 1)Clinical Commissioning Group

(Pop approx. 250,000)

• “at risk” populations• De-prescribing• EoLC/ACPs• Supported-self management

etc, etc………..


Summary:

• The eFI relates to the cumulative deficit model of frailty and uses existing primary care data (Read codes) to identifies people with mild, moderate and severe frailty

• Currently implemented in SystmOne (30% GPs) as a practice level report

• eFI has potential to inform development of proactive care for older people across the frailty spectrum

• Good early take up by CCGs in England

• May enable better targeting of interventions to reduce health inequalities in older age

www.clahrc-yh.nihr.ac.uk Collaboration for Leadership in Applied Health Research and Care, Yorkshire and Humber

Delivering innovative research through effective partnerships www.clahrc-yh.nihr.ac.uk

Acknowledgements: This presentation presents independent research by the Collaboration for Leadership in Applied Health Research and Care Yorkshire and Humber (NIHR CLAHRC YH). The views and opinions expressed are those of the authors, and not necessarily those of the NHS, the NIHR or the Department of Health. CLAHRC YH would also like to acknowledge the participation and resources of our partner organisations. www.clahrc-yh.nihr.ac.uk

Thank you.

University of Leeds

Andrew Clegg

John Young

Tizzy Teale

TPP

Chris Bates

John Parry

Ankit Sharma

University of Bradford

M A Mohammed

University of Birmingham

Ronan Ryan

Linda Nichols

Tom Marshall

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