The Pathfields Tool: a frailty case-finding tool using primary care IT-implications for population health management

Area of Science:

• Gerontology
• Primary Care Medicine
• Health Informatics

Background:

• Identifying frailty in older adults is crucial for improving health and independence.
• Systematic identification of frail patients within primary care settings remains a significant challenge.

Purpose of the Study:

• To compare the diagnostic yield of a newly developed 'Pathfields High Risk Cohort' (PHRC) tool against the existing NHS England Electronic Frailty Index (eFI) for identifying patients with frailty in primary care.
• To assess the effectiveness of opportunistic clinical assessment and diagnosis facilitated by primary care IT reprogramming.

Main Methods:

• A primary care IT system was reprogrammed to establish a 'Pathfields High Risk Cohort' (PHRC) to identify patients likely to have undiagnosed frailty.
• Clinicians were invited to opportunistically assess and diagnose frailty within the PHRC group.
• Results were compared with the NHS England's Electronic Frailty Index (eFI) approach to determine the highest diagnostic yield.

Main Results:

• The Pathfields Tool identified 1,348 patients in the PHRC group, with 951 (70.5%) assessed and diagnosed.
• The eFI (moderate and severe) identified 683 patients, with 598 (87.6%) assessed and diagnosed.
• Extrapolated data suggests a frailty prevalence of 22.5% in the practice population aged 65+ (5.5% severe, 8.8% moderate, 8.1% mild).

Conclusions:

• The Pathfields Tool identified more patients with clinically confirmed, previously undiagnosed frailty compared to using eFI (moderate and severe frailty) alone.
• Sub-segmenting frailty by residential status holds potential for significantly improving population health management strategies for older adults.