Subjective Assessment Underestimates Fraility in Patients With Heart Failure Referred for Advanced Therapies

Abstract

Assessment of frailty is key for evaluation for advanced therapies (ATs). Most programs use a subjective provider assessment (SPA) or "eye-ball" test; however, objective measures exist. The modified five-item Fried Frailty Index (mFFI) is a validated tool to assess frailty. We compared SPA to mFFI testing in patients referred for AT. We also compared levels of macrophage migration inhibitory factor (MIF), an inflammatory biomarker associated with worse outcomes in heart failure, between frail and not frail subjects. Seventy-eight patients referred for evaluation for AT underwent both SPA and mFFI testing. Three cardiac surgeons independently assessed patients for frailty (SPA). SPA significantly underestimated frailty compared with mFFI testing and correlation between SPA and mFFI was not strong (κ = 0.02-0.14). Providers were correct 84% of the time designating a subject as frail, but only 40% of the time designating as not frail. Agreement between all three providers was robust (76%), which was primarily driven by designation as not frail. There was no significant difference in plasma MIF levels between frail and not frail subjects (47.6 ± 25.2 vs. 45.2 ± 18.9 ng/ml; p = 0.6). Clinicians significantly underestimate frailty but are usually correct when designating a patient as frail.

Differences in preoperative frailty assessment of surgical candidates by sex, age, and race

“…In a study of advanced chronic kidney disease patients, Fried criteria identified 34 % to be frail, whereas 44 % of patients were qualified as frail by physician impression, with a weak agreement between assessments [ 32 ]. Among patients with heart failure, two separate studies reported fair agreement between formal and subjective provider assessment of frailty, yet overall, physicians tended to significantly overestimate non-frail patients and underestimate the true prevalence of frailty [ 19 , 20 ]. These results have encouraged the inclusion of self-rated indices in frailty measurements to improve detection rates, particularly in younger patients in which fitness status may not be visibly apparent [ 37 ].…”

“…Although most surgeons view frailty screening favorably, only one-third of practices include formal assessments due to concerns regarding clinical feasibility, doubt regarding its impact on decision-making, and belief that frailty is identified without questionnaires or physical testing [ [14] , [15] , [16] ]. Notably, subjective frailty assessments have demonstrated poor-to-fair agreement with objective frailty measures and often underestimate the prevalence of pre- to intermediately frail patients [ [17] , [18] , [19] , [20] , [21] ].…”

Perceptions of Bedside Nurses Caring for Patients with Left Ventricular Assist Devices (LVAD): A Qualitative Study

“…Caregiving has been related to stress, hopelessness, and isolation, as well as tiredness and sleep disturbances, elevations in circulatory cortisol, and the resulting losses in immunological function, illnesses, and early death ( Liu et al, 2020 ). Practitioners tend to prioritize the needs of patients over their own, and caregiver illness has been related to poor clinical outcomes ( Heaney et al, 2019 ). Caregiving for LVADs has been linked to an upsurge in depression, stress, and post-traumatic stress disorder ( Streur et al, 2020 ).…”

Prognostic Significance of the “Frailty Syndrome” in Elderly Patients with Diastolic Dysfunction and Heart Failure with Preserved Ejection Fraction

“…Multiple age-related changes occur in the cardiovascular system. Frailty has been defined as a state of late-life decline and vulnerability, identified as physical weakness and decreased physiologic reserve [17,18]. Differences between normal age-related change and frailty-related change in the cardiac structure and function have not been well described [19,20].…”