Rationing care by frailty during the COVID-19 pandemic

Mortality Trend of Severe COVID-19 in Under-Vaccinated Population Admitted to ICU in French Amazonia

(1) Background: Until December 2021, French Guiana (FG), located in South America, faced four consecutive COVID-19 epidemic waves. This study sought to analyze the mortality trend of severe COVID-19 patients admitted to the referral ICU of FG. (2) Methods: We conducted a prospective, observational, and non-interventional study in ICU at Cayenne Hospital. We included 383 patients older than 18 admitted with SARS-CoV-2-related pneumonia hospitalized from May 2020 to December 2021. The study covers three periods. Period 1 (Waves 1 and 2, original variant), period 2 (Wave 3, Gamma variant), and period 3 (Wave 4, Delta variant). (3) Results: The median age was 63 years (52-70). Frailty was diagnosed in 36 patients over 70 (32.4%). Only 4.8% of patients were vaccinated. The median ICU LOS was 10 days (6-19). Hospital mortality was 37.3%. It was 30.9% in period 1, 36.6% in period 2 (p = 0.329 vs. period 1), and 47.1% in period 3 (0.015 vs. period 1). In multivariate analysis, independent factors associated with hospital mortality included age greater than 40 years (]40-60 years] OR = 5.2, 95%CI: 1.4-19.5; (]60-70 years] OR = 8.5, 95%CI: 2.2-32; (]70+ years] OR = 17.9, 95%CI: 4.5-70.9), frailty (OR = 5.6, 95%CI: 2.2-17.2), immunosuppression (OR = 2.6, 95%CI: 1.05-6.7), and MV use (OR = 11, 95%CI: 6.1-19.9). This model had an overall sensitivity of 72%, a specificity of 80.4%, a positive predictive value of 68.7%, and a negative predictive value of 82.8%. (4) Conclusions: The mortality of severe COVID-19 patients in French Amazonia was higher during the Delta variant wave. This over-death could be explained by the virulence of the responsible SARS-CoV-2 variant and the under-vaccination coverage of the studied population.

Cardio pulmonary resuscitation (CPR) in the frail and those with multiple health conditions: Outcomes before and during the COVID pandemic

Coronavirus 2019 (COVID-19)-era resuscitation guidelines advised personal protective equipment before chest compressions and proactive advanced care planning. We investigated the impact of COVID-19 on cardiopulmonary resuscitation (CPR) outcomes according to scoring of frailty and of multiple health conditions. A retrospective single-centre analysis of clinical and electronic records for all adult cardiac arrest calls on wards between June 2020 and June 2021 was performed. Data were compared with a cohort pre-COVID (March 2017-March 2018). In total, 62 patients received CPR in 2020-21 compared with 113 in 2017-18. Similar rates of return of spontaneous circulation (ROSC) and a statistically insignificant survival increase from 23.8% to 32.2% (p=0.210). There were linear relationships between Clinical Frailty Scale (CFS) or Charlson Comorbidity Index (CCI) and diminished survival in the pooled data (both p<0.001). Both increasing frailty (measured by CFS) and comorbidity (measured by CCI) were associated with reduced survival from CPR. However, survival and ROSC during COVID-19 were no worse than before the pandemic.

Recent developments in frailty identification, management, risk factors and prevention: A narrative review of leading journals in geriatrics and gerontology

Frailty is an age-related clinical condition characterised by an increased susceptibility to stressors and an elevated risk of adverse outcomes such as mortality. In the light of global population ageing, the prevalence of frailty is expected to soar in coming decades. This narrative review provides critical insights into recent developments and emerging practices in frailty research regarding identification, management, risk factors, and prevention. We searched journals in the top two quartiles of geriatrics and gerontology (from Clarivate Journal Citation Reports) for articles published between 01 January 2018 and 20 December 2022. Several recent developments were identified, including new biomarkers and biomarker panels for frailty screening and diagnosis, using artificial intelligence to identify frailty, and investigating the altered response to medications by older adults with frailty. Other areas with novel developments included exercise (including technology-based exercise), multidimensional interventions, person-centred and integrated care, assistive technologies, analysis of frailty transitions, risk-factors, clinical guidelines, COVID-19, and potential future treatments. This review identified a strong need for the implementation and evaluation of cost-effective, community-based interventions to manage and prevent frailty. Our findings highlight the need to better identify and support older adults with frailty and involve those with frailty in shared decision-making regarding their care.

The impact of frailty on intra-hospital survival in older patients with COVID-19 infection: the importance of early identification. SEMI-COVID National Registry

BACKGROUND

Emerging evidence suggests that frailty may be a significant predictor of poor outcomes in older individuals hospitalized due to COVID-19. This study aims to determine the prognostic value of frailty on intrahospital patient survival.

METHODS

This observational, multicenter, nationwide study included patients aged 70 years and older who were hospitalized due to COVID-19 in Spain between March 1 and December 31, 2020. Patient data were obtained from the SEMI-COVID-19 Registry of the Spanish Society of Internal Medicine. Frailty was assessed using the Clinical Frailty Scale. The primary outcome was hospital survival. Cox proportional hazards models were used to assess predictors of survival.

RESULTS

A total of 1,878 participants (52% men and 48% women) were included, with 1,351 (71.9%) survivors and 527 (28.1%) non-survivors. The non-survivor group had higher mean age (83.5 vs. 81 years), comorbidities (6.3 vs. 5.3 points on the Charlson index), degree of dependency (26.8% vs. 12.4% severely dependent patients), and frailty (34.5% vs. 14.7% severely frail patients) compared to survivors. However, there were no differences in terms of sex. Our results demonstrate that a moderate-severe degree of frailty is the primary factor independently associated with shorter survival [HR 2.344 (1.437-3.823; p<0.001) for CFS 5-6 and 3.694 (2.155-6.330; p<0.001) for CFS 7-9].

