“C5-75”: CENTRE FOR FAMILY MEDICINE CASE-FINDING FOR COMPLEX CHRONIC CONDITIONS IN PERSONS 75+

A PRIMARY CARE INITIATIVE TO ADDRESS FRAILTY ANDASSOCIATED COMPLEX GERIATRIC CONDITIONS

L. Lee, MD, MClSc(FM), CCFP(COE), FCFP T. Patel, BScPharm, PharmD

Sept 2018

Source: www.thestar.com

19 Academic Family Practices

Primary Care Memory Clinic

“C5-75”Frail

Older Adults

Addressing challenging gaps in community-based health care:

Pro-active Primary care-based Interprofessional Evidence-informed Efficient, feasible Evaluative research

Practice

Centre for Family Medicine Family Health Team

Established in 2005 Serving 28,309 patients

in Kitchener, Waterloo, and Wellesley, Ontario

Measures of Frailty

At least 67 frailty instruments have been developed…

• Clinical phenotype of (i) slowed walking speed, (ii) low physical activity, (iii) unintentional weight loss, (iv) low energy and (v) low grip strength (weakness) where 3 of 5 = frail [Fried Phenotype]

• Counting of accumulated deficits across multiple domains, eg. Frailty Index• Clinical judgment, eg. CSHA Clinical Frailty Scale

Buta BJ, et al. Ageing Res Rev 2017Bouillon K, et al. BMC Geriatr 2005

Fried LP, et al. Geronto A: Biol Sci Med Sci 2001Minitski AB, et al. BMC Geriatr 2002

Rockwood K, et al. Can Med Assoc J 2005

C5-75: Development1. Conducted and published reviews of the frailty literature to inform our program

development Systematic review of frailty markers or risk tools validated in the ambulatory

care setting (Lee, Patel, Hillier, et al. Geriatr Gerontol Int 2017;17:1358-77)

We found none that were clinically useful and psychometrically sound Review of frailty in primary care (Lee, Heckman, Molnar, et al. Can Fam Physician

2015;61:227-31)

2. Demonstrated the use of gait speed and handgrip measures together to be an accurate, precise, specific, and sensitive proxy for the Fried frailty phenotype (Lee, Patel, Costa, et al. Can Fam Physician 2017;63:e51-7)

C5-75: Development 3. Design of C5-75 program informed by iterative process of testing and

evaluation, using feedback obtained from patients, healthcare providers, staff, and knowledge users (physicians) to refine program elements and processes

4. Awarded funding support in 2013 as a Ministry of Health and Long Term Care Medically Complex Demonstration Project

5. Recently demonstrated that the C5-75 program is feasible and acceptable in a less-resourced family practice setting through collaboration with community pharmacy (presented at the 2017 Canadian Geriatric Society Annual Scientific Meeting)

6. C5-75 program description and outcomes published (Lee, Patel, Hillier, et al. Geriatrics 2018;3, doi:10.3390/geriatrics3030039)

C5-75: Level 1 and Level 2Level 1 Screening - nurses offer to all patients 75+during a regular office visit, annually

• Frailty – 4-meter gait speed + hand grip strength • Exercise – self-reported level of physical activity• COPD – Canadian Thoracic Society screening questions• Falls• Exertional dyspnea / Heart Failure

Level 2 Screening – interprofessional assessment for those identified as frail (gait speed ≥ 6 seconds and hand grip strength <14kg/24kg)

• Nutrition • Cognitive impairment• Urinary Incontinence• Depression, Anxiety, Social Isolation• Caregiver burden, if applicable• Falls/Fracture risk• Full medication review• Assessment Urgency Algorithm (AUA) – those identified

at highest risk to be referred to Geriatric Medicine

, or those with Heart Failure or high risk of falls

Results and specific recommendations sent to physician via Electronic Medical Records

Results and specific recommendations sent to physician via Electronic Medical Records

C5-75 is feasible to implement within a busy family practiceLevel 1:

• Implemented during regular office visits, annually• < 7 minutes to complete• Over 5 years, 1,073 older adults have been assessed (75% of persons

aged 75+ in our Family Health Team)Level 2:

• < 30 minutes to complete• Requires extra appointment but only for those who are frail (7%)

or at high risk (Heart Failure, falls)

Within nurse and AHP scope of practice Low cost

• Minimal staff training• Dynamometer - $300-$400 CAD

C5-75: Level 1 and Level 2

• Screening for frailty• Case-finding in C5-75• Medication use• Community pilot

Research: C5-75

Screening for Frailty: Applicability in Family Practice

Goal: to improve practicality and feasibility of screening for frailty in primary care

