1363 ‘Frailty as an Adjective Rather Than a Diagnosis’ - The Identification of Frailty in Primary Care: A Qualitative Interview Study

Abstract

Introduction In 2017 NHS England introduced proactive identification of frailty into the General Practitioners (GPs) Contract. There is currently little information as to how this policy has been operationalised by front-line clinicians, their working understanding of frailty, or perceptions of impact on patient care. Evidence from international settings suggests primary care clinicians may have mixed interpretations of frailty, with important implications for their willingness to support different frailty interventions. We aimed to explore the conceptualisation of frailty, and how community-dwelling frail older adults are identified in primary care. Methods Semi-structured interviews were conducted with primary care staff across England, including GPs, physician associates, nurse practitioners, paramedics and pharmacists. Thematic analysis was facilitated through NVivo (Version 13). Results 31 practitioners participated (12 GPs, 19 non-GPs). Frailty was seen as difficult to define, with uncertainty in its value as a medical diagnosis. The most common working model was the frailty phenotype, associated with deterioration at end of life. There was a mixture of formal and informal processes for identifying frailty. A few practices had embedded population screening and structured reviews. Informal processes included use of ‘housebound’ as a proxy for frailty, identification through chronic disease and medication reviews, and holistic assessment through good continuity of care. Many clinicians described poor accuracy of the electronic Frailty Index, yet it was commonly used to grade frailty during protocolised chronic disease reviews. The Clinical Frailty Score, in contrast, was felt to be easy to use and interpret, but inconsistently recorded within electronic health records. Most clinicians favoured better tools for identifying frailty, alongside resources to support these individuals. Conclusions Concepts of frailty in primary care differ. Identification is predominantly ad-hoc, opportunistic and associated with terminal illness. A more cohesive approach to frailty, relevant to primary care, together with better diagnostic tools, may encourage wider recognition.

Identifying and Managing Frailty: A Survey of UK Healthcare Professionals

“…However, in a study with Australian orthopedic surgeons, frailty screening was considered positive in principle but unlikely to be helpful or feasible in their everyday practice (Archibald et al, 2020). HCPs from both acute and community settings have suggested that frailty screening is less valuable as they informally assess this anyway without needing a formal tool (Archibald et al, 2020; Canbolat Seyman & Sara, 2023; Mulla et al, 2021; Papadopoulou et al, 2021; Seeley et al, 2023). Previous qualitative work with GPs, psychiatrists, orthopedic nurses, dietitians, and primary and community care staff also suggests frailty is not always well defined or consistently understood by HCPs, particularly across different professions (Anantapong & Tinker, 2019; Canbolat Seyman & Sara, 2023; Coker et al, 2019; Mulla et al, 2021; Roberts et al, 2023; Seeley et al, 2023), with variations in preference of screening tool by discipline (Liu et al, 2022).…”

“…HCPs from both acute and community settings have suggested that frailty screening is less valuable as they informally assess this anyway without needing a formal tool (Archibald et al, 2020; Canbolat Seyman & Sara, 2023; Mulla et al, 2021; Papadopoulou et al, 2021; Seeley et al, 2023). Previous qualitative work with GPs, psychiatrists, orthopedic nurses, dietitians, and primary and community care staff also suggests frailty is not always well defined or consistently understood by HCPs, particularly across different professions (Anantapong & Tinker, 2019; Canbolat Seyman & Sara, 2023; Coker et al, 2019; Mulla et al, 2021; Roberts et al, 2023; Seeley et al, 2023), with variations in preference of screening tool by discipline (Liu et al, 2022). Lack of support and resources has also been cited as a barrier in both acute and primary care settings (Liu et al, 2022; Mulla et al, 2021; Papadopoulou et al, 2021).…”

“…Lack of support and resources has also been cited as a barrier in both acute and primary care settings (Liu et al, 2022; Mulla et al, 2021; Papadopoulou et al, 2021). Patients often view frailty as an unmalleable, downward trajectory (D’Avanzo et al, 2017), and therefore concerns have been raised around the acceptability of the frailty label to patients (Archibald et al, 2020; Kennedy et al, 2021; Seeley et al, 2023), and in particular understanding of the malnutrition element (Roberts et al, 2023).…”

“…Only 38.1% UK hospital doctors had received frailty identification training, with 67.9% agreeing they would like more teaching on this (Taylor et al, 2017). Particular training needs identified in other studies include the different grades of frailty (Mulla et al, 2021; Seeley et al, 2023), malnutrition assessment and interpretation (Roberts et al, 2023), and guidance on using specific tools with clear instructions as to what the scoring should be used for and how to explain in to other HCPs and patients (Coker et al, 2019). HCPs suggested that frailty training should be incorporated into the curriculum at an early stage (Mulla et al, 2021; Papadopoulou et al, 2021).…”

Developing a framework of concerns from people living with frailty, for the Measure Yourself Concerns and Wellbeing (MYCaW) person-centred outcome measure

“…As the average age of the UK population continues to increase, identifying and supporting people 65 years and over who live with moderate or severe frailty was made a routine part of the National Health Service (NHS) General Practice contract in 2017/2018. There is debate on how useful the electronic frailty index is, which was recommended for identifying people who are frail,6 7 how frailty is conceptualised by medical practitioners6 and what outcome measures are suitable to monitor impact of frailty on a person 8. Nevertheless, local frailty strategies are being put into action in the English NHS 9…”