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

      research-article
      , MD 1 , , MD, MSc, FRCPC 1 , , MD, MSc, FRCPC 2 , , PhD 3 , , MD, FRCPC 1 ,
      Canadian Geriatrics Journal
      Canadian Geriatrics Society
      frailty, critical illness, measurement, interrater reliability

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          Abstract

          Background

          The Clinical Frailty Scale (CFS) is a commonly used frailty measure in intensive care unit (ICU) settings. We are interested in the test characteristics, especially interrater reliability, of the CFS in ICU by comparing the scores of intensivists to geriatricians.

          Methods

          We conducted a prospective cohort study on a convenience sample of newly admitted patients to an ICU in Edmonton, Canada. An intensivist and a resident in Geriatric Medicine (GM) independently assigned a CFS score on 158 adults within 72 hours of admission. A specialist in Geriatric Medicine assigned a CFS score independently of 20 of the 158 patients to assess agreement between the two raters trained in geriatrics. Predictive validity was captured using mortality and length of stay.

          Results

          Agreement on CFS score was fair for intensivists vs. GM resident (kappa 0.32) and for intensivists vs. GM specialist (0.29), but substantial for GM resident vs. staff (0.79). Despite this, the CFS remained prognostically relevant, regardless of rater background. Frailty (CFS ≥ 5) as assessed by either intensivist or GM resident was a strong predictor of in-hospital mortality (odds ratio [OR] 3.6; 95% CI, 1.6–8.4, p = .003 and OR 3.0; 95% CI 1.3–6.9; p = .01, respectively). Frailty was also positively correlated with age, illness severity measured by APACHE II score, and length of hospital stay.

          Conclusions

          The interrater reliability of the CFS in ICU settings is fair for intensivists vs. geriatricians.

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          Most cited references24

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          The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine.

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            Frailty assessment instruments: Systematic characterization of the uses and contexts of highly-cited instruments.

            The medical syndrome of frailty is widely recognized, yet debate remains over how best to measure it in clinical and research settings. This study reviewed the frailty-related research literature by (a) comprehensively cataloging the wide array of instruments that have been utilized to measure frailty, and (b) systematically categorizing the different purposes and contexts of use for frailty instruments frequently cited in the research literature. We identified 67 frailty instruments total; of these, nine were highly-cited (≥ 200 citations). We randomly sampled and reviewed 545 English-language articles citing at least one highly-cited instrument. We estimated the total number of uses, and classified use into eight categories: risk assessment for adverse health outcomes (31% of all uses); etiological studies of frailty (22%); methodology studies (14%); biomarker studies (12%); inclusion/exclusion criteria (10%); estimating prevalence as primary goal (5%); clinical decision-making (2%); and interventional targeting (2%). The most common assessment context was observational studies of older community-dwelling adults. Physical Frailty Phenotype was the most used frailty instrument in the research literature, followed by the Deficit Accumulation Index and the Vulnerable Elders Survey. This study provides an empirical evaluation of the current uses of frailty instruments, which may be important to consider when selecting instruments for clinical or research purposes. We recommend careful consideration in the selection of a frailty instrument based on the intended purpose, domains captured, and how the instrument has been used in the past. Continued efforts are needed to study the validity and feasibility of these instruments.
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              Association between frailty and short- and long-term outcomes among critically ill patients: a multicentre prospective cohort study.

              Frailty is a multidimensional syndrome characterized by loss of physiologic and cognitive reserves that confers vulnerability to adverse outcomes. We determined the prevalence, correlates and outcomes associated with frailty among adults admitted to intensive care. We prospectively enrolled 421 critically ill adults aged 50 or more at 6 hospitals across the province of Alberta. The primary exposure was frailty, defined by a score greater than 4 on the Clinical Frailty Scale. The primary outcome measure was in-hospital mortality. Secondary outcome measures included adverse events, 1-year mortality and quality of life. The prevalence of frailty was 32.8% (95% confidence interval [CI] 28.3%-37.5%). Frail patients were older, were more likely to be female, and had more comorbidities and greater functional dependence than those who were not frail. In-hospital mortality was higher among frail patients than among non-frail patients (32% v. 16%; adjusted odds ratio [OR] 1.81, 95% CI 1.09-3.01) and remained higher at 1 year (48% v. 25%; adjusted hazard ratio 1.82, 95% CI 1.28-2.60). Major adverse events were more common among frail patients (39% v. 29%; OR 1.54, 95% CI 1.01-2.37). Compared with nonfrail survivors, frail survivors were more likely to become functionally dependent (71% v. 52%; OR 2.25, 95% CI 1.03-4.89), had significantly lower quality of life and were more often readmitted to hospital (56% v. 39%; OR 1.98, 95% CI 1.22-3.23) in the 12 months following enrolment. Frailty was common among critically ill adults aged 50 and older and identified a population at increased risk of adverse events, morbidity and mortality. Diagnosis of frailty could improve prognostication and identify a vulnerable population that might benefit from follow-up and intervention.
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                Author and article information

                Journal
                Can Geriatr J
                Can Geriatr J
                Canadian Geriatrics Journal
                Canadian Geriatrics Society
                1925-8348
                September 2020
                01 September 2020
                : 23
                : 3
                : 235-241
                Affiliations
                [1 ]Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB
                [2 ]Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB
                [3 ]Research Facilitation, Data Integration, Management and Reporting (DIMR), Alberta Health Services, Edmonton, AB
                Author notes
                Correspondence to: Darryl B. Rolfson, md, frcpc, Division of Geriatric Medicine, Faculty of Medicine and Dentistry and School of Public Health, University of Alberta, 1–198, Clinical Sciences Building, 11350 83 Ave., Edmonton, AB T6G 2P4, Canada, E-mail: darryl.rolfson@ 123456ualberta.ca
                Article
                cgj-23-235
                10.5770/cgj.23.398
                7458598
                32904800
                f37d7156-a82c-4420-bf5b-6b3f40431a14
                © 2020 Author(s). Published by the Canadian Geriatrics Society

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No-Derivative license ( http://creativecommons.org/licenses/by-nc-nd/2.5/ca/), which permits unrestricted non-commercial use and distribution, provided the original work is properly cited.

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                Categories
                Original Research

                Geriatric medicine
                frailty,critical illness,measurement,interrater reliability
                Geriatric medicine
                frailty, critical illness, measurement, interrater reliability

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