The Limited Utility of the Hospital Frailty Risk Score as a Frailty Assessment Tool in Neurosurgery: A Systematic Review

Abstract

BACKGROUND AND OBJECTIVES: The Hospital Frailty Risk Score (HFRS) is an International Classification of Disease 10th Revision-based scale that was originally designed for, and validated in, the assessment of patients 75 years or older presenting in an acute care setting. This study highlights central tenets inherent to the concept of frailty; questions the logic behind, and utility of, HFRS' recent implementation in the neurosurgical literature; and discusses why there is no useful role for HFRS as a frailty-based neurosurgical risk assessment (FBNRA) tool. METHODS: The authors performed a systematic review of the literature per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, including all cranial and spinal studies that used HFRS as their primary frailty tool. Seventeen (N = 17) studies used HFRS to assess frailty's impact on neurosurgical outcomes. Thirteen total journals, 10 of which were neurosurgical journals, including the highest impact factor journals, published the 17 papers. RESULTS: Increasing HFRS score was associated with adverse outcomes, including prolonged length of stay (11 of 17 studies), nonroutine discharge (10 of 17 studies), and increased hospital costs (9 of 17 studies). Four different HFRS studies, of the 17, predicted one of the following 4 adverse outcomes: worse quality of life, worse functional outcomes, reoperation, or in-hospital mortality. CONCLUSION: Despite its rapid acceptance and widespread proliferation through the leading neurosurgical journals, HFRS lacks any conceptual relationship to the frailty syndrome or FBNRA for individual patients. HFRS measures acute conditions using International Classification of Disease 10th Revision codes and awards “frailty” points for symptoms and examination findings unrelated to the impaired baseline physiological reserve inherent to the very definition of frailty. HFRS lacks clinical utility as it cannot be deployed point-of-care at the bedside to risk stratify patients. HFRS has never been validated in any patient population younger than 75 years or in any nonacute care setting. We recommend HFRS be discontinued as an individual FBNRA tool.

Commentary: The Limited Utility of the Hospital Frailty Risk Score as a Frailty Assessment Tool in Neurosurgery: A Systematic Review

“…4,5 The paper titled "The Limited Utility of the Hospital Frailty Risk Score as a Frailty Assessment Tool in Neurosurgery: A Systematic Review" presents a critical analysis of the Hospital Frailty Risk Score (HFRS) and its application in neurosurgical contexts. 6 The authors of this paper conducted a comprehensive review of 17 papers, in accordance with PRISMA criteria. They found that these studies had a consensus in reporting that HFRS was predictive of postoperative mortality, complications, extended length of stay, and discharge to a higher level of care facility (skilled nursing facility).…”

“…4 HFRS is criticized for being computationally impossible to distinguish whether frailty assessment occurs preoperatively or postoperatively, which is essential for neurosurgical frailty research. 5,6,11 Hence, the application of the tool in neurosurgical population introduces inaccuracies in the measured "frailty" of the surgical population and hence does not have practical utility in the context of guiding personalized intervention decisions or generating treatment guidelines without further validation studies. However, this does not entirely discredit previous studies using HFRS to predict mortality; rather, it might be possible to reframe their interpretation.…”

“…In comparison with existing literature, the paper aligns with other studies that have criticized HFRS for its limitations and lack of validation in specific patient populations. 6,[11][12][13][14] It underscores the importance of using frailty assessment tools that are appropriate for the context and have been rigorously validated, such as the Risk Analysis Index, which has shown strong discriminatory accuracy in predicting surgical outcomes across various age groups. [15][16][17] The authors also present a brief comparison of frailty scores based on the 10 core principles defined in Table 4 that offers comparison for these tools.…”

“…[15][16][17] The authors also present a brief comparison of frailty scores based on the 10 core principles defined in Table 4 that offers comparison for these tools. 6 However, a more comprehensive exposition is warranted, and a balanced comparison of the limitations inherent in both Risk Analysis Index and HFRS and other alternate risk scores should be undertaken to attain consensus within the field for a tool with most accurate predictability and better utilization across practice settings for risk-stratification and intervention decisions of our patients.…”

“…4,5 The paper titled “The Limited Utility of the Hospital Frailty Risk Score as a Frailty Assessment Tool in Neurosurgery: A Systematic Review” presents a critical analysis of the Hospital Frailty Risk Score (HFRS) and its application in neurosurgical contexts. 6…”