Heart failure

Clinician estimates of frailty in heart failure too “vague and unreliable”


Clinician-estimated frailty is too subjective and therefore has no place in the treatment of heart failure, researchers say.

Writing in Heart, Lung and Circulation, the research team from New South Wales and Queensland noted that frailty was common in heart failure and was associated with mortality and re-hospitalisation. 

Although a formal frailty assessment was recommended in international guidelines, ambiguity around how to define and measure frailty meant clinicians often relied on subjective ‘end-of-the-bed’ or ‘eyeball’ frailty tests to determine suitability for advanced therapies and/or surgical intervention.

In the current study, 39 cardiovascular clinicians (physicians, allied health and nurses) were asked to rate the frailty of 75 outpatients and inpatients with an average age of 54 years with heart failure as either: frail, pre-frail, or non-frail. Their clinical assessment was then compared to a modified version of the Frailty Phenotype. 

Results revealed that clinicians overestimated the ‘non-frail’ group by more than two-fold (44% clinician-estimated frailty vs 21% formal frailty) but underestimated those who were ‘pre-frail’ and ‘frail’. 

Interestingly, NYHA class did not have an effect on how the clinicians estimated patient frailty, the researchers found. When stratified by NYHA class III-IV, 25% of patients were estimated as ‘frail’, compared to 45% formally assessed as ‘frail’. NYHA class I–II was also associated with misclassification, with 59%  estimated as ‘non-frail’ compared to 27% formally assessed as ‘non-frail’. 

Of the three professional groups, allied health clinician frailty estimates showed the strongest agreement and correlation to the formal frailty assessment. However, the research team noted that the allied health clinicians included occupational therapists and physiotherapists who likely had experience undertaking frailty assessments as part of their clinical role. 

“Our results suggest that subjective estimates of frailty have no place in the treatment of patients with heart failure,” the research team concluded, acknowledging that there was a pressing need for frailty to be universally defined and a frailty instrument validated.

“Frailty, when correctly identified with an instrument, can be used as a highly sensitive and predictive risk-stratification tool, while subjective clinician estimates of frailty are vague and unreliable…therefore, clinician estimates of frailty and other informal subjective frailty identification methods should finally be made a thing of the past and formal frailty assessment put in its place,” they added.

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