The challenge
The Ageing Well Workstream of the North East and North Cumbria (NENC) Integrated Care Board (ICB) required a means to improve the identification and coding of frailty within the Primary Care Data Set (PCDS).
This work was driven by the knowledge that the coding of frailty within the PCDS under (and in places over) reported the true prevalence within the community despite the evidence-based work of the national electronic Frailty Index [eFI]. This was also having a direct impact on the associated development of the Anticipatory Care (Proactive Care) Case-Finding dashboard that has been developed in RAIDR.
Our response
NECS worked collaboratively with clinical leaders across the ICS and members of the Ageing Well Workstream to identify key areas within the PCDS which could indicate a frailty assessment is required.
These included patients over the age of 65 years and any of the following:
- Palliative care flag
- Dementia diagnosis flag
- Care home resident
- Risk of falls flag
- Housebound flag
- Aged over 90 years.
Data extraction and analysis of the PCDS was carried out to identify the population in the above criteria. A data extraction of all existing patients with a diagnosis of frailty aided in gap analysis performed between both datasets. Frequency analysis was carried out to identify which combinations of the criteria were most frequently identified.
Techniques and tools:
- SQL reports written from PCDS.
- Excel report template was created to enable PDF printed reports.
Outcomes
NECS was able to produce frailty case finding intelligences reports at Regional and Place based levels. This enables the local Frailty Leads to review their own Primary Care Data (PCD) to determine where the potential coding of frailty could be improved. Identifying that potentially across North East and North Cumbria (NENC), there is an additional 10% of the population which may require a diagnosis of mild, moderate or severe frailty (April 2023).
Areas of potential batch coding of frailty and areas of significant under reporting (possibly through under reporting of the 36 deficits that contribute to the eFI) were identified within the reports. It is hoped highlighting these results to the individual place bases across the region will continue to help improve the mechanisms of recording frailty which will directly impact on the development of the Anticipatory Care Case-Finding dashboard.
“People living with frailty have significantly poorer outcomes (e.g., mortality, hospital, and admission to long-term care) than people living without frailty. Identifying groups of people potentially living with frailty, and making an accurate diagnosis, is critical for health and care systems that want to support personhood, healthy-ageing and workforces to offer robust age-friendly services to improve outcomes.”