title: Development and validation of an electronic frailty index using routine primary care electronic health record data.
abstract: frailty is an especially problematic expression of population ageing. International guidelines recommend routine identification of frailty to provide evidence-based treatment, but currently available tools require additional resource.
  
  
  
  to develop and validate an electronic frailty index (eFI) using routinely available primary care electronic health record data.
  
  
  
  retrospective cohort study. Development and internal validation cohorts were established using a randomly split sample of the ResearchOne primary care database. External validation cohort established using THIN database.
  
  
  
  patients aged 65-95, registered with a ResearchOne or THIN practice on 14 October 2008.
  
  
  
  we constructed the eFI using the cumulative deficit frailty model as our theoretical framework. The eFI score is calculated by the presence or absence of individual deficits as a proportion of the total possible. Categories of fit, mild, moderate and severe frailty were defined using population quartiles.
  
  
  
  outcomes were 1-, 3- and 5-year mortality, hospitalisation and nursing home admission.
  
  
  
  hazard ratios (HRs) were estimated using bivariate and multivariate Cox regression analyses. Discrimination was assessed using receiver operating characteristic (ROC) curves. Calibration was assessed using pseudo-R(2) estimates.
  
  
  
  we include data from a total of 931,541 patients. The eFI incorporates 36 deficits constructed using 2,171 CTV3 codes. One-year adjusted HR for mortality was 1.92 (95% CI 1.81-2.04) for mild frailty, 3.10 (95% CI 2.91-3.31) for moderate frailty and 4.52 (95% CI 4.16-4.91) for severe frailty. Corresponding estimates for hospitalisation were 1.93 (95% CI 1.86-2.01), 3.04 (95% CI 2.90-3.19) and 4.73 (95% CI 4.43-5.06) and for nursing home admission were 1.89 (95% CI 1.63-2.15), 3.19 (95% CI 2.73-3.73) and 4.76 (95% CI 3.92-5.77), with good to moderate discrimination but low calibration estimates.
  
  
  
  the eFI uses routine data to identify older people with mild, moderate and severe frailty, with robust predictive validity for outcomes of mortality, hospitalisation and nursing home admission. Routine implementation of the eFI could enable delivery of evidence-based interventions to improve outcomes for this vulnerable group.
authors.affiliation: Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford, West Yorkshire, United Kingdom of Great Britain and Northern Ireland a.p.clegg@leeds.ac.uk.
authors.forename: Andrew
authors.initials: A
authors.lastname: Clegg
authors.affiliation: ResearchOne, TPP, Leeds, West Yorkshire, United Kingdom of Great Britain and Northern Ireland.
authors.forename: Chris
authors.initials: C
authors.lastname: Bates
authors.affiliation: Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford, West Yorkshire, United Kingdom of Great Britain and Northern Ireland.
authors.forename: John
authors.initials: J
authors.lastname: Young
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom of Great Britain and Northern Ireland.
authors.forename: Ronan
authors.initials: R
authors.lastname: Ryan
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom of Great Britain and Northern Ireland.
authors.forename: Linda
authors.initials: L
authors.lastname: Nichols
authors.affiliation: Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford, West Yorkshire, United Kingdom of Great Britain and Northern Ireland.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Ann Teale
authors.affiliation: Faculty of Health Studies, University of Bradford, Bradford, West Yorkshire, United Kingdom of Great Britain and Northern Ireland.
authors.forename: Mohammed A
authors.initials: MA
authors.lastname: Mohammed
authors.affiliation: SystmOne, TPP, Leeds, West Yorkshire, United Kingdom of Great Britain and Northern Ireland.
authors.forename: John
authors.initials: J
authors.lastname: Parry
authors.affiliation: Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom of Great Britain and Northern Ireland.
authors.forename: Tom
authors.initials: T
authors.lastname: Marshall
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D016208:Databases, Factual; D057286:Electronic Health Records / Q000706:statistics & numerical data*; D005260:Female; D016330:Frail Elderly / Q000706:statistics & numerical data*; D015577:Geriatric Assessment / Q000379:methods*; D006707:Homes for the Aged / Q000706:statistics & numerical data; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D009735:Nursing Homes / Q000706:statistics & numerical data; D017063:Outcome Assessment, Health Care; D011237:Predictive Value of Tests; D011320:Primary Health Care / Q000458:organization & administration*; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D016019:Survival Analysis; D006113:United Kingdom
keywords: cumulative deficit; electronic frailty index; electronic health record; frailty; older people; primary care