CONCLUSION

Frailty is the main predictor of adverse outcomes in older patients with COVID-19. The utilization of tools such as the Clinical Frailty Scale is crucial for early detection in this population.

Age and Comorbidity Burden of Patients Critically Ill with COVID-19 Affect Both Access to and Outcome of Ventilation Therapy in Intensive Care Units

During the COVID-19 pandemic, large numbers of elderly, multimorbid people required treatment in intensive care units. This study investigated how the inherent patient factors age and comorbidity burden affected the treatment strategy and the outcome achieved. Retrospective analysis of data from intensive care patients enrolled in the Lean European Open Survey on SARS-CoV2-Infected Patients (LEOSS) cohort found that a patient's age and comorbidity burden in fact influenced their mortality rate and the use of ventilation therapy. Evidence showed that advanced age and multimorbidity were associated with the restrictive use of invasive ventilation therapies, particularly ECMO. Geriatric patients with a high comorbidity burden were clustered in the sub-cohort of non-ventilated ICU patients characterized by a high mortality rate. The risk of death generally increased with older age and accumulating comorbidity burden. Here, the more aggressive an applied procedure, the younger the age in which a majority of patients died. Clearly, geriatric, multimorbid COVID-19 patients benefit less from invasive ventilation therapies. This implies the need for a holistic approach to therapy decisions, taking into account the patient's wishes.

Predictors of survival in elderly patients with coronavirus disease 2019 admitted to the hospital: derivation and validation of the FLAMINCOV score

OBJECTIVE

To identify predictors of 30-day survival in elderly patients with coronavirus disease 2019 (COVID-19).

METHODS

Retrospective cohort study including patients with COVID-19 aged ≥65 years hospitalized in six European sites (January 2020 to May 2021). Data on demographics, comorbidities, clinical characteristics, and outcomes were collected. A predictive score (FLAMINCOV) was developed using logistic regression. Regression coefficients were used to calculate the score. External validation was performed in a cohort including elderly patients from a major COVID-19 centre in Israel. Discrimination was evaluated using the area under the receiver operating characteristic curve (AUC) in the derivation and validation cohorts. Survival risk groups based on the score were derived and applied to the validation cohort.

RESULTS

Among 3010 patients included in the derivation cohort, 30-day survival was 74.5% (2242/3010). The intensive care unit admission rate was 7.6% (228/3010). The model predicting survival included independent functional status (OR, 4.87; 95% CI, 3.93-6.03), a oxygen saturation to fraction of inspired oxygen (SpO₂/FiO₂₎ ratio of >235 (OR, 3.75; 95% CI, 3.04-4.63), a C-reactive protein level of <14 mg/dL (OR, 2.41; 95% CI, 1.91-3.04), a creatinine level of <1.3 (OR, 2.02; 95% CI, 1.62-2.52) mg/dL, and absence of fever (OR, 1.34; 95% CI, 1.09-1.66). The score was validated in 1174 patients. The FLAMINCOV score ranges from 0 to 15 and showed good discrimination in the derivation (AUC, 0.79; 95% CI, 0.77-0.81; p < 0.001) and validation cohorts (AUC, 0.79; 95% CI, 0.76-0.81; p < 0.001). Thirty-day survival ranged from 39.4% (203/515) to 95.3% (634/665) across four risk groups according to score quartiles in the derivation cohort. Similar proportions were observed in the validation set.

DISCUSSION

The FLAMINCOV score identifying elderly with higher or lower chances of survival may allow better triage and management, including intensive care unit admission/exclusion.

Covid-19 and age discrimination: benefit maximization, fairness, and justified age-based rationing

Age-based rationing remains highly controversial. This question has been paramount during the Covid-19 pandemic. Analyzing the practices, proposals, and guidelines applied or put forward during the current pandemic, three kinds of age-based rationing are identified: an age-based cut-off, age as a tiebreaker, and indirect age rationing, where age matters to the extent that it affects prognosis. Where age is allowed to play a role in terms of who gets treated, it is justified either because this is believed to maximize benefits from scarce resources or because it is believed to be in accordance with the value of fairness understood as (a) fair innings, where less priority is given to those who have lived a full life or (b) an egalitarian concern for the worse off. By critically assessing prominent frameworks and practices for pandemic rationing, this article considers the balance the three kinds of age-based rationing strike between maximizing benefits and fairness. It evaluates whether elements in the proposals are, in fact, contrary to the justifications of these measures. Such shortcomings are highlighted, and it is proposed to adjust prominent proposals to care for the worse off more appropriately and better consider whether the acquired benefits befalls the young or the old.

Scope of treatment and clinical-decision making in the older patient with COVID-19 infection, a European perspective

PURPOSE

Older patients were particularly vulnerable to severe COVID-19 disease resulting in high in-hospital mortality rates during the two first waves. The aims of this study were to better characterize the management of older people presenting with COVID-19 in European hospitals and to identify national guidelines on hospital admission and ICU admission for this population.

METHODS

Online survey based on a vignette of a frail older patient with Covid-19 distributed by e-mail to all members of the European Geriatric Medicine Society. The survey contained questions regarding the treatment of the vignette patient as well as general questions regarding available services. Additionally, questions on national policies and differences between the first and second wave of the pandemic were asked.

RESULTS

Survey of 282 respondents from 28 different countries was analyzed. Responses on treatment of the patient in the vignette were similar from respondents across the 28 countries. 247 respondents (87%) would admit the patient to the hospital, in most cases to a geriatric COVID-19 ward (78%). Cardiopulmonary resuscitation was found medically inappropriate by 85% of respondents, intubation and mechanical ventilation by 91% of respondents, admission to the ICU by 82%, and ExtraCorpular Membrane Oxygenation (ECMO) by 93%. Sixty percent of respondents indicated they would consult with a palliative care specialist, 56% would seek the help of a spiritual counsellor. National guidelines on admission criteria of geriatric patients to the hospital existed in 22 different European countries.

