Using the Clinical Frailty Scale in Allocating Scarce Health Care Resources

Abstract

The key idea behind the Clinical Frailty Scale (CFS) is that, as people age, they are more likely to have things wrong with them. Those things they have wrong (health deficits) can, as they accumulate, erode their ability to do the high order functions which define their overall health. These high order functions include being able to: think and do as they please; look after themselves; interact with other people; and move about without falling. The Clinical Frailty Scale brings that information together in one place. This paper is a guide for people new to the Clinical Frailty Scale. It also introduces an updated version (CFS version 2.0), with revised level names (e.g., “vulnerable” becomes “living with very mild frailty”) and minor edits to level descriptions. The key points discussed are that the Clinical Frailty Scale assays the baseline state, it is not widely validated in younger people or those with stable single-system disabilities, and it requires clinical judgement. The Clinical Frailty Scale is now commonly used as a triage tool to make important clinical decisions such as allocating scarce health care resources for COVID-19 management; therefore, it is important that the scale is used appropriately.

Association between Clinical Frailty Scale score and hospital mortality in adult patients with COVID-19 (COMET): an international, multicentre, retrospective, observational cohort study

“…During the COVID-19 pandemic, the scarcity of resources necessitated triage of critical care for patients with COVID-19. 1 Triage decisions for critical care in older patients outside of the COVID-19 pandemic are regularly made on the basis of the degree of frailty. [2][3][4][5] Frailty is a condition with a high prevalence in older people and is characterised by a decline in multiple physiological systems and increased vulnerability to stressors.…”

“…Furthermore, the CFS has only been validated in samples of older (≥65 years) patients. 1,6 However, the widely used CFS might also be relevant in younger patients with COVID-19. Several studies have applied the CFS in younger populations with COVID-19; for example, Aw and colleagues 11 used the CFS in a population of patients aged 18 years and older with COVID-19, but only analysed the data in patients aged 65 years and older.…”

“…Several studies have applied the CFS in younger populations with COVID-19; for example, Aw and colleagues 11 used the CFS in a population of patients aged 18 years and older with COVID-19, but only analysed the data in patients aged 65 years and older. Hewitt and colleagues 8 showed in a subanalysis in patients younger than 65 years with COVID-19 that frailty (CFS score of 5-7 [CFS [5][6][7]) was associated with a higher mortality by day 7 than nonfrailty (CFS score of 1-4 [CFS [1][2][3][4] ]; appendix p 11). In an earlier study from Hewitt and colleagues, 15 in which patients aged 18 years and older without COVID-19 were admitted to an acute surgical unit, it was shown that worsening frailty was associated with significantly poorer patient outcomes, including mortality.…”

Oncogeriatric. Other frailty assessment instruments

“…In 2020, the CFS was further revised (version 2.0) with minor clarifying edits to the level descriptions and their correspon-ding labels. Most notably, CFS level 2 changed from "well" to "fit", level 4 from "vulnerable" to "living with very mild frailty", and levels 5-8 were restated as "living with... " mild, moderate, severe, and very severe frailty, respectively [18].…”

Frailty and mortality in patients with COVID-19 – Authors' reply

“… 2 However, in the UK, CFS scoring was recommended at the government level for triaging patients with COVID-19, 3 and so the exploration of the properties of the CFS in this context seemed timely and relevant. Use of frailty assessments in COVID-19 care is not exclusive to the UK; Rockwood and Theou 4 highlighted the need for all health-care professionals working with patients with COVID-19 to familiarise themselves with frailty assessment.…”