Comparing the Hospital Frailty Risk Score and the Clinical Frailty Scale Among Older Adults With Chronic Obstructive Pulmonary Disease Exacerbation

Abstract

ImportanceFrailty is associated with severe morbidity and mortality among people with chronic obstructive pulmonary disease (COPD). Interventions such as pulmonary rehabilitation can treat and reverse frailty, yet frailty is not routinely measured in pulmonary clinical practice. It is unclear how population-based administrative data tools to screen for frailty compare with standard bedside assessments in this population.ObjectiveTo determine the agreement between the Hospital Frailty Risk Score (HFRS) and the Clinical Frailty Scale (CFS) among hospitalized individuals with COPD and to determine the sensitivity and specificity of the HFRS (vs CFS) to detect frailty.Design, Setting, and ParticipantsA cross-sectional study was conducted among hospitalized patients with COPD exacerbation. The study was conducted in the respiratory ward of a single tertiary care academic hospital (The Ottawa Hospital, Ottawa, Ontario, Canada). Participants included consenting adult inpatients who were admitted with a diagnosis of acute COPD exacerbation from December 2016 to June 2019 and who used a clinical care pathway for COPD. There were no specific exclusion criteria. Data analysis was performed in March 2022.ExposureDegree of frailty measured by the CFS.Main Outcomes and MeasuresThe HFRS was calculated using hospital administrative data. Primary outcomes were the sensitivity and specificity of the HFRS to detect frail and nonfrail individuals according to CFS assessments of frailty, and the secondary outcome was the optimal probability threshold of the HFRS to discriminate frail and nonfrail individuals.ResultsAmong 99 patients with COPD exacerbation (mean [SD] age, 70.6 [9.5] years; 56 women [57%]), 14 (14%) were not frail, 33 (33%) were vulnerable, 18 (18%) were mildly frail, and 34 (34%) were moderately to severely frail by the CFS. The HFRS (vs CFS) had a sensitivity of 27% and specificity of 93% to detect frail vs nonfrail individuals. The optimal probability threshold for the HFRS was 1.4 points or higher. The corresponding sensitivity to detect frailty was 69%, and the specificity was 57%.Conclusions and RelevanceIn this cross-sectional study, using the population-based HFRS to screen for frailty yielded poor detection of frailty among hospitalized patients with COPD compared with the bedside CFS. These findings suggest that use of the HFRS in this population may result in important missed opportunities to identify and provide early intervention for frailty, such as pulmonary rehabilitation.

Association of Frailty with Patient-Report Outcomes and Major Clinical Determinants in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease

“… 32 The frailty status based on the FRAIL scale indicated that frailty was prevalent in these patients (85.7%), with 40.7% pre-frail and 45.0% frail. This result is consistent with the results of the study by Chin et al, 33 who used the Clinical Frailty Scale (CFS) to detect frailty in 86% of such patients included in their study, which is higher than the patients with COPD. In addition, the results of two previous studies 7 , 10 on patients hospitalized with AECOPD revealed that the incidence of COPD exacerbations in frail individuals was 42% higher than that in non-frail individuals (incidence rate ratio [IRR] 1.42, 95% CI 0.94–2.17).…”

Validation of the Hospital Frailty Risk Score in older adults hospitalized with community‐acquired pneumonia

“…Additionally, the HFRS does not account for the severity of comorbidities and does not consider the functional status and abilities of the patient, which are important aspects of frailty assessment. Interestingly, this was demonstrated in a recent cross‐sectional study in patients with COPD exacerbations that showed disagreement between the HFRS and CFS in categorizing frail patients 35 . We were only able to capture the functional baseline of 30% of the study population owing to insufficient data, making correlations between HFRS and function difficult.…”

“…Interestingly, this was demonstrated in a recent cross-sectional study in patients with COPD exacerbations that showed disagreement between the HFRS and CFS in categorizing frail patients. 35 We were only able to capture the functional baseline of 30% of the study population owing to insufficient data, making correlations between HFRS and function difficult.…”

Adaptation of the Risk Analysis Index for Frailty Assessment Using Diagnostic Codes

“…For example, the HRFS relies heavily on acute diagnoses (eg, acute kidney failure or hypotension); the CFI-Kim includes infectious diseases (eg, pneumonia and influenza), lacerations, and paternity tests 33 ; and both the CFI-Segal and VA-FI include comorbidities (eg, hypertension and hyperlipidemia) highly prevalent in robust populations and not particular to frailty. As such, the face validity of these tools can be challenged, and these inconsistencies may explain their poor performance in specific disease states and among those that are critically ill. 39 , 40 Furthermore, the excellent discrimination of the HRFS for in-hospital mortality in the NIS may, in fact, highlight the tool’s selection of highly morbid, acute conditions without necessarily demonstrating specificity for frailty. For example, a 25-year-old professional athlete who slips on their stairs at home and falls again upon getting up with a resulting concussion and small traumatic intracranial hemorrhage would obtain an HFRS score consistent with frailty despite being an elite athlete (eMethods in Supplement 1 ).…”