Study objective: examine relative accuracy of individual Fried frailty phenotype measures in identifying the Fried frailty phenotype in a primary care setting

Fried phenotype:• Gait speed (# seconds/ 4m)• Hand grip (dynamometer)• Self-reported exhaustion, low physical activity, unintended weight loss

Retrospective chart review

516 patients aged 75 years+ completed C5-75 screening

Lee, Patel, et al. Can Fam Physician, 2017;63:e51-7

Criteria Sensitivity Specificity

Positivepredictive

value AccuracyGait speed 87.5% 94.6% 52.5% 94.2%Hand grip 100% 90.5% 42.4% 91.1%Combined 87.5% 99.2% 87.5% 98.4%

N = 383 patients with complete frailty screening dataFrailty prevalence (≥ 3 more frailty criteria) = 6.5% Gait speed or grip strength alone were sensitive and specific as a proxy for the

Fried phenotype Dual-trait measure of grip strength with grip strength was more accurate,

sensitive, and specific Lee, Patel, et al. Can Fam Physician, 2017;63:e51-7

Combined Gait Speed and Grip Strength

Level

Total # assessments

completed# uniquepatients

# repeated annual

assessmentsLevel 1 1,461 965 496Level 2 640 582 58

Lee, Patel et al., Geriatrics, 2018;3:39

C5-75 Case Finding (April 2013-December 2016)

50

31

2623 23

21

11 11

0

10

20

30

40

50

60

Hypertension Heart Failure Hyperlipidemia Diabetes Osteoporosis CAD (MI,Angina, CABG)

Atrial Fibrillation MCI/Dementia

Perc

ent

Patient Population CharacteristicsN = 965 Mean age (years ± SD): 81 ± 5 Gender, female (n, %): 505, 52%

COPD – Chronic Obstructive Pulmonary Disease; CAD – Coronary Artery Disease; MI – Myocardial Infarction; CABG – Coronary Artery Bypass Graft; MCI – Mild Cognitive Impairment

Lee, Patel et al., Geriatrics, 2018;3:39

48

36

16

0

10

20

30

40

50

60

Physically active:30+ min

moderateintensity 5+days/week

Physically active:occasionally orduring some

seasons

Not physicallyactive beyond

activities of dailyactivities

Perc

ent

Exercise (N = 945)

14

7

0

2

4

6

8

10

12

14

16

Gait Speed Gait Speed _Hand Grip

Perc

ent

Frailty (N = 965)

Level 1 Screening Results

4

5

0

1

2

3

4

5

6

2+ in past 6months

Falls in past 6months requiringmedical attention

Perc

ent

Falls (N = 750)

Lee, Patel et al., Geriatrics, 2018;3:39

Screening Component n (%)

Fracture Risk (N = 119)Prescribed medications for osteoporosis 23 (19%)Not prescribed medication for osteoporosis /T-L spine x-rays were ordered 27 (23%)Not prescribed medication for osteoporosis/ BMD testing ordered. 51 (43%)Mental Health ScreeningPHQ-9 – positive screen for depression (N = 50) 11 (7%)GAD-7 – positive screen for anxiety disorder (N = 94) 4 (3%)LSNS-6 – positive screen for social isolation (N = 117) 29 (20%)Zarit Caregiver Burden – positive screen for high burden (N = 103) 15 (15%)Cognition Screening (N = 119)Mini-Cog – positive screen 26 (22%)Urinary Incontinence Screening (N = 147)Patients reporting symptoms of urinary incontinence 47 (39%)

Assessment Urgency Algorithm (N = 68) Level 1Level 2Level 3Level 4Level 5Level 6

21 (31%) 8 (12%)

22 (32%) 5 (7%) 1 (1%)

10 (15%)

Lee, Patel et al., Geriatrics, 2018;3:39

Level 2 Screening Results

Initial medication review (n = 41)

Total medications/patient (mean/range) 11 (5 – 23)

Prescribed medications/patients (mean/range) 8 (3 – 15)

Over the Counter Medication per patient (mean/range) 4 (0 – 9)

PRN per patient (mean/range) 1.44 (0 – 8)

High Risk Drug (HRD) per patient (mean/range) 3.27 (0 – 7)

% patients on 1+ HRD 95%

% patients on 5+ prescribed medications 90%

% patients on 5+ total medications 100%

Medication Use in Frailty(April 2013 – August 2015; Pharmacist Review)

Patel T, Bauer J, Lee L et al. CPJ 2016; 149: S27

Top 10 prescription medications (n = 142)

77%

56%

43% 42% 42%

32% 30% 30% 27% 27%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% o

f pat

ient

s us

ing

≥1

7%

90%

32%

17% 15%

63%

10%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Insulin CV meds NSAIDs O/N BD2 AP/AC Other

