Thank you for participating in this session. I am Kim Lavin, an Associate of the American College of Cardiology's Registry Science Development Team, and I will be presenting Why Clinical Frailty? The Chest Pain in My Registry version 3.1 dataset is expected in 2023 and will include the new data element, Canadian Study of Health and Aging Clinical Frailty Scale, creating a new synergy between the CATH PCI Registry and the Chest Pain in My Registry. Whether you are engaged in one or both registries, this session will discuss the rationale which supported adding this data element to both datasets, how it should be captured, and review the impact and anticipated impact it has on informing metrics. The learning objectives for this session include recognize documentation that will support coding clinical frailty, and identify one rationale for including frailty in a registry dataset. During this session, we will provide information on the definition of frailty, the importance of assessing frailty, answer the question on how frailty can inform the registry, and lastly, how the NCDR is utilizing frailty data. So how do we define frailty? While there are multiple definitions, Kenneth Rockwood, who developed the Canadian Study of Health and Aging Clinical Frailty Scale, which is currently utilized in the CATH PCI Registry, describes frailty as a term widely used to denote a multidimensional syndrome of loss of reserves that includes energy, physical ability, cognition, and health that gives rise to vulnerability. There are many other operational descriptions, conceptual definitions of frailty. These usually consider several functional domains, such as physical, cognitive, psychosocial, nutritional, et cetera. Keep in mind that the etiology of frailty is multifactorial and patient-specific. There are many reasons why performing an assessment on a patient's frailty status is important. These reasons include cardiovascular disease and frailty are associated. What is meant by this is that they share some of the same physiological foundations that predispose us to the progression of both disease processes. Research has shown that frail patients with no known cardiovascular disease have a higher incidence of myocardial infarction, mortality, and stroke during a five-year follow-up period. Frailty has also been shown to be independently associated with mortality and adverse events. We also have a rapidly growing population of those over the age of 65. However, we need to remember that frailty can occur at any age. We have an overall increase in the prevalence of cardiovascular disease in the population. Also, assessment is necessary to provide guidance on interventions focused on reversing or preventing frailty. Frailty is a dynamic process and can change over time and is potentially reversible. Another important reason is that the assessment of frailty can assist the CV team in predicting outcomes and take appropriate precautions to prevent them. For example, in 2018, a study by Dotson and others was performed to determine if frailty was associated with an increased bleeding risk in the setting of acute myocardial infarction. Data from the Action Registry was utilized, and at that time, the data collected within the registry included three frailty status elements, walking, cognition, and activity of daily living. The study found that 16.4% had frailty, and among those that underwent catheterization, frailty was independently associated with bleeding risk compared to the non-frail group. The study also found that frail patients were less likely to undergo diagnostic cardiac catheterization. Several other independent studies have shown that frailty is associated with higher observed mortality both in a hospital in 30-day as well as 30-day readmissions. So how are we reporting frailty in the registry? Well, we do have limitations in our data collection process, and so we need to be thoughtful about the data we are collecting. To minimize data collection burden, we are not able to capture data on every possible disease process, physical condition, and activities of daily living in order to determine a patient's frailty status. There are also many different instruments and tools available to screen for frailty. Examples include hand grip, six-minute walk test, weight loss, activity level, general questionnaires, and scores based on administrative or claims-based data. We also understand it is challenging to implement and adopt new assessment tools, and we do have an overall awareness of the time and resources needed to perform frailty assessments and the need to balance this with collecting meaningful data. The Canadian study on health and aging clinical frailty scale is considered to be a deficit accumulation approach to formulate an index of frailty. The results are based on a clinician's judgment of a patient's functional status and independence. The domains taken into account in the scale include physical, cognitive, and psychosocial. The clinical frailty scale mixes items such as comorbidity, cognitive impairment, and disability that some other groups separate when focusing on physical frailty. As you may know, this is currently included in the CAF PCI version 5 dataset and will be included in the Chest Pain MI version 3.1 dataset when released in 2023. This next slide provides a screenshot from the data dictionaries of both CAF PCI version 5.0 and the proposed Chest Pain MI version 3.1 dataset. At first glance, it appears that these data elements are exactly alike. However, on the next slide, we will highlight the differences. As you can see, we have highlighted the differences between these data elements in red. CAF PCI is a procedure-based registry, and so the target