Reliability of frailty assessment in the critically ill: a multicentre prospective observational study

Abstract

Demand for critical care among older patients is increasing in many countries. Assessment of frailty may inform discussions and decision making, but acute illness and reliance on proxies for history-taking pose particular challenges in patients who are critically ill. Our aim was to investigate the inter-rater reliability of the Clinical Frailty Scale for assessing frailty in patients admitted to critical care. We conducted a prospective, multi-centre study comparing assessments of frailty by staff from medical, nursing and physiotherapy backgrounds. Each assessment was made independently by two assessors after review of clinical notes and interview with an individual who maintained close contact with the patient. Frailty was defined as a Clinical Frailty Scale rating > 4. We made 202 assessments in 101 patients (median (IQR [range]) age 69 (65-75 [60-80]) years, median (IQR [range]) Acute Physiology and Chronic Health Evaluation II score 19 (15-23 [7-33])). Fifty-two (51%) of the included patients were able to participate in the interview; 35 patients (35%) were considered frail. Linear weighted kappa was 0.74 (95%CI 0.67-0.80) indicating a good level of agreement between assessors. However, frailty rating differed by at least one category in 47 (47%) cases. Factors independently associated with higher frailty ratings were: female sex; higher Acute Physiology and Chronic Health Evaluation II score; higher category of pre-hospital dependence; and the assessor having a medical background. We identified a good level of agreement in frailty assessment using the Clinical Frailty Scale, supporting its use in clinical care, but identified factors independently associated with higher ratings which could indicate personal bias.

Interrater Reliability of the Clinical Frailty Scale by Geriatrician and Intensivist in Patients Admitted to the Intensive Care Unit

“…The lowest level of agreement was found between physician/nurse pairings, while the highest level of agreement was found between nurses and physiotherapists. ( 17 ) In contrast, in our study, the comparison was between intensivist assessment and the comprehensive geriatric assessment.…”

“…( 12 ) Six studies, in addition to the original validation done in community dwelling outpatients, examined concurrent validity. ( 17 – 21 ) Of these, three had a primary objective of evaluating the reliability of frailty assessment in the ICU; however, none of them explicitly tested agreement with geriatricians based on CGA. ( 17 , 18 , 22 ) Instead, CFS ratings were obtained from chart review rather than direct patient or family contact, ( 18 ) or included only raters without formal training in geriatrics.…”

“…( 17 – 21 ) Of these, three had a primary objective of evaluating the reliability of frailty assessment in the ICU; however, none of them explicitly tested agreement with geriatricians based on CGA. ( 17 , 18 , 22 ) Instead, CFS ratings were obtained from chart review rather than direct patient or family contact, ( 18 ) or included only raters without formal training in geriatrics. ( 17 , 22 ) Given this existing gap in the literature, we sought to evaluate the test characteristics of the CFS, comparing geriatricians and intensivists in a critically ill population.…”

“…( 17 , 18 , 22 ) Instead, CFS ratings were obtained from chart review rather than direct patient or family contact, ( 18 ) or included only raters without formal training in geriatrics. ( 17 , 22 ) Given this existing gap in the literature, we sought to evaluate the test characteristics of the CFS, comparing geriatricians and intensivists in a critically ill population. We postulated poor agreement in the CFS score between geriatricians and intensivists.…”

Epidemiology of the First Wave of COVID-19 ICU Admissions in South Wales—The Interplay Between Ethnicity and Deprivation

“…As our patient population was relatively young, with fewer comorbidities and frailty than the Welsh average, we have opted for keeping active treatment as long as feasible in a bid to improve outcomes (3,9). Compared to some large European cohorts, our patients were significantly younger, however this was in line with the national experience in the UK and Wales and similar to the United States (10-13).…”