The Role of General Medicine in the Evaluation of Frailty in the Elderly Population: Definition of a Standardized Instrument for the Correct Framing of Frailty and Comparison with Currently Existing Instruments for Stratification of Clinical Risk
Authors:   MedOnLine-Statte, Statte (TA), Italy, Robusto Fabio , Colucci Giovanni ,   MedOnLine-Statte, Statte (TA), Italy, Zamparella Maria ,   MedOnLine-Statte, Statte (TA), Italy, Pellegrini Enrico Maria ,   MedOnLine-Statte, Statte (TA), Italy, Martucci Brigida ,   MedOnLine-Statte, Statte (TA), Italy, Iacovazzo Pasquale ,   MedOnLine-Statte, Statte (TA), Italy, Colucci Enza ,   MedOnLine-Statte, Statte (TA), Italy, Minardi Martino ,   MedOnLine-Statte, Statte (TA), Italy, Giliberti Cristina ,   Senior Lecturer in Italian Rice University, Houston, Texas, USA, Bossone Vito ,   Keiron AsMeG, Verona, Italy, Lepore Vito ,   Neurologist, former researcher, department of Neuroscience, Univerisity of Bari, Bari, Italy, Ivis Stefano ,   Keiron AsMeG, Verona, Italy
Published: March 2022

Frailty is a chronic condition that increases the vulnerability to stressogenic factors and prevents the patient from returning to the preceding condition of homeostasis. This increases the risk of negative outcomes and progressively brings the patient toward disability, leading to higher use of healthcare resources. Clinical risk stratification systems can generally be useful for identifying frail patients from the standpoint of a healthcare system, though General Practitioners (GPs) assume a key and irreplaceable role in the definition and correct diagnosis of frailty. This study developed a standardized instrument (called SVaFra) for the definition of frailty in the elderly population in a general medicine setting and compared it with a few clinical risk stratification tools that have already been validated and are in wide use. In addition, the impact of the application of SVaFra on healthcare outcomes was evaluated. A scientific board composed of experienced GPs, biomedical engineers, and other healthcare professionals, involved in the management of patients suffering from frailty, developed a framework in the form of a questionnaire for the evaluation of frailty by creating four principal groupings of the components that characterize it (clinical complexity, disability, family environment, and management complexity). An observational study, involving 98 GPs from four Italian regions who filled out the questionnaire, was then developed. The doctors were asked to provide a judgment for the four frailty components and the overall frailty. Additionally, a cohort of patients was stratified by applying Charlson Comorbidity Index (CCI) and Drug Derived Complexity Index (DDCI) to administrative databases. The utilization of healthcare resources in the year following the administration of the SVaFra framework with this population was compared with a control group with similar clinical or demographic characteristics. A total of 1,305 frail geriatric patients were identified (males 36.0%; mean age 83.1 ±8.52 years). Regarding the four principal areas used by the GPs to formulate a frailty judgment, the clinical categorization “moderate-severe” was most frequently noted (57.0%). The GPs then specified the following most frequent pathologies: arterial hypertension (76.4%), congestive heart failure (31.5%), dementia (30.7%), diabetes (29.9%), cardiac arrhythmia (27.6%), major depression (25.2%), stroke (22.0%), respiratory insufficiency (22.0%), chronic renal insufficiency (12.6%), management complexity (48.3%), disability (43.2%), and family environment (23.8%). For 165 subjects (12.6%), the GPs expressed an overall frailty judgment of “severe” based on management complexity and disability. Record linkage with administrative databases was possible in 102 cases. The presence of a CCI score of >0 was recorded in only 20 (15.3%) patients identified as frail by GPs, while high DDCI scores were recorded for 88 (86.3%) patients. As for the utilization of healthcare resources, a net reduction of healthcare costs, especially those associated with emergency services, was observed for the population characterized as frail by GPs as compared with the control group with similar clinical or demographic characteristics. The SVaFra instrument was simple to apply, with transferability for the individualization and characterization of frail patients in diverse healthcare realities. However, CCI, which was useful for the stratification of clinical risk profiles, classified the majority of patients who were identified as frail by GPs as low risk. On the other hand, high scores were identified by DDCI for the majority of frail patients. The simple focus of GPs on the problem of frailty obtained by the administration of the SVaFra framework led to a reduction of healthcare costs due to emergency room treatments. Thus, the development of adequate diagnostic and therapeutic pathways to be developed about healthcare systems based on the use of SVaFra may result in more careful and accurate management of frail patients in the future.