Development of a frailty measure to inform quality of care Joseph - PowerPoint PPT Presentation

Defining Frailty in Acute Care: Development of a frailty measure to inform quality of care Joseph Emmanuel Amuah Canadian Institute for Health Information cihi.ca @cihi_icis September 27, 2019 Jamuah@

Why measure frailty in acute care now? Frailty measures are An increasing Comprehensive Frail individuals available and in use for number Canadians geriatric assessments have increased home care, long term will become frail are preferred but care needs that care, and assisted living expensive to implement are dynamic but not in systematic use in acute care There is no commonly used pan-Canadian measure in inpatient acute care 2

Methodology 3

Development of a frailty risk score • Accumulation of deficits is used to determine the frailty risk score. ‒ Cumulative deficit models are closely related to the biological age of the individual being examined for frailty ‒ Common deficits include signs, symptoms, abnormal lab values, disease states and disabilities • List of deficits were established based on extensive consultation with experts in the field, the Searle et al. criteria, and data analysis. • Linear regression analysis was performed to assign weights to each deficit. Weights were then used to calculate frailty risk scores. 4

Inclusion and exclusion criteria • Includes all in-patient hospital stays during a one year period (FY2016-2017) • Includes patients aged 65 and older • Excludes maternity and abortion patients • Excludes patients who received care in Quebec a Quebec health card number • Databases for inclusion or validation: ‒ Discharge Abstract Database (DAD) ‒ Continuing Care and Home Care Reporting Systems (CCRS and HCRS) ‒ National Rehabilitation System (NRS) 5

List of deficits (36 condition categories) Morbidity Function Sensory Loss Other • Anemia • Instrumental activities • Sensory impairment • Endocrine • Cardiac • Epilepsy of daily living (IADLs) • History of medications • Cancer • Arthritis and • Infections • Cerebrovascular inflammation • Diabetes • Movement and • Nutrition and wasting Cognition & Mood • Gastrointestinal • Pain immobility • Hypo- and • Fatigue • Organ transplants and • Delirium • Functional hypertension ostomies • Delusions and • Other frailty conditions • Incontinence dependence hallucinations • Renal • Fractures and and diseases • Dementia and • Respiratory • Other injuries osteoporosis Alzheimer's • Thrombosis and • Musculoskeletal • Ulcers and soft tissue • Other cognitive • Machine dependence embolisms disorders disorders • Edema • Mood disorders 6

Preliminary Results 7

Distribution of frailty risk score among patients aged 65+ 18% 16% 14% 12% % of patients 10% 8% 6% 4% 2% 0% 0.00 0.03 0.06 0.08 0.11 0.14 0.17 0.19 0.22 0.25 0.28 0.31 0.33 0.36 0.39 0.42 0.44 0.47 0.50 0.53 0.56 0.58 Frailty Risk Score (Unweighted) Risk of frailty increases 8

Distribution of weighted frailty risk score among patients aged 65+ 20 18 16 14 % of patients 12 10 8 6 4 2 0 0.18 0.19 0.2 0.21 0.22 0.23 0.24 0.25 0.26 0.27 0.28 0.29 0.3 0.31 0.32 0.33 0.34 0.35 0.36 0.37 0.38 0.39 0.4 0.41 0.42 0.43 Weighted Frailty Risk Score Risk of frailty increases 9

Frailty risk score – Condition category weights Top 10 highest weighted condition categories Condition category Weight Dementia and Alzheimer’s 0.0386 Cerebrovascular 0.038 Instrumental activities of daily living (IADLs) 0.0333 Functional dependence 0.0219 Movement and immobility 0.0195 Delirium 0.0187 Diabetes 0.0175 Fatigue 0.017 Infections 0.0169 Fractures and osteoporosis 0.0147 10

Validation process • Comparison with other published frailty indices • Construct and predictive validity • Sensitivity analysis (planned) • Frail status over time (planned) 11

Comparison with other frailty measures Correlation with Correlation with Frailty Measure Description of Frailty measure CIHI’s Unweighted CIHI’s Weighted Frailty Risk Score Frailty Risk Score Frailty risk score (Gilbert Risk score created using cluster analysis on ICD-10 0.77 0.73 et al., 2018) codes in electronic hospital records Index created using Resident Assessment Frailty Index using HCRS Instrument (RAI) data in HCRS clients with full 0.24 0.36 (Campitelli, 2016) assessments. 72-items were included. Frailty Scale using HCRS Frailty scale created using RAI data in HCRS clients (Morris, Howard, & Steel, 0.21 0.37 with full assessments. 70-items were included. 2016) Frailty measure using CHESS scores from the HCRS full assessments 0.10 0.13 HCRS CHESS Score Index created using Resident Assessment Frailty Index CCRS Instrument (RAI) data in CCRS clients with full 0.10 0.14 (Campitelli, 2016) assessments. 72-items were included. Note: All p values are <0.0001 • Gilbert et al (2018), Campitelli (2016), and Morris, Howard, & Steel (2016) were found to be most highly correlated 12