CONCLUSION

This pandemic has fostered the collaboration between geriatricians and palliative care specialists to improve the care for older patients with a severe disease and often an uncertain prognosis.

Contribution of information about acute and geriatric characteristics to decisions about life-sustaining treatment for old patients in intensive care

BACKGROUND

Life-sustaining treatment (LST) in the intensive care unit (ICU) is withheld or withdrawn when there is no reasonable expectation of beneficial outcome. This is especially relevant in old patients where further functional decline might be detrimental for the self-perceived quality of life. However, there still is substantial uncertainty involved in decisions about LST. We used the framework of information theory to assess that uncertainty by measuring information processed during decision-making.

METHODS

Datasets from two multicentre studies (VIP1, VIP2) with a total of 7488 ICU patients aged 80 years or older were analysed concerning the contribution of information about the acute illness, age, gender, frailty and other geriatric characteristics to decisions about LST. The role of these characteristics in the decision-making process was quantified by the entropy of likelihood distributions and the Kullback-Leibler divergence with regard to withholding or withdrawing decisions.

RESULTS

Decisions to withhold or withdraw LST were made in 2186 and 1110 patients, respectively. Both in VIP1 and VIP2, information about the acute illness had the lowest entropy and largest Kullback-Leibler divergence with respect to decisions about withdrawing LST. Age, gender and geriatric characteristics contributed to that decision only to a smaller degree.

CONCLUSIONS

Information about the severity of the acute illness and, thereby, short-term prognosis dominated decisions about LST in old ICU patients. The smaller contribution of geriatric features suggests persistent uncertainty about the importance of functional outcome. There still remains a gap to fully explain decision-making about LST and further research involving contextual information is required.

TRIAL REGISTRATION

VIP1 study: NCT03134807 (1 May 2017), VIP2 study: NCT03370692 (12 December 2017).

Frailty as a Priority-Setting Criterion for Potentially Lifesaving Treatment-Self-Fulfilling Prophecy, Circularity, and Indirect Discrimination?

Frailty is a state of increased vulnerability to poor resolution of homeostasis after a stressor event. Frailty is most frequently assessed in the old using the Clinical Frailty Scale (CSF) which ranks frailty from 1 to 9. This assessment typically takes less than one minute and is not validated in patients with learning difficulties or those under 65 years old. The National Institute for Health and Care Excellence (NICE) developed guidelines that use "frailty" as one of the priority-setting criteria for how scarce, but potentially lifesaving, health care resources should be allocated during the COVID-19 pandemic. Similar guidelines have been developed elsewhere. This paper discusses the ethical implications of such rationing and argues that this is an unproven and ethically problematic form of health care rationing. It specifically discusses: (1) how the frailty ascription becomes a self-fulfilling prophecy, (2) the problematic use of "frailty" in COVID-19 "triage," (3) the circularity of the link between age and frailty, (4) indirect discrimination because of the use of a seemingly neutral criterion in health care rationing, and (5) the difficult link between comorbidities and frailty. It is found that there was no research into the use of global frailty scores as a criterion for access to acute treatment before January 2020 and so it is concerning how readily frailty scoring has been adopted to ration access to potentially lifesaving treatments. Existing gerontological frailty scoring systems have not been developed for this purpose, and repurposing them creates significant ethical issues.

Differences in urban and suburban/rural settings regarding care provision and barriers of cancer care for older adults during COVID-19

PURPOSE

Care for older adults with cancer became more challenging during the COVID-19 pandemic, particularly in urban hotspots. This study examined the potential differences in healthcare providers' provision of as well as barriers to cancer care for older adults with cancer between urban and suburban/rural settings.

METHODS

Members of the Advocacy Committee of the Cancer and Aging Research Group, with the Association of Community Cancer Centers, surveyed multidisciplinary healthcare providers responsible for the direct care of patients with cancer. Respondents were recruited through organizational listservs, email blasts, and social media messages. Descriptive statistics and chi-square tests were used.

RESULTS

Complete data was available from 271 respondents (urban (n = 144), suburban/rural (n = 127)). Most respondents were social workers (42, 44%) or medical doctors/advanced practice providers (34, 13%) in urban and suburban/rural settings, respectively. Twenty-four percent and 32.4% of urban-based providers reported "strongly considering" treatment delays among adults aged 76-85 and > 85, respectively, compared to 13% and 15.4% of suburban/rural providers (Ps = 0.048, 0.013). More urban-based providers reported they were inclined to prioritize treatment for younger adults over older adults than suburban/rural providers (10.4% vs. 3.1%, p = 0.04) during the pandemic. The top concerns reported were similar between the groups and related to patient safety, treatment delays, personal safety, and healthcare provider mental health.

CONCLUSION

These findings demonstrate location-based differences in providers' attitudes regarding care provision for older adults with cancer during the COVID-19 pandemic.

Frailty, Comorbidity, and Associations With In-Hospital Mortality in Older COVID-19 Patients: Exploratory Study of Administrative Data

BACKGROUND

Older adults have worse outcomes following hospitalization with COVID-19, but within this group there is substantial variation. Although frailty and comorbidity are key determinants of mortality, it is less clear which specific manifestations of frailty and comorbidity are associated with the worst outcomes.

OBJECTIVE

We aimed to identify the key comorbidities and domains of frailty that were associated with in-hospital mortality in older patients with COVID-19 using models developed for machine learning algorithms.