value is set to the last value prior to the start of the first procedure. Chest Pain MI is a disease-based registry, and therefore, the target value is not reliant on the timing of a procedure. The target value for the Chest Pain MI data element is the last value between 24 hours prior to arrival at the first facility and arrival at this facility. Based on both target values, the frailty status reporting in both Chest Pain MI and CAF PCI will take into account recent symptoms and the clinical status of the patient. So let's review the clinical frailty scale selection and definitions. As you can see here in the data element, we provide a value set of selections with the associated definitions. There may be instances when the documentation in the medical record may not provide the actual selection by name, example vulnerable. However, there is documentation included in the medical record on the patient's baseline reliance on assistance with ADLs, as seen in mildly frail or moderately frail. Documentation may also include functional status and associated limitations, mental status, et cetera, that can assist with coding when trying to determine if a patient is merely vulnerable or meets the definition for a higher level of frailty. Then additional documentation may support coding a higher selection, such as severely frail or very severely frail. We also have the clinical frailty scale infographic that can assist with coding this data element. This infographic can be found on the CAF PCI registry documents homepage in the user guide documents. It will be available in the CHESSPAN MI user guide documents when version 3.1 goes live. A link can also be found on the CAF PCI registry announcement page to request a poster of the clinical frailty scale infographic. This also will be available in the CHESSPAN MI registry when version 3.1 goes live. As you can see from the infographic, it provides even more information and help on assigning the selection within the frailty scale. Measuring frailty is important to understand the patient's risk of poor outcomes to determine the best treatment plan possible. This information can assist with guiding patient-centered care decisions, shared decision-making, especially informing the conversation, care planning, risk assessment, such as risk of bleeding mentioned earlier, and identification of patients who may benefit from a frailty intervention, such as cardiac rehabilitation, physical therapy, et cetera. The importance of assessment of frailty was highlighted in a recent ACC news story as seen in the slide, which advocated for the inclusion of the assessment of frailty being integrated into cardiovascular practice. The rationale for inclusion included the identification of patients that could benefit from frailty interventions and improve their overall health and well-being. A reference to this publication is included in the last slide. I next wanted to provide you examples of how the frailty data from the CAHPS PCI registry is being used to predict adverse events and mortality. Once we begin to collect this information with the CHESSPAN MI registry, we will be able to assess the impacts this may have on patient overall risk. As many of you may know, the CAHPS PCI registry is now reporting four new metrics based on a new risk-standardized mortality model. During the model development, we found that the new frailty variable introduced with CAHPS PCI version 5.0 added important prognostic information when predicting the risk of in-hospital mortality for patients undergoing PCI, specifically severe frailty, which we defined as severe, severely frail, and terminally ill in patients without cardiac arrest, shock, or PCI status of salvage. This frailty variable in the model excluded those with cardiac arrest, shock, or PCI status of salvage who were found to be severely frail because the team wanted to isolate frailty. And what we mean by that is we just wanted to focus on why the frailty being the cause of the severely frail and not confounded by those that might have had shock or arrest. And in that way, we were able to understand how predictive our variable of severe frailty was. As you can see in this slide, this is what I mentioned previously. The mortality frailty variable added important prognostic information, like we said before. We included severely frail, very severely frail, and terminally ill patients without cardiac arrest, shock, or PCI status of salvage. Just wanted to highlight this and make sure everyone understood how and why we made that decision within the model. Another example of how frailty status is being utilized is that there has been a new publication that looked at frailty and its association with bleeding after percutaneous coronary intervention. While the study did not utilize data from the NCDR, they did utilize the same frailty scale that we are currently collecting. Their research did show an association with major bleeding and frailty status in the one year post-PCI, irrespective of the presence or absence of acute coronary syndrome presentation or cardiogenic shock. I've provided the reference there if you're interested. Also want to inform you that the new AKI or acute kidney injury model will also consider frailty status, as that's been shown to be predictive of that outcome as well. So in closing, I would like to reiterate the importance of the assessment of frailty. This information will not only benefit the registry, but also has the potential to inform clinicians with novel information to consider when defining the optimal care for each patient. Thank you.

Kim Lavin

clinical frailty

Chest Pain in My Registry

frailty data

Canadian Study of Health and Aging Clinical Frailty Scale