% o

f pat

ient

s us

ing

≥1

Initial medication review

Review of Medications in C5-75High risk drugs used by patients with an initial medication review (n = 41)

Patel T, Bauer J, Lee L et al. CPJ 2016; 149: S27Hu C. Can J Ger

Anti-HTN: Antihypertensives; HMG-CoA RI: 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitor; AP: Antiplatelet (including ASA); GI Protection: Histamine 2 blocker or proton pump inhibitor; AD: Antidepressants; Topicals: Topical creams/ointments/lotions; APAP: Acetaminophen; BP: Biphosphates/bone modifying agents

CV meds: Digoxin, antihypertensive medications; NSAIDS: Nonsteroidal anti-inflammatory drugs; O/N: Opiods/Narcotics; BD2: Benzodiazepines and analogues; AP/AC: Antiplatelets/Anticoagulants

Pilot test of C5-75 in less well resourced practice setting• Urban family practice, 14 physicians; 11,819 patients• Co-located with a community pharmacy

Community pharmacists/staff trained to complete C5-75 screeningScreening was completed with 46 patients

• Mean age = 80 (± 4.7); range = 72 – 97 years• 71% female

Frailty based on • Gait speed: 13% (6/46) • Gait speed with grip strength: 9% (4/46)

Level 2 Screening: 12 (26%) Surveys of staff (N = 2) and patients (N = 33): feasibility, acceptability and satisfaction

• Patient Satisfaction: mean = 4.5/5; 93% ≥4 ratings• Pharmacy staff: screening perceived as feasible and acceptable

• Time concerns in only 2 (4%) of cases• No staff reported lack of comfort with screening

Community Pilot

• Continue developing program to improve effectiveness and efficiency• Impact of interventions• Challenges, barriers

• Healthcare providers, patients and caregivers• Performance of individual components

• Diagnostic accuracy• Influence on healthcare• Perceived value to stakeholders• Perceived practicality (efficiency and acceptability) to stakeholders

Future of C5-75

Between 2014-2015, surveys completed by 123 patients who received C5-75 assessments demonstrated high levels of satisfaction with screening processes, time required, and contributions to care decisions resulting from this program; none expressed dissatisfaction

Between 2014-2015, surveys were also completed by 31 health care providers, including 18 family physicians whose patients whose patients received C5-75 assessments.

Patient and Health Care Provider impacts

Comments from 18 family physicians in response to the question, “Is there any other feedback you would like to provide relating to your experience as a healthcare provider as part of this pilot project?”:

• “The C5-75 program has been essential in coordinating & delivering truly effective care to these patients. Patients themselves have appreciated the continuity of care. This clinic utilized the best of various professionals.”

• “This has been very helpful in a busy practice to identify complex patients and screen them. This has led to helpful suggestions and improved care (additional interventions that were needed).”

• “I find this program to be very valuable to identify frail patients, and especially to help us as practitioners understand how to reduce risks and better treat this complex population.”

• “C5-75 has identified issues as yet less obvious in a variety of my patients. It has been very positive.”

• “Has helped automate some screening, which would normally be missed in regular practice setting.”

• “Excellent response from patients.”

Impact Testimonials

In summary, C5-75:1. Utilizes a feasible, objective, valid means of quickly screening for frailty

during busy clinical practice using gait speed with hand grip strength

2. Integrates a structured, multidisciplinary, evidence-informed approach to systematically and pro-actively screen for and manage frailty and its associated conditions

3. Has been developed by practicing primary care practitioners, tested, piloted, and designed for integration into Canadian primary care practice

4. Aims to change the system of primary healthcare to better address the needs of frail older adults, enabling them to maintain health and wellbeing with best quality of life for as long as possible

Core Project Team Members Dr. Linda Lee, Dr. Tejal Patel, Dr. James Milligan, Dr. John Pefanis,

Ms. Kara Skimson, Dr. Jason Locklin, Dr. Stephanie LuContributors to Research Dr. Andrew Costa, Dr. Lora Giangregorio, Dr. Susan Hunter,

Dr. Heather Keller, Dr. Veronique Boscart, Dr. Karen Slonim, Dr. Erin Bryce, Ms. Loretta M. Hillier

Contributors to Clinical Expertise Dr. Joseph Lee, Dr. Frank Molnar, Dr. George Heckman,

Dr. Robert McKelvie, Dr. Eric Hentschel, Dr. Alex Papaionnou, Dr. Satish Rangaswamy

We gratefully acknowledge Lindsay Donaldson, Wende Bederian. Wendy Batte, Marg Alfieri, and the CFFM FHT