A scale that measures clinical frailty might help health care professionals assess which older hospitalized patients are at increased risk for readmission or death, according to researchers from the University of Alberta in Edmonton, Canada.
Identifying vulnerable patients and addressing the factors contributing to readmission might help reduce recurrences, which are common and costly. However, it is difficult to predict accurately who is likely to be readmitted, the researchers said.
The researchers assessed whether the Clinical Frailty Scale can help predict readmission or death within 30 days after hospital discharge in a group of 495 patients at two Alberta hospitals (CMAJ 2015 May. The Clinical Frailty Scale, an easy-to-use tool developed several years ago, can be used at the bedside by physicians and other health care professionals to determine frailty. The scale measures difficulty in daily living activities, with “mild” frailty (score of 5) corresponding to difficulty with one or more complicated daily living activities, such as finances, shopping, meal preparation and housework. “Moderate” frailty (score of 6) indicates difficulty in bathing, dressing or climbing stairs. “Severe” frailty (score of 7) means a patient is physically or mentally dependent on someone for three or more daily living activities.
Of the patients enrolled in the study, half were women, and the median age was 64 years. One-third of the patients (n=162) were frail, with a score of 5 or higher on the Clinical Frailty Scale in the week before admission to hospital. Within 30 days after discharge, 85 patients (17%) were readmitted or had died. Compared with patients who were not frail, frail patients were at greater risk for readmission or death within 30 days (24% vs. 14%), especially those with moderate or severe frailty (31% vs. 14%).
“Frailty can be assessed at any stage [of patient care], including in the outpatient setting,” said Finely McAllister, MD, MSc, a professor of medicine at the University of Alberta. “The gold standard for assessing frailty would be a comprehensive geriatric assessment, which often involves a multidisciplinary team looking at various parameters of the patient, looking at physiologic function, psychosocial support and psychosocial functioning.”
A good predictive index (CMAJ 2010;182:551-557) for whether any person is likely to be readmitted within 30 days, regardless of age, is the LACE index, which is a mnemonic:
- Length of hospital stay;
- Acuity of hospital stay;
- Charleson Comorbidity Index score; and
- Emergency room visits within the previous six months.
Inclusion of frailty assessments using the Lace index improved the prediction of post-discharge outcomes in older patients, leading the authors to suggest that this assessment be included in discharge planning procedures to help identify patients at highest risk for poor transition from hospital to home.
The Clinical Frailty Scale can be a useful tool for health care professionals to identify patients with high probability of readmission and provide support to lessen this likelihood, they said.
“Assessing for frailty—assessing for an individual’s ability to complete activities of daily living prior to discharge can identify a group that is at increased risk for admissions, emergency department use and death within the first 30 days,” he said. Hospital staff should make sure there is better follow-up with the primary care physician after discharge and there are more home services and community support, if needed. Some patients might even benefit from a transition to a sub-acute care facility, such as inpatient rehabilitation, before being sent home, Dr. McAllister said.
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