METHODS

This was a retrospective study that used the Hospital Episode Statistics administrative data set from March 1, 2020, to February 28, 2021, for hospitalized patients in England aged 65 years or older. The data set was split into separate training (70%), test (15%), and validation (15%) data sets during model development. Global frailty was assessed using the Hospital Frailty Risk Score (HFRS) and specific domains of frailty were identified using the Global Frailty Scale (GFS). Comorbidity was assessed using the Charlson Comorbidity Index (CCI). Additional features employed in the random forest algorithms included age, sex, deprivation, ethnicity, discharge month and year, geographical region, hospital trust, disease severity, and International Statistical Classification of Disease, 10th Edition codes recorded during the admission. Features were selected, preprocessed, and input into a series of random forest classification algorithms developed to identify factors strongly associated with in-hospital mortality. Two models were developed; the first model included the demographic, hospital-related, and disease-related items described above, as well as individual GFS domains and CCI items. The second model was similar to the first but replaced the GFS domains and CCI items with the HFRS as a global measure of frailty. Model performance was assessed using the area under the receiver operating characteristic (AUROC) curve and measures of model accuracy.

RESULTS

In total, 215,831 patients were included. The model using the individual GFS domains and CCI items had an AUROC curve for in-hospital mortality of 90% and a predictive accuracy of 83%. The model using the HFRS had similar performance (AUROC curve 90%, predictive accuracy 82%). The most important frailty items in the GFS were dementia/delirium, falls/fractures, and pressure ulcers/weight loss. The most important comorbidity items in the CCI were cancer, heart failure, and renal disease.

CONCLUSIONS

The physical manifestations of frailty and comorbidity, particularly a history of cognitive impairment and falls, may be useful in identification of patients who need additional support during hospitalization with COVID-19.

Impact of frailty on clinical outcomes in patients with and without COVID-19 pneumonitis admitted to intensive care units in Australia and New Zealand: a retrospective registry data analysis

BACKGROUND

It is unclear if the impact of frailty on mortality differs between patients with viral pneumonitis due to COVID-19 or other causes. We aimed to determine if a difference exists between patients with and without COVID-19 pneumonitis.

METHODS

This multicentre, retrospective, cohort study using the Australian and New Zealand Intensive Care Society Adult Patient Database included patients aged ≥ 16 years admitted to 153 ICUs between 01/012020 and 12/31/2021 with admission diagnostic codes for viral pneumonia or acute respiratory distress syndrome, and Clinical Frailty Scale (CFS). The primary outcome was hospital mortality.

RESULTS

A total of 4620 patients were studied, and 3077 (66.6%) had COVID-19. The patients with COVID-19 were younger (median [IQR] 57.0 [44.7-68.3] vs. 66.1 [52.0-76.2]; p < 0.001) and less frail (median [IQR] CFS 3 [2-4] vs. 4 [3-5]; p < 0.001) than non-COVID-19 patients. The overall hospital mortality was similar between the patients with and without COVID-19 (14.7% vs. 14.9%; p = 0.82). Frailty alone as a predictor of mortality showed only moderate discrimination in differentiating survivors from those who died but was similar between patients with and without COVID-19 (AUROC 0.68 vs. 0.66; p = 0.42). Increasing frailty scores were associated with hospital mortality, after adjusting for Australian and New Zealand Risk of Death score and sex. However, the effect of frailty was similar in patients with and without COVID-19 (OR = 1.29; 95% CI: 1.19-1.41 vs. OR = 1.24; 95% CI: 1.11-1.37).

CONCLUSION

The presence of frailty was an independent risk factor for mortality. However, the impact of frailty on outcomes was similar in COVID-19 patients compared to other causes of viral pneumonitis.

Treatment limitations and clinical outcomes in critically ill frail patients with and without COVID-19 pneumonitis

BACKGROUND

The presence of treatment limitations in patients with frailty at intensive care unit (ICU) admission is unknown. We aimed to evaluate the presence and predictors of treatment limitations in patients with and without COVID-19 pneumonitis in those admitted to Australian and New Zealand ICUs.

METHODS

This registry-based multicenter, retrospective cohort study included all frail adults (≥16 years) with documented clinical frailty scale (CFS) scores, admitted to ICUs with admission diagnostic codes for viral pneumonia or acute respiratory distress syndrome (ARDS) over 2 years between January 01, 2020 and December 31, 2021. Frail patients (CFS ≥5) coded as having viral pneumonitis or ARDS due to COVID-19 were compared to those with other causes of viral pneumonitis or ARDS for documented treatment limitations.

RESULTS

884 frail patients were included in the final analysis from 129 public and private ICUs. 369 patients (41.7%) had confirmed COVID-19. There were more male patients in COVID-19 (55.3% vs 47.0%; p = 0.015). There were no differences in age or APACHE-III scores between the two groups. Overall, 36.0% (318/884) had treatment limitations, but similar between the two groups (35.8% [132/369] vs 36.1% [186/515]; p = 0.92). After adjusting for confounders, increasing frailty (OR = 1.72; 95%-CI 1.39-2.14), age (OR = 1.05; 95%-CI 1.04-1.06), and presence of chronic respiratory condition (OR = 1.58; 95%-CI 1.10-2.27) increased the likelihood of instituting treatment limitations. However, the presence of COVID-19 by itself did not influence treatment limitations (odds ratio [OR] = 1.39; 95%-CI 0.98-1.96).

CONCLUSIONS

The proportion of treatment limitations was similar in patients with frailty with or without COVID-19 pneumonitis at ICU admission.

Predictors of Respiratory Support Use in Emergency Department Patients With COVID-19-Related Respiratory Failure

BACKGROUND

Given the known downstream implications of choice of respiratory support on patient outcomes, all factors influencing these decisions, even those not limited to the patient, warrant close consideration. We examined the effect of emergency department (ED)-specific system factors, such as work load and census, on the use of noninvasive versus invasive respiratory support.

