Creating objective frailty criteria: A new standard

The management of complex populations presents a significant challenge for both payers and providers. Frailty — a multifaceted condition that encompasses age, cognitive and functional impairments and other comorbidities — increases the vulnerability of a patient’s status (clinically and socially) to adverse outcomes, inpatient hospital mortality, length of stays and functional decline at hospital discharge.^1,2 Literature supports the fact that patients with comorbidities, poor dietary habits and sedentary lifestyles have even higher risk of developing frailty.² It is therefore vital to account for these complexities when determining the medical necessity for inpatient admissions.

In clinical practice, clinical definitions have emerged to more accurately characterize frailty — one as a clinical syndrome and the other as a state of accumulating deficits which, over time, leads to this vulnerability:¹

1. First, the Fried frailty phenotype helps define the syndrome in the form of impaired metabolism in conjunction with abnormal responses to different stressors. Examples of this include exhaustion, generalized weakness, physical inactivity and loss of weight.
2. The second concept, deficit accumulation, focuses on the poor health status of a patient exacerbated by age-related deficits. Some components that are used to measure and quantify degree of frailty that could be obtained from the electronic medical records or comprehensive geriatric assessments include diagnoses, existing physical and cognitive impairments, poor nutritional status and abnormal labs.

Thus, curating InterQual® criteria that reflect these measurable constituents accurately and comprehensively as elements of frailty in these patients, even when suspected, remained a persistent developmental challenge. Although frailty is recognized as a clinically accepted risk factor, there is still no “gold standard” assessment tool to define it. 

Recognizing the patient risks that this issue presents, the InterQual® Level of Care content development team committed to creating a more objective definition of frailty. Our goal was to support payers and providers in making the most informed decisions to enhance the quality and effectiveness of care delivery for the frail patient population.

As an initial effort, we sought to achieve this goal by leveraging the best available evidence to incorporate frailty criteria as an appropriate comorbid risk factor on an admission review across 6 medical and surgical subsets within our InterQual® Acute Adult Criteria. Our team employed a systematic approach, breaking down the complex process into manageable components and allowing evidence to guide the development of objective criteria. Ultimately, we needed to establish a robust framework that ensures the highest standards of clinical accuracy and real-world applicability.

Our journey to creating evidence-based frailty content began with extensive research. We started by identifying appropriate search terminology and formulating research questions that focused on how frailty is defined in literature. Our initial findings revealed frailty as a very broad topic, characterized by marked clinical and social vulnerabilities that lead to adverse health outcomes.

To ensure the evidence we gathered met our rigorous standards, our clinical team — comprised of experts in evidence-based medicine and trained in the Delfini method of critical appraisal — reviewed over 65 articles related to characterizing frailty, its negative impact on certain conditions such as heart failure or chronic obstructive pulmonary disease and its impact on the healthcare system. As an example, patients with heart failure who present to the emergency department (ED) with an acute exacerbation in the setting of being frail have increased in-hospital mortality and increased lengths of stays with higher incidence of recurrent hospitalizations.^3,4 Our team eventually cited 31 unique articles.

After evaluating more than 60 frailty clinical assessment tools, we found no single "gold standard" method for diagnosis to incorporate as criteria. Given frequent documentation challenges within electronic medical records, we decided to focus on components easily accessible for the reviewer. We extracted common characteristics from the widely used tools and developed criteria that reflect what would be appropriately captured in an acute care setting.

As part of our standard process and to further refine our criteria, we sent initial drafts for external feedback and validation using our peer review process. We collaborated with a multi-specialty panel of geriatricians, emergency medicine and internal medicine physician peer reviewers, whose insights were invaluable in shaping the frailty criteria. Their feedback helped us add or remove criteria to better define our target population, ensuring the criteria are defensible from both payer and provider perspectives.

Our team was fortunate to work closely with Holly Gardner, MD, through this process. Over the years, she has had a significant role as one of our extensive panelists of external peer reviewers. As a frontline emergency medicine physician, she has provided valuable and important feedback related to frailty, helping to identify patients in her ED who would be most appropriate for an acute care hospitalization based on their age, pertinent comorbidities and clinical risk factors that could lead to potential negative outcome while ensuring the highest level of patient safety.

The longstanding absence of a standardized approach to evaluating a frail patient (or one suspected to be frail) jeopardized achieving quality outcomes in this specific patient population. In response, our team at InterQual developed comprehensive criteria for first-level reviews that embrace a patient-centric philosophy, considering the multitude of factors and conditions that could influence a patient's health trajectory during an acute care hospitalization. With these evidence-backed guidelines, clinicians can increase the likelihood of complex cases being approved (even for second-level reviews, when necessary).

The InterQual frailty criteria set a new benchmark to achieve clinical precision and practical relevance, addressing a significant customer enhancement request based on syndrome prevalence, awareness and its impact. This achievement underscores our dedication to evidence-based content development and expertise, and I commend our team's accomplishments.