Unweighted frailty risk score distribution by age group 70% 60% 50% 40% 30% 20% 10% 0% 65 to 74 75 to 84 85 to 94 95 and over 0.00 to 0.09 0.10 to 0.19 0.20 to 0.29 0.30 to 0.39 0.40 to 0.49 0.50 to 0.59 13

Next steps • Gather feedback and input on preliminary measure • Validate measure with stakeholders • Investigate further validity of measure in other sectors/community 14

Acknowledgements • Dr. Melissa Andrews , Dalhousie University • Dr. Colleen Maxwell , University of Waterloo • Dr. Susan Bronskill , Institute for Clinical • Dr. John Muscedere , Canadian Frailty Evaluative Sciences Network • Dr. Simon Conroy , University of Leicester • Dr. Kenneth Rockwood , Dalhousie University • Dr. Robert Fowler , Sunnybrook Health • Dr. Samir Sinha , Sinai Health System Sciences Centre • Dr. Olga Theou , Dalhousie University • Dr. Andrea Hill , Sunnybrook Health Sciences • Dr. Robin Urquhart , Dalhousie University Centre • Dr. Hannah Wunsch , Sunnybrook Health • Dr. John Hirdes , interRAI Canada Sciences Centre • Dr. David Hogan , University of Calgary 16

Expert Advisory Group members • Dr. Susan Bronskill, Institute for Clinical • Dr. John Muscedere, Canadian Frailty Evaluative Sciences Network • Dr. Simon Conroy, University of Leicester • Dr. Kenneth Rockwood, Dalhousie University • Dr. David Hogan, University of Calgary • Dr. Samir Sinha, Sinai Health System • Megan Klammer, Vancouver Island Health Authority • Dr. Olga Theou, Dalhousie University • Dr. Colleen Maxwell, University of Waterloo 17

Key references • Acute Care: ‒ Gilbert, T., et al. Development and validation of a Hospital Frailty Risk Score focusing on older people in acute care settings using electronic hospital records: an observational study. The Lancet . 2018. ‒ McIsaac, DI., et al. Derivation and validation of a gernealizable preoperative frailty index using population-based health administrative data. Annals of Surgery . 2018. ‒ Hubbard, RE., et al. Derivation of a frailty index from the interRAI acute care instrument. BMC Geriatrics. 2015. • Long-Term Care: ‒ Maclagan, LC., et al. Frailty and potentially inappropriate medication use at nursing home transition. Journal of the American Geriatrics Society . July 2017. • Assisted Living: ‒ Hogan, DB., et al. Comparing frailty measures in their ability to predict adverse outcome among older residents of assisted living. BMC Geriatrics. 2012. • Home Care: Campitelli, MA., et al. The prevalence and health consequences of frailty in a population-based older home care cohort: A comparison of different measures. BMC Geriatrics . 2016. 18

List of deficits and weights (36 condition categories) Morbidity Function Sensory Loss Other • Anemia (0.2073) • Instrumental activities of • Endocrine (-0.583) • Sensory impairment • Epilepsy (0.2963) • Cardiac (0.2285) daily living (IADLs) (-0.411) • Cancer (0.2869) • History of medications (1.1083) • Cerebrovascular (1.1088) • Arthritis and inflammation (-0.457) • Infections (0.5492) • Diabetes (0.1343) (-0.458) Cognition & Mood • Gastrointestinal (-0.232) • Movement and • Nutrition and wasting • Hypo- and hypertension (0.3679) immobility (0.5917) • Fatigue (0.5448) • Pain (-0.376) (-0.726) • Delirium (0.9861) • Organ transplants and • Incontinence (0.619) • Functional dependence • Delusions and • Renal (0.6528) ostomies (-0.785) (0.8479) hallucinations (-0.434) • Respiratory (0.26) • Fractures and • Other frailty conditions • Dementia and Alzheimer's • Thrombosis and and diseases (0.2282) osteoporosis (0.3089) (1.9785) • Musculoskeletal (-0.626) • Other injuries (0.0833) embolisms (-0.128) • Other cognitive disorders • Ulcers and soft tissue • Machine dependence (0.1064) disorders (-0.544) (-0.489) • Mood disorders (-0.015) • Edema (0.0869) Note: All weight values are in brackets 19

Unweighted Frailty Risk Score by Sex 20

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