METHODS

We conducted a multi-center retrospective cohort study of all adult subjects with severe COVID-19 requiring an ICU admission from 5 EDs within a single urban health care system. Subject demographics, severity of illness, and the type of respiratory support used were obtained. Using continuous measures of ED census, boarding, and active management, we estimated ED work load for each subjects' ED stay. The subjects were categorized by type(s) of respiratory support used: low-flow oxygen, noninvasive respiratory support (eg, noninvasive ventilation [NIV] and/or high-flow nasal cannula [HFNC]), invasive mechanical ventilation, or invasive mechanical ventilation after trial of NIV/HFNC. We used multivariable logistic regression to examine system factors associated with the type of respiratory support used in the ED.

RESULTS

A total of 634 subjects were included. Of these, 431 (70.0%) were managed on low-flow oxygen alone, 108 (17.0%) on NIV/HFNC, 54 (8.5%) on invasive mechanical ventilation directly, and 41 (6.5%) on NIV/HFNC prior to invasive mechanical ventilation in the ED. Higher severity of illness and underlying lung disease increased the odds of requiring invasive mechanical ventilation compared to low-flow oxygen (odds ratio 1.05 [95% CI 1.03-1.07] and odds ratio 3.47 [95% CI 1.37-8.78], respectively). Older age decreased odds of being on invasive mechanical ventilation compared to low-flow oxygen (odds ratio 0.96 [95% CI 0.94-0.99]). As ED work load increased, the odds for subjects to be managed initially with NIV/HFNC prior to invasive mechanical ventilation increased 6-8-fold.

CONCLUSIONS

High ED work load was associated with higher odds on HFNC/NIV prior to invasive mechanical ventilation.

A national study of 23 major trauma centres to investigate the effect of frailty on clinical outcomes in older people admitted with serious injury in England (FiTR 1): a multicentre observational study

BACKGROUND

Older people are the largest group admitted to hospital with serious injuries. Many older people are living with frailty, a risk factor for poor recovery. We aimed to examine the effect of preinjury frailty on outcomes.

METHODS

In this multicentre observational study (FiTR 1), we extracted prospectively collected data from all 23 adult major trauma centres in England on older people (aged ≥65 years) admitted with serious injuries over a 2·5 year period from the Trauma Audit and Research Network (TARN) database. Geriatricians assessed the preinjury Clinical Frailty Scale (CFS), a 9-point scale of fitness and frailty, with a score of 1 indicating a patient is very fit and a score of 9 indicating they are terminally ill. The primary outcome was inpatient mortality, with patients censored at hospital discharge. We used a multi-level Cox regression model fitted with adjusted hazards ratios (aHRs) to assess the association between CFS and mortality, with CFS scores being grouped as follows: a score of 1-2 indicated patients were fit; a score of 3 indicated patients were managing well; and a score of 4-8 indicated patients were living with frailty (4 being very mild, 5 being mild, 6 being moderate, and 7-8 being severe).

FINDINGS

Between March 31, 2019, and Oct 31, 2021, 193 156 patients had records were held by TARN, of whom 16 504 had eligible records. Median age was 81·9 years (IQR 74·7-88·0), 9200 (55·7%) were women, and 7304 (44·3%) were men. Of 16 438 patients with a CFS score of 1-8, 11 114 (67·6%) were living with frailty (CFS of 4-8). 1660 (10·1%) patients died during their hospital stay, with a median time from admission to death of 9 days (IQR 4-18). Compared in patients with a CFS score of 1-2, risk of inpatient death was increased in those managing well (CFS score of 3; aHR 1·82 [95% CI 1·39-2·40]), living with very mild frailty (CFS score of 4: 1·99 [1·51-2·62]), living with mild frailty (CFS score of 5: 2·61 [1·99-3·43]), living with moderate frailty (CFS score of 6: 2·97 [2·26-3·90]), and living with severe frailty (CFS score of 7-8: 4·03 [3·04-5·34]).

INTERPRETATION

Our findings support inclusion of the CFS in trauma pathways to aid patient management. Additionally, people who exercise regularly (CFS of 1-2) have better outcomes than those with lower activity levels (CFS of ≥3), supporting exercise as an intervention to improve trauma outcomes.

FUNDING

None.

Mechanical Ventilation in COVID-19 Patients: Insights into the Role of Age and Frailty from a Multicentre Observational Study

In patients with COVID-19, frailty has been shown to better predict outcomes than age alone. We investigated factors associated with mechanical ventilation (MV) during hospitalization for COVID-19 among older adults in a multicentre study during the first two waves in Italy. Using data from the FRACOVID project, we included consecutive patients admitted to the participating centres during the first and second waves. We recorded sociodemographics, comorbidities, time since symptom onset, ventilatory support at admission, and chest X-ray findings. Frailty was assessed using a frailty index (FI). Results are reported as hazard ratios (HR) with 95%CI. 1,344 patients were included; 487 females (36.2%), median age 68 (56; 79) years; 52.4% had hypertension, 10.6% had chronic obstructive pulmonary disease, 15.2% were obese. Median FI was 0.088 (0.03, 0.20), and 67% had bilateral consolidations at admission. Median time since symptom onset was 7 days (4, 10). During hospitalization, 47 patients (3.6%, 95%CI 0.33-13.6%) received MV. Multivariable Cox regression analysis found that the likelihood of intubation decreased with increasing age (HR 0.945 (95%CI 0.921-0.969), p<0.0001), while heart rate >110bpm (HR 3.429 (95%CI 1.583-7.429), p=0.0018), and need for continuous positive airway pressure (CPAP) at admission (HR 2.626 (95%CI 1.330-5.186), p=0.0054) were significantly associated with a greater likelihood of intubation. Older patients are less likely to receive intubation, while those with heart rate >110 bpm and need for CPAP at admission are more likely to receive MV during hospitalization for COVID-19.

