This study assessed the feasibility and acceptability of several commonly used screening instruments to identify frailty among community-dwelling older people within a general practice setting. We found that of all the instruments, the P7 returned the highest overall feasibility and acceptability results. It required minimal space, equipment, skills and time to implement and had the fastest completion rate of all the instruments analysed. Moreover, it had the highest acceptability rating for both patients and administering nurses, and was rated first for five of six individual criteria ranked by nurses. These findings for the P7 are consistent with respect to completion rate, skills, equipment, time to complete, space requirements and provider acceptability as a previous study conducted in general practice [26]. Recent research has also indicated that it returns relatively high diagnostic and predictive accuracy in primary care settings [13, 42,43,44], although more replication studies are needed to ensure generalisability. As a rapid screening instrument intended to be followed by more comprehensive assessment, the P7 may indeed prove viable in general practice settings, although more feasibility and acceptability testing under real world conditions is required.
Our findings lend weight to the viewpoint that rapid frailty screening instruments of the type included within this study are more practical to implement than reference standards within busy general practice settings. It has frequently been asserted within the frailty literature that GPs and their teams need to be able to implement simple, rapid frailty screening due to time constraints [4, 12, 25, 26, 42]. Our results show that screening instruments took consistently less time to implement than the reference standards, which in the case of the FP also required physical space and equipment that may not be readily available within most general practice settings. However, it is important to acknowledge that the instruments tested are intended primarily for screening purposes, while the reference standards are intended for diagnosis. Ideally, a positive result should be followed up by a lengthier, more comprehensive assessment in which frailty status is ascertained. Further, it is important to acknowledge that feasibility is both subjective and contingent on local context. Clinicians may differ over their perception of the ease with which even rapid frailty screening can be integrated into existing work flows, as demonstrated by prior research [25]. Several contextual factors can mediate clinician perception of feasibility, including factors relating to the patient, the clinician and the setting. For example, in our prior research on general practitioner attitudes towards frailty and frailty screening, age of the GP was identified as a potential factor shaping perceptions [45]. Further research is required to determine how contextual factors impact on the feasibility of screening in practice.
Self-administered instruments show potential as one means of offering greater efficiency within general practice settings, although their diagnostic accuracy and feasibility have not been well determined to date [46]. Time to complete was not collected for the two self-administered instruments assessed within this study (KC and REFS). However, the relatively high non-completion rate of these instruments in comparison with the nurse-administered instruments suggests that some adaptation to the approach adopted in our study may be needed to support their implementation in practice. Such adaptation could include having nurses check over the questionnaire after patient self-completion, modifying the instrument to remove problematic items, or supplementing missing data with information (e.g. recorded height and weight) drawn from the patient record. Given that any modification may alter the accuracy of the instruments, any such steps should be taken advisedly.
Our results suggest that the act of completing a frailty screening instrument stimulated self-reflection on both the potential and limits of their own functional ability among several patient participants. For some, this took the form of gratitude for what they were yet able to do; for others, the act of reflection led to a sense of realisation about what they could do no longer. These results would seem to support, at least in part, the potential for frailty to act as an opportunity for self-awareness and reflection, as sometimes espoused in frailty-focused editorials within the literature [47]. However, the extent to which this realisation leads to positive outcomes for older people is not yet clear. Certainly, the possibility that a frailty diagnosis may lead to formation of a negative self-concept within older people, and the ensuing negative impacts on health and wellbeing, has been widely acknowledged in the frailty literature [48,49,50,51]. Further, the prospect that even the act of completing a screening instrument may cause a similar effect has not been so readily recognised. More research is needed to untangle the complexities inherent in these, and similar, questions.
Several barriers and enablers for implementing frailty screening into clinical practice are implied by our analysis. Frequently, nurses in our study questioned whether patients had understood the full intent of a question and/or the instructions that accompanied a screening task. While there are a number of attributable causes for patients not fully comprehending an instrument (including ambiguous wording and question structures), one possibility is that the presence of mild cognitive impairment (MCI) in the patient may have impacted the results. This prospect underlines the importance of interpreting screening results in light of the patient’s medical history, and may signal a need to schedule a more comprehensive follow-up assessment following screening. Another barrier is the propensity for some patients to intentionally present an overly positive front, fearing the ramifications of a frailty diagnosis. In these cases, inclusion of objective measures such as a timed walk may give a more accurate depiction of true frailty status. Lastly, a number of enablers to support screening were implied by our discussions with administering nurses. These include the provision of training to ensure nurses are confident and comfortable when implementing instruments that address psychosocial concerns, and of resources and tools to support scoring of instruments where necessary.
Strengths and limitations
To our knowledge, this is the most comprehensive study to date to explore the feasibility and acceptability of several widely used frailty screening instruments within a general practice setting. Further, in presenting both health service provider and patient perspectives of acceptability we have been able to address a significant imbalance within the existing literature and provide additional contextual evidence for providers seeking to implement responsive, person-centred care. In applying a mixed-methods approach, we have enabled a broader understanding of the feasibility and acceptability of instruments, as illustrated by the differentiation between ease of completion and acceptability identified when triangulating patient quantitative and qualitative responses.
However, there are some limitations to the study. It was not within the scope of the study to assess the feasibility and acceptability of the two reference standards (FP, FI). However, the limited data we were able to collect (time to administer and completion rate) was advantageous with respect to illustrating the time advantages of screening instruments over reference standards. Further, a full complement of results across the four sub-studies was not possible for all instruments included within the study. For example, it was not possible to individually time certain instruments (KC, REFS) due to their inclusion within the self-completed survey. This decision was taken to reduce participant burden and the overall complexity of the study. However, it is possible that this aspect of the study design led to lower feasibility rankings for these instruments, wherein nurses may have conflated the perceived time taken to complete individual instruments with the time to complete the whole survey.
Our sample of administering nurses was intentionally small in order to reduce practice burden. Although capturing administering nurse perspectives in our study added valuable insight into the feasibility of instruments in practice, generalisability to other contexts is limited, with more replication studies needed. Further, the delay in interview time of up to two months post-study may have impacted on accurate recall, although nurses were provided with a quick refresher on each instrument prior to interview commencement. Another limitation was that all of the administering nurses who participated in providing feasibility and acceptability data were female and highly experienced, thus constituting a relatively homogenous group. Further research is needed with a more diverse range of health service provider groups to provide a broader perspective. Our patient cohort was highly proficient in English; our results are likely not generalisable to patient cohorts with a large percentage of persons born in culturally and linguistically diverse contexts. We did not include all frailty screening instruments currently in use, for reasons of practicality and suitability to the Australian general practice context. Lastly, patient acceptability responses were paraphrased by the nurse for administered instruments but self-completed (handwritten by patients) for self-completed instruments. We expect that this may have somewhat reduced the richness of the acceptability data obtained for the administered instruments.