by Laura Dobie, Knowledge and Information Skills Specialist

The Challenge

A person with frailty can experience serious adverse outcomes following even a relatively minor illness. Timely identification of frailty can help to reduce the likelihood of a poor outcome following an intervention (or eliminate the need for an intervention entirely) and support the long-term management of people’s health needs.

If we can identify people with frailty in the community, we can offer preventative support that could improve their quality of life and reduce the risk of unscheduled admissions.

There are a number of tools which professionals can use to screen people for frailty (see the British Geriatric Society’s Fit for Frailty guidance). However, many of these tools are based on questionnaires that require practitioners to have direct contact with individuals and can only be used to assess people who are actively engaged with services.  It would be resource-intensive and challenging for services to screen large population groups for frailty using these individual assessments.

The risk stratification tool, Scottish Patients at Risk of Re-admissions or Admissions (SPARRA) identifies individuals within the whole population at risk of hospital admission based on nationally-collected data on acute admissions and community prescribing.  However, it does not discriminate frailty from other high-risk population groups and can only identify individuals who are known to services, as they have had recent acute admissions or have been prescribed high-risk medications.  Alternative population screening tools are needed to identify people with frailty living in the community.

What is the electronic frailty index?

The electronic frailty index (eFI) uses existing electronic health record data to detect and assess the severity of frailty. It uses a cumulative deficit model of frailty, in which frailty is defined through the accumulation of deficits, which can be clinical signs, symptoms, diseases and disability (see below).

Adapted from Clegg et al (2016), Development and validation of an electronic frailty index using routine primary care electronic health record data

The eFI comprises 36 deficits, which have been developed using GP read codes. A frailty score is calculated by dividing the total number of deficits that the person has by the total number of possible deficits. The score is used to stratify the population into not frail, mildly frail, moderately frail and severely frail. It has been externally validated using data from over 900,000 UK primary care patients, and is a reliable predictor of those who are at risk of adverse outcomes, such as care home admission, hospitalisation and mortality.

Copyright and database rights for the eFI are held by the University of Leeds. The eFI is licensed under terms stating that it is freely available to providers of electronic health record systems on the basis that the licensor will not charge any additional premium to its end users that is attributable to the inclusion of the eFI.

The eFI enables services and treatments to be targeted on the basis of people’s frailty status, rather than their chronological age and has the potential to transform care for older people living in the community.

What we are doing

The Living Well in Communities team is working with Health and Social Care Partnerships across Scotland to test the eFI with a Scottish population.

So far, we have carried out an initial test of the eFI with GP practices in Glasgow City, West Dunbartonshire and Midlothian. The results are displayed below:

We selected a random sample of patients scored in each category of the tool and reviewed the patient journeys to establish whether the scoring was accurate. We have used a combination of intelligence from two test phases to identify gaps in understanding and areas for improvement to the approach.

The test sites will agree interventions for each category of frailty and test on a small scale, and we will then implement interventions following the learning from the test sites.

Comparing the eFI and SPARRA

It is unclear whether the eFI identifies the same people at risk of admission as the frail elderly cohort of SPARRA. We’re aiming to work with Information Services Division (ISD) to link eFI population profiles with historic SPARRA scores to determine if the eFI identifies the same or a different group of individuals from the frailty cohort in SPARRA.  The analysis can also determine if individuals are identified as mildly, moderately or severely frail by eFI before they joined the frail elderly group in SPARRA.

These results could lead to a business case to develop eFI reports at NHS board-level, or the Scottish Primary Care Information Resource (SPIRE) could be used to calculate the eFI nation-wide to supplement SPARRA.

Determining the best use of health and social care resources

Strategic commissioning is at the heart of planning future health and social care services. We will be working with ISD to link eFI population profiles to Source to determine which services and resources are required to support each group. The results could build an evidence base to support strategic planning groups to shift the balance of care from unscheduled acute care to preventative community care.