The Impact of Age on In-Hospital Mortality in Critically Ill COVID-19 Patients: A Retrospective and Multicenter Study

Introduction: For the past two years, healthcare systems worldwide have been battling the ongoing COVID-19 pandemic. Several studies tried to find predictive factors of mortality in COVID-19 patients. We aimed to research age as a predictive factor associated with in-hospital mortality in severe and critical SARS-CoV-2 infection. Methods: Between 1 March and 20 April 2020, we conducted a multicenter and retrospective study on a cohort of severe COVID-19 patients who were all hospitalized in the Intensive Care Unit (ICU). We led our study in nine hospitals of northeast France, one of the pandemic’s epicenters in Europe. Results: The median age of our study population was 66 years (58−72 years). Mortality was 24.6% (CI 95%: 20.6−29%) in the ICU and 26.5% (CI 95%: 22.3−31%) in the hospital. Non-survivors were significantly older (69 versus 64 years, p < 0.001) than the survivors. Although a history of cardio-vascular diseases was more frequent in the non-survivor group (p = 0.015), other underlying conditions and prior level of autonomy did not differ between the two groups. On multivariable analysis, age appeared to be an interesting predictive factor of in-hospital mortality. Thus, age ranges of 65 to 74 years (OR = 2.962, CI 95%: 1.231−7.132, p = 0.015) were predictive of mortality, whereas the group of patients aged over 75 years was not (OR = 3.084, CI 95%: 0.952−9.992, p = 0.06). Similarly, all comorbidities except for immunodeficiency (OR = 4.207, CI 95%: 1.006−17.586, p = 0.049) were not predictive of mortality. Finally, survival follow-up was obtained for the study population. Conclusion: Age appears to be a relevant predictive factor of in-hospital mortality in cases of severe or critical SARS-CoV-2 infection.

The value of qualitative data in Quality Improvement Projects in the care of older adults: the case of frailty scores in the emergency department

This commentary discusses the role and value of qualitative data when undertaking quality improvement (QI) focussing on the care of older adults. To illustrate this, we reflect on our own experiences of planning a QI project to improve the documentation of Clinical Frailty Scale (CFS) scores in the emergency department (ED) during the coronavirus disease of 2019 (COVID-19) pandemic. National clinical guidance for COVID-19 states that all adults over the age of 65 should be given a CFS at the first point of contact during hospital admission. Therefore, there is a need to improve CFS documentation, specifically in acute care settings.

We describe how qualitative methods facilitated an understanding of the barriers to CFS documentation in ED. Staff see the CFS as a useful tool for inter-professional communication, though there are tensions between clinical guidance and their beliefs. Staff had moral concerns about how an ED-allocated CFS might limit available treatment options for older adults. Our findings demonstrate how qualitative methods can illuminate the important social and moral dimensions of why improvement does or does not occur.

The Diagnostic Accuracy and Clinimetric Properties of Screening Instruments to Identify Frail Older Adults Attending Emergency Departments: A Protocol for a Mixed Methods Systematic Review and Meta-Analysis

Background: Prompt and efficient identification and stratification of patients who are frail is important, as this cohort are at high risk of adverse healthcare outcomes. Numerous frailty screening tools have been developed to support their identification across different settings, yet relatively few have emerged for use in emergency departments (EDs). This protocol provides details for a systematic review aiming to synthesize the accumulated evidence regarding the diagnostic accuracy and clinimetric properties of frailty screening instruments to identify frail older adults in EDs. Methods: Six electronic databases will be searched from January 2000 to March 2021. Eligible studies will include adults aged ≥60 years screened in EDs with any available screening instrument to identify frailty (even if not originally designed for this purpose). Studies, including case-control, longitudinal, and cohort studies, will be included, where instruments are compared to a reference standard to explore diagnostic accuracy. Predictive accuracy for a selection of outcomes, including mortality, institutionalization, and readmission, will be assessed. Clinical and methodological heterogeneity will be examined, and a random effects meta-analysis performed if appropriate. Conclusion: Understanding whether frailty screening on presentation to EDs is accurate in identifying frailty, and predicting these outcomes is important for decision-making and targeting appropriate management.

[Intensive care and Covid]

The health crisis linked to COVID-19 has put the whole hospital under stress. Intensive care units (ICU) have been on the front line to manage the most serious cases. The number of new admissions together with cumulative number of occupied intensive care beds have been and still are a key element in measuring the intensity of the crisis. Intensive care is a specialty largely unknown to the general public which is problematic when dealing with such difficult questions as should we give priority to health or to the economy; is there a loss of chance for non-COVID patients due to deprogramming? The increase in the demand for critical care has necessitated an extension of hospitalization capacities by transforming intermediate care beds into ICU beds, by creating neo-ICU, or in some regions by carrying out critical care, usually performed in ICU, in regular wards. Among the several limiting factors, human resources with qualified personnel was a key element together with the relative shortage of drugs. The mismatch between demand and supply has led to the establishment of rules for prioritizing access to ICU. This review deals with all these issues and can contribute to a reflection on the adaptation of the critical care department to cope with major sanitary crisis.

What have we learned from the first to the second wave of COVID-19 pandemic? An international survey from the ESCMID Study Group for Infection in the Elderly (ESGIE) group

The purpose of this survey is to explore changes in the management of COVID-19 during the first versus the second wave, with particular emphasis on therapies, antibiotic prescriptions, and elderly care. An internet-based questionnaire survey was distributed to European Society of Clinical Microbiology and Infectious Diseases (ESCMID) members. Therapeutic approach to patients with mild-to-moderate (PiO₂/FiO₂ 200–350) and severe (PiO₂/FiO₂ < 200) COVID-19, antibiotic use, and reasons for excluding patients from the intensive care unit (ICU) were investigated. A total of 463 from 21 countries participated in the study. Most representatives were infectious disease specialists (68.3%). During the second wave of pandemic, physicians abandoned the use of hydroxychloroquine, lopinavir/ritonavir, and azithromycin in favor of dexamethasone, low-molecular weight heparin (LMWH), and remdesivir in mild-to-moderate COVID-19. In critically ill patients, we detected an increased use of high-dose steroids (51%) and a decrease in tocilizumab use. The use of antibiotics at hospital admission decreased but remained high in the second wave. Age was reported to be a main consideration for exclusion of patients from ICU care by 25% of responders; a third reported that elderly were not candidates for ICU admission in their center. The decision to exclude patients from ICU care was based on the individual decision of an intensivist in 59.6% of cases. The approach of physicians to COVID-19 changed over time following evidence accumulation and guidelines. Antibiotic use at hospital admission and decision to exclude patients from ICU care remain critical aspects that should be better investigated and harmonized among clinicians.

