Evaluating frailty index integrity: insights from an international network study

Deficit-accumulation frailty indices (FIs) have rapidly been integrated into health systems worldwide to quantify the state of reduced physiologic reserve to recover from a health insult in the aging population. Common data models (CDMs) have further enabled international, interinstitutional applications of FIs. However, the validity of such applications is unknown. The objective of this study was to evaluate the validity of 2 common FIs across disparate contexts.

We conducted an international network study comparing estimates of frailty prevalence from 2 electronic health record (EHR)-based FIs: United States-based Veterans Affairs FI (VAFI) and United Kingdom-based electronic FI (eFI) across 5 research and clinical databases. United States: All of Us (n = 159 721), IQVIA Pharmetrics+ (n = 5 099 557); United Kingdom: IMRD-THIN (n = 3 036 003), IMRD-EMIS (n = 832 455), and BioBank (n = 207 202).

In US databases, VAFI identified higher proportions of frailty ([VAFI; eFI] All of US: 10.3%; 2.5%, Pharmetrics+: 9.6%; 2%) while in UK databases, the eFI identified higher proportions (IMRD-THIN: <0.003%; 0.08%, IQVIA-EMIS: 0.09%; 0.4%, UK BioBank: 0.03%; 0.1%). Additional manipulations (alternative lookback periods, FI variations) were examined.

Frailty prevalence across databases and indices was inconsistent with expected frailty measurement trends. FIs are likely dependent on their development context, such as local coding behaviors and incentives, limiting their external validity despite CDM harmonization. We suggest caution in the application of FIs outside of their development context and recommend further instrument development before more widespread application of FIs using CDMs.