Assessing the Appropriateness of Frailty Screening in the Australian General Practice Context: Ethics, Accuracy, Feasibility and Acceptability

Frailty exposes older people to significant negative impacts on health and well being. Evidence suggesting that frailty is reversible has led to calls for greater proactivity on its identification and treatment within general practice, although implementation research is lacking in many countries, including Australia. This study aimed to explore the appropriateness of introducing frailty screening within Australian general practice, with specific objectives addressing the 1) ethics 2) accuracy 3) feasibility and 4) acceptability of screening within this context. Seven sub-studies addressed these objectives. The first, a narrative review exploring the principles of ethical screening, suggested that the most appropriate current application of frailty screening within general practice is for case-finding of vulnerable older people. Next, a systematic review of self-reported frailty screening instruments demonstrated insufficient validation evidence for many, providing justification for the third sub-study (n=243), in which the DTA of several instruments was assessed against the Frailty Phenotype (FP) and Frailty Index (FI). Several instruments (Kihon Checklist (KC), Reported Edmonton Frail Scale (REFS) and PRISMA-7) showed promise for broader implementation. In a fourth sub-study, the DTA and feasibility of an electronic Frailty Index (eFI) was assessed (n=60). Although sufficiently accurate, the findings suggest that an eFI is currently unviable for Australian general practice. The fifth sub-study explored attitudes of Australian general practitioners (GPs) towards frailty and frailty screening. GPs largely saw frailty as a cycle of worsening decline, with few having attempting intervention, but most were open to screening given sufficient support. The sixth sub-study assessed the feasibility and acceptability of several instruments in practice. Of these, the PRISMA-7 performed best. The two self administered instruments (KC and REFS) returned higher rates of non completion than the nurse-administered instruments. The final sub-study explored perceived feasibility and acceptability with a broader sample of GPs and practice nurses (n=43), with participants preferring multi-dimensional instruments perceived as delivering clinical utility, fitting feasibly with the setting and supporting patient-centred care. Taken together, this dissertation’s findings indicate that a case-finding approach to frailty screening within Australian general practice based on the integration of accurate, multi-dimensional instruments into the 75+ annual health assessment will deliver the greatest chance of success. However, further replication research will be needed to support implementation in practice, along with policy and funding analyses to identify the best business models to support the sustainability of screening into the future.