Frailty Triage: Is Rationing Intensive Medical Treatment on the Grounds of Frailty Ethical?

In early 2020, a number of countries developed and published intensive care triage guidelines for the pandemic. Several of those guidelines, especially in the UK, encouraged the explicit assessment of clinical frailty as part of triage. Frailty is relevant to resource allocation in at least three separate ways, through its impact on probability of survival, longevity and quality of life (though not a fourth-length of intensive care stay). I review and reject claims that frailty-based triage would represent unjust discrimination on the grounds of age or disability. I outline three important steps to improve the ethical incorporation of frailty into triage. Triage criteria (ie frailty) should be assessed consistently in all patients referred to the intensive care unit. Guidelines must make explicit the ethical basis for the triage decision. This can then be applied, using the concept of triage equivalence, to other (non-frail) patients referred to intensive care.

Analysis of the Effects of COVID-19 Mask Mandates on Hospital Resource Consumption and Mortality at the County Level

Coronavirus disease 2019 has continued to spread despite measures put in place to help slow the spread. It remains unclear which measures are effective. Data guiding policymakers on efficacy will help focus efforts. We found that mask orders were ineffective in slowing the spread of coronavirus disease 2019 at the county level.

Supplemental digital content is available in the text.

Coronavirus disease 2019 (COVID-19) threatens vulnerable patient populations, resulting in immense pressures at the local, regional, national, and international levels to contain the virus. Laboratory-based studies demonstrate that masks may offer benefit in reducing the spread of droplet-based illnesses, but few data are available to assess mask effects via executive order on a population basis. We assess the effects of a county-wide mask order on per-population mortality, intensive care unit (ICU) utilization, and ventilator utilization in Bexar County, Texas.

The Italian document: decisions for intensive care when there is an imbalance between care needs and resources during the COVID-19 pandemic

BACKGROUND

In early 2020, the Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) published clinical ethics recommendations for the allocation of intensive care during COVID-19 pandemic emergency. Later the Italian National Institute of Health (ISS) invited SIAARTI and the Italian Society of Legal and Insurance Medicine to prepare a draft document for the definition of triage criteria for intensive care during the emergency, to be implemented in case of complete saturation of care resources.

METHODS

Following formal methods, including two Delphi rounds, a multidisciplinary group with expertise in intensive care, legal medicine and law developed 12 statements addressing: (1) principles and responsibilities; (2) triage; (3) previously expressed wishes; (4) reassessment and shifting to palliative care; (5) collegiality and transparency of decisions. The draft of the statements, with their explanatory comments, underwent a public consultation opened to Italian scientific or technical-professional societies and other stakeholders (i.e., associations of citizens, patients and caregivers; religious communities; industry; public institutions; universities and research institutes). Individual healthcare providers, lay people, or other associations could address their comments by e-mail.

RESULTS

Eight stakeholders (including scientific societies, ethics organizations, and a religious community), and 8 individuals (including medical experts, ethicists and an association) participated to the public consultation. The stakeholders' agreement with statements was on average very high (ranging from 4.1 to 4.9, on a scale from 1-full disagreement to 5-full agreement). The 4 statements concerning triage stated that in case of saturation of care resources, the intensive care triage had to be oriented to ensuring life-sustaining treatments to as many patients as possible who could benefit from them. The decision should follow full assessment of each patient, taking into account comorbidities, previous functional status and frailty, current clinical condition, likely impact of intensive treatment, and the patient's wishes. Age should be considered as part of the global assessment of the patient.

CONCLUSIONS

Lacking national guidelines, the document is the reference standard for healthcare professionals in case of imbalance between care needs and available resources during a COVID-19 pandemic in Italy, and a point of reference for the medico-legal assessment in cases of dispute.

A classification tree to assist with routine scoring of the Clinical Frailty Scale

Background

the Clinical Frailty Scale (CFS) was originally developed to summarise a Comprehensive Geriatric Assessment and yield a care plan. Especially since COVID-19, the CFS is being used widely by health care professionals without training in frailty care as a resource allocation tool and for care rationing. CFS scoring by inexperienced raters might not always reflect expert judgement. For these raters, we developed a new classification tree to assist with routine CFS scoring. Here, we test that tree against clinical scoring.

Objective/Methods

we examined agreement between the CFS classification tree and CFS scoring by novice raters (clerks/residents), and the CFS classification tree and CFS scoring by experienced raters (geriatricians) in 115 older adults (mean age 78.0 ± 7.3; 47% females) from a single centre.

Results

the intraclass correlation coefficient (ICC) for the CFS classification tree was 0.833 (95% CI: 0.768–0.882) when compared with the geriatricians’ CFS scoring. In 93%, the classification tree rating was the same or differed by at most one level with the expert geriatrician ratings. The ICC was 0.805 (0.685–0.883) when CFS scores from the classification tree were compared with the clerk/resident scores; 88.5% of the ratings were the same or ±1 level.

Conclusions

a classification tree for scoring the CFS can help with reliable scoring by relatively inexperienced raters. Though an incomplete remedy, a classification tree is a useful support to decision-making and could be used to aid routine scoring of the CFS.

