This prospective analysis of 592 adults enrolled into the Western Sydney Clinical Frailty registry demonstrates that pre-morbid frailty assessed using the simple, pictorial CFS is a powerful independent predictor of the composite endpoint ‘rehospitalisation and/or mortality’ within 12 months post-discharge. These results suggest that routine frailty screening using the CFS for older adults presenting to acute geriatric settings is not only feasible but clinically useful. For example, frailty scores could help inform shared decision-making conversations on the likelihood of readmission and/or death after discharge. These data could also improve decision-making in the context of invasive procedures (such as endoscopy), de-prescribing, and advanced care planning, at a local level in Western Sydney and more broadly at a national level. There is future hope for real-time frailty assessment via Electronic Medical Records and dashboards (16–18), which would eliminate costly human resources needed to undertake more time-consuming performance-based frailty measures.
A recent systematic review examining the association between CFS and adverse health outcomes in older adults in acute care settings supports our findings, reporting that all studies (n = 29) demonstrated that a CFS score could independently predict multiple adverse outcomes, such as rehospitalisation, mortality, length-of-stay, functional decline (12). Another recent study evaluating the CFS in adults ≥ 70 years admitted to geriatric acute care, reported that the CFS showed high inter-rater reliability between consultant doctors, nurses and other medical officers (intraclass correlation coefficient = 0.859, 95% CI: 0.827-0.885, P < 0.001) (19). Furthermore, the CFS is extremely quick to complete, which is useful in a busy clinical setting.
Clinical implications and future directions
Recently, the HARMONY model (acHieving dAta-dRiven quality iMprovement to enhance frailty Outcomes using a learNing health sYstem), a new frailty learning health system model of implementation science and practice improvement was applied to the Western Sydney Frailty Clinical Frailty Registry (20). Clinicians at the study site were presented with interim results from the frailty registry and in general, there was surprise at the high mortality rate for the frailest participants. This has important implications for acute geriatric medicine care. On the one hand, this could represent missed opportunities for preventative care, but may also be compatible with the view that such patients are in the final years of their life. If this is the case, then the patient’s preferences for goals of care should be discussed, including advanced care planning. It also demonstrates the importance of routinely collecting post-discharge outcome data that might be important in how future patients are managed.
The Western Sydney Clinical Frailty Registry recently had ethical amendments approved for ‘opt-out’ consent procedures. A consumer advisory group with Aged Care and Rehabilitation services consumers revealed that consumers believed that the post-discharge phone calls provided within the registry follow-up should be standard practice. Having opt-out consent is not only less burdensome for participants, researchers, and clinicians, but it allows greater access to the increased follow-up post-discharge for all people admitted to the Aged Care and Rehabilitation services at Blacktown Mount Druitt Hospitals. Further, this model of consent is aimed at reducing study selection and recruitment bias.
As per a recent recommendation by the Australian Registry of Clinical Quality Registries, we have also been approved to collect additional patient-reported outcome measures (PROMS) on participants who are willing and able to do so. The PROMs include quality of life, self-reported frailty, and depression, and will be collected at baseline and repeated at the 12-month follow-up.
Readmission was common in this cohort, with one in two patients rehospitalised within 12 months. The research team are conducting qualitative research with consumers, clinicians, and expert stakeholders to explore hospital transition for older, frail adults who are at greatest risk. Consumer priorities were brain health and functional independence. Further, the use of the hospital was often viewed as an entitlement of older Australians, which contrasts hospital management and policy priorities of reducing readmissions and emergency department presentations. We intend to co-design and pilot an intervention targeted at improving the hospital transition experience.
Strengths and Limitations
The oldest and most frail patients are often left out of clinical trials. We have demonstrated the feasibility of prospectively recruiting and following up a large cohort of frail older people from a busy geriatric medicine service. As noted, follow-up data was available on all participants because this was permitted from the participant’s electronic medical record. This ongoing study presents an opportunity for trials within a cohort study design for the evaluation of frailty interventions and data linkage studies. Our consumer advisory panel were supportive of the research and helped revise our registry procedures.
The major weakness of our registry was the inevitable selection bias, for example, the eligibility criteria for the Western Sydney Clinical Frailty Registry stipulates that participants must speak English or have a family member who can provide consent on their behalf which has inevitably resulted in a selected population. We also did not have the resources to recruit all admitted patients, however, we have assembled a cohort with a range of frailty that has allowed us to explore the effects of frailty on important outcomes.