Subjective Assessment Underestimates Frailty in Patients with Heart Failure Referred for Advanced Therapies

Purpose Objective assessments of frailty using tools like the Modified Fried Frailty Index (mFFI) have been validated in elderly heart failure (HF) populations. However, most programs use a subjective provider assessment (SPA) of frailty, or “eye-ball” test, for patient selection. We compared SPA to mFFI in a cohort of patients referred for evaluation for advanced therapies. Methods Patients referred to our center for evaluation for advanced HF therapies were studied. Those unable to undergo mFFI due to other comorbidities were excluded. mFFI testing assigns a frailty point in each of five domains (weight loss, fatigue, activity, walk time, grip strength). Patients are designated as frail when score ≥3. In addition, three cardiac surgeons independently evaluated and designated patients as frail or not-frail. Surgeons were blinded to designations given by the other surgeons as well as to the mFFI score. Results Over seven months, 19 patients (57±13 yrs) were studied. All patients were assessed by at least one surgeon, 18 by at least two, and 11 by all three. Frailty testing found 47% of patients to be frail as compared to SPA, which found only 0-16% to be frail (p=0.004) (Figure 1). Correlation between subjective and objective assessment was not strong, with providers only agreeing 50-68% of the time with frailty testing (κ W =0.54). In this cohort, provider agreement was primarily driven by patients whom they assessed to be not frail. Conclusion While agreement between providers is strong, SPA significantly underestimates frailty when compared to formal testing in patients with advanced HF. Further study will determine which approach is optimal for patient selection in this population.