The impact of frailty on survival in elderly intensive care patients with COVID-19: the COVIP study

BACKGROUND

The COVID-19 pandemic has led highly developed healthcare systems to the brink of collapse due to the large numbers of patients being admitted into hospitals. One of the potential prognostic indicators in patients with COVID-19 is frailty. The degree of frailty could be used to assist both the triage into intensive care, and decisions regarding treatment limitations. Our study sought to determine the interaction of frailty and age in elderly COVID-19 ICU patients.

METHODS

A prospective multicentre study of COVID-19 patients ≥ 70 years admitted to intensive care in 138 ICUs from 28 countries was conducted. The primary endpoint was 30-day mortality. Frailty was assessed using the clinical frailty scale. Additionally, comorbidities, management strategies and treatment limitations were recorded.

RESULTS

The study included 1346 patients (28% female) with a median age of 75 years (IQR 72-78, range 70-96), 16.3% were older than 80 years, and 21% of the patients were frail. The overall survival at 30 days was 59% (95% CI 56-62), with 66% (63-69) in fit, 53% (47-61) in vulnerable and 41% (35-47) in frail patients (p < 0.001). In frail patients, there was no difference in 30-day survival between different age categories. Frailty was linked to an increased use of treatment limitations and less use of mechanical ventilation. In a model controlling for age, disease severity, sex, treatment limitations and comorbidities, frailty was independently associated with lower survival.

CONCLUSION

Frailty provides relevant prognostic information in elderly COVID-19 patients in addition to age and comorbidities. Trial registration Clinicaltrials.gov: NCT04321265 , registered 19 March 2020.

COVID-19 is not over and age is not enough: Using frailty for prognostication in hospitalized patients

Background

Frailty screening using the Clinical Frailty Scale (CFS) has been proposed to guide resource allocation in acute care settings during the pandemic. However, the association between frailty and coronavirus disease 2019 (COVID‐19) prognosis remains unclear.

Objectives

To investigate the association between frailty and mortality over 6 months in middle‐aged and older patients hospitalized with COVID‐19 and the association between acute morbidity severity and mortality across frailty strata.

Design

Observational cohort study.

Setting

Large academic medical center in Brazil.

Participants

A total of 1830 patients aged ≥50 years hospitalized with COVID‐19 (March–July 2020).

Measurements

We screened baseline frailty using the CFS (1–9) and classified patients as fit to managing well (1–3), vulnerable (4), mildly (5), moderately (6), or severely frail to terminally ill (7–9). We also computed a frailty index (0–1; frail >0.25), a well‐known frailty measure. We used Cox proportional hazards models to estimate the association between frailty and time to death within 30 days and 6 months of admission. We also examined whether frailty identified different mortality risk levels within strata of similar age and acute morbidity as measured by the Sequential Organ Failure Assessment (SOFA) score.

Results

Median age was 66 years, 58% were male, and 27% were frail to some degree. Compared with fit‐to‐managing‐well patients, the adjusted hazard ratios (95% confidence interval [CI]) for 30‐day and 6‐month mortality were, respectively, 1.4 (1.1–1.7) and 1.4 (1.1–1.7) for vulnerable patients; 1.5 (1.1–1.9) and 1.5 (1.1–1.8) for mild frailty; 1.8 (1.4–2.3) and 1.9 (1.5–2.4) for moderate frailty; and 2.1 (1.6–2.7) and 2.3 (1.8–2.9) for severe frailty to terminally ill. The CFS achieved outstanding accuracy to identify frailty compared with the Frailty Index (area under the curve = 0.94; 95% CI = 0.93–0.95) and predicted different mortality risks within age and acute morbidity groups.

Conclusions

Our results encourage the use of frailty, alongside measures of acute morbidity, to guide clinicians in prognostication and resource allocation in hospitalized patients with COVID‐19.

Rationing care in COVID-19: if we must do it, can we do better?

The COVID-19 pandemic has seen a proposal for frailty to be used as a rationing criterion. This commentary suggests circumstances under which that is defensible: in the face of lack of capacity to treat everyone, and as an alternative to age in stratifying risk. How best to stratify risk is likely to evolve and may include information about illness severity and dynamic measures. Current research must focus on mobilizing better, COVID-19-specific prognostic information, with a goal of best discriminating which lives are most and least likely to be saved should scarcity of resources dictate that not everyone can receive critical care.

A scoping review of the Clinical Frailty Scale

BACKGROUND

Frailty is increasingly recognized as an important construct which has health implications for older adults. The Clinical Frailty Scale (CFS) is a judgement-based frailty tool that evaluates specific domains including comorbidity, function, and cognition to generate a frailty score ranging from 1 (very fit) to 9 (terminally ill). The aim of this scoping review is to identify and document the nature and extent of research evidence related to the CFS.

METHODS

We performed a comprehensive literature search to identify original studies that used the Clinical Frailty Scale. Medline OVID, Scopus, Web of Science, CINAHL, PsycINFO, Cochrane Library and Embase were searched from January 2005 to March 2017. Articles were screened by two independent reviewers. Data extracted included publication date, setting, demographics, purpose of CFS assessment, and outcomes associated with CFS score.

RESULTS

Our search yielded 1688 articles of which 183 studies were included. Overall, 62% of studies were conducted after 2015 and 63% of the studies measured the CFS in hospitalized patients. The association of the CFS with an outcome was examined 526 times; CFS was predictive in 74% of the cases. Mortality was the most common outcome examined with CFS being predictive 87% of the time. CFS was associated with comorbidity 73% of the time, complications 100%, length of stay 75%, falls 71%, cognition 94%, and function 91%. The CFS was associated with other frailty scores 94% of the time.

CONCLUSIONS

This scoping review revealed that the CFS has been widely used in multiple settings. The association of CFS score with clinical outcomes highlights its utility in the care of the aging population.