Health Services Research - Development and evaluation of the electronic frailty index+ (eFI+) tool: integrated prognostic-decision modelling to target interventions for older people with moderate or severe frailty


Frailty is common in older age. It develops because as we get older our bodies change, and can lose their inbuilt reserves, for example we lose muscle strength. These changes mean that older people with frailty can experience sudden, dramatic changes in their health as a result of seemingly small problems, such as an infection or new medication.

People with frailty are at risk of losing their independence, and help from home care services may be needed. They are also at higher risk of falling, admission to nursing homes and death. These problems can reduce quality of life and are costly for the NHS and social care.

Previous research has shown that treatments such as community rehabilitation, falls prevention programmes and comprehensive geriatric assessment (provided by a team of doctors, nurses, therapists and social workers) can improve independence, reduce falls and reduce nursing home admission for people with frailty. Also, advance care planning (which is a conversation between people, their families and those looking after them to decide on future wishes) can increase quality of care and reduce hospital admission for people nearing end of life. We have developed a tool called the electronic frailty index (eFI), which uses routine information from the GP record to help identify frailty.

However, the problem at the moment is that we do not know which older people living with moderate or severe frailty are most likely to benefit from these treatments.

In this study, we will develop an improved version of the eFI, the eFI+, to help health and social care practitioners know which people with moderate and severe frailty are most likely to benefit from treatments. To do this, we will use anonymous patient information from three very large databases that include detailed health and social care information, and data from a national study - the Community Ageing Research 75+ (CARE75+) study.

The first step in eFI+ development will be to use information from the three very large databases to

predict, in the next 12 months, which older people with moderate or severe frailty are at risk of:

1. Needing new or increased home care services.

2. Hospital admission with a fall or fracture.

3. Nursing home admission.

4. Dying.

We will also use CARE75+ data to see if simple tests like measuring walking speed can help us identify people with frailty at risk of losing independence.

The second step will be to use this data on risk prediction to find out how much benefit we might expect from the treatments, using a process called 'decision modelling'.

The third step will be to test whether offering such treatments is likely to be cost-effective – important information for the NHS and social care.

We will work closely with older people, carers, policy makers, doctors, nurses, therapists, and

commissioners of services to make sure that our work is useful for the NHS and social care. We will also work with companies that provide software to the NHS and social care to ensure that the eFI+ is made available at no extra cost.

Our research to develop the eFI+ will enable identification of older people with moderate or severe frailty who are most likely to benefit from treatments to improve health and wellbeing. We expect to have major positive impact on the health and wellbeing of older people


We anticipate major potential for immediate and longer-term impact, in line with the major national impact achieved through our previous national eFI implementation.

The 2019 NHS Long Term Plan includes supporting people to age well as a key objective, with a greater focus on proactive care based on population health management for people living with frailty. The contemporary national health and care focus on frailty, including in the Long Term Plan, means that there will be sustained interest in identifying and commissioning evidence-based frailty services. This means that the eFI+ has potential to achieve major, sustained impact, as it will guide robust commissioning of evidence-based interventions for older people living with moderate and severe frailty, including cost-effectiveness.

Our links with the four leading providers of primary care EHR systems, and existing license agreement with these partners, means that we will be able to rapidly implement the eFI+ into primary care EHR systems, at no additional cost to the end NHS user, with immediate impact.