Frailty is an aging-related syndrome characterised by progressive physiological decline and increased vulnerability to minor stressors, which can cause significant changes in a patient’s health status.(1) This vulnerability can lead to what some term “unstable disability”, in which a minor insult will render a usually independent patient dependent, followed by a slow recovery which often does not return them to their pre-morbid baseline.(2)
There are various validated tools available to assess frailty in clinical practice, ranging from simple assessments of functional status(3) to complex, multi-domain scoring systems that assess cognitive, physical and functional ability.(4–6) The most well-validated approaches used are the phenotype model, in which 5 criteria (exhaustion, poor handgrip strength, involuntary weight loss, inactivity and slow walking speed) are assessed and the number of criteria met used to categorise patients into levels of frailty(6), and the frailty index (FI), which quantifies a patient’s accumulated deficits to generate an index.(7)
Spontaneous pneumothorax (SP), in which there is abnormal accumulation of air in the pleural space due to leak of air from the lung, is a common condition, responsible for more than 6,000 hospital admissions annually in the UK.(8) Secondary spontaneous pneumothorax (SSP), occurring in the presence of an underlying lung disease or in smokers over the age of 50, represents 60% of all patients presenting with SP. This cohort of patients is challenging to manage; they represent a highly diverse population with a variety of underlying lung diseases and are, by definition, older with a higher co-morbidity burden than their younger primary spontaneous pneumothorax (PSP) counterparts. In addition, SSP is known to be more refractory to medical treatment (9), yet this cohort are frequently deemed unfit for definitive surgical management due to comorbidity and poor performance status.(10, 11) The long hospital admissions associated with the condition can further impact on a patient’s functional baseline.
Existing studies exploring the relationship between frailty and outcomes in respiratory disease have primarily focussed on Chronic Obstructive Pulmonary Disease (COPD) and Interstitial Lung Disease (ILD).(12, 13) Recent studies have evaluated the association between frailty and outcomes in pleural disease(14, 15) but none have explored frailty in spontaneous pneumothorax. Understanding the prevalence of frailty, how it can be assessed and the impact that it has on patient outcomes will help clinicians evaluate which patients may be fit for more interventional management and improve outcomes.
Large datasets are a useful tool to explore frailty at the population level. The Secure Anonymised Information Linkage (SAIL) Databank is a government funded national dataset based in Swansea, Wales, comprising multiple linked health records. This databank applies a validated frailty score, the electronic frailty index (eFI) to the population using read codes within a patient’s electronic health records to identify cumulative deficits associated with frailty and calculate a score.(4) This enables the identification of people living with frailty on a population level.
We will use the SAIL Databank to identify patients with episodes of secondary spontaneous pneumothorax, assess their frailty status using the eFI and explore the relationship between frailty and several outcome measures, including mortality, length of stay and readmission. This is the first study to explore the association between frailty and secondary spontaneous pneumothorax at large scale.
Aims
To investigate the impact of frailty on patient outcomes in secondary spontaneous pneumothorax. We will address the following research questions:
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What is the prevalence of frailty in adults with SSP?
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How does frailty status at first presentation with SSP impact on survival?
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How does frailty status in patients with SSP impact on clinical outcomes, including length of hospital stay, readmission rates and time to readmission?