Frailty assessment in vascular surgery

Welsh, Silje Alvsåker (2025) Frailty assessment in vascular surgery. MD thesis, University of Glasgow.

Abstract

Background: Frailty describes a syndrome characterised by reduced physiological reserve and increased vulnerability to even minor stressors due to age-associated changes in physiological substrate. Frailty is common in vascular surgery populations and has demonstrated associations with adverse health outcomes and increased risk of mortality. However, in the absence of clear guidelines there is uncertainty over the approach to frailty identification and its management. Frailty identification can be considered the critical first step to improving health outcomes for this vulnerable population. A role is identified for exploring approaches to frailty assessment and the implications this might bring to vascular surgery services.

Aims: This thesis addresses the following aims:
1. To explore the methodological approaches to frailty assessment described
in vascular surgery research and clinical practice.
2. To explore the practical utility of frailty in vascular surgery clinical
practice.
3. To explore stakeholders perceptions of frailty assessment in clinical
practice.

Methods: Three approaches were adopted to target research questions. First a two-part systematic review was performed. The first part included any study describing any form of frailty assessment in vascular surgery populations for any reason. Data collection included which frailty assessment tools were used, the methodological application of each tool and how data was analysed. The second review set out to explore how the clinimetric properties have been assessed for the ten most commonly used frailty assessment tools identified in the aforementioned review. Any study with the aim of exploring any clinimetric property was included. The search criteria was expanded to include studies of any surgical population as initial search strategy found restricting to vascular surgery populations only yielded a low number of eligible studies.

Secondly, a prospective observational study was conducted to explore the practical utility of frailty assessments in clinical practice. Patients were recruited from a vascular rapid-access clinic, baseline data were collected and five different frailty assessments were performed (Clinical Frailty Scale, Healthcare Improvement Scotland FRAIL, Frail NonDisabled questionnaire, subjective clinical assessment and 11-item modified frailty index). Outcome measures include feasibility parameters, comparisons of the demographic differences between
robust and frail patients and clinimetric property assessment (interrater reliability and convergent validity), using clinician-assessed CFS as reference standard. A short-term (30-day) follow-up explores prognostic properties of frailty assessment tools.

Finally, a national mixed methods study recruited vascular surgeons and allied healthcare professionals and explored their perceptions and utilisation of frailty assessment in clinical practice. An 18-item questionnaire was distributed purposively by email with respondents given the option to volunteer for follow-up interview/focus groups through the questionnaire.

Results:

Research aim 1: Screening 5358 records identified 111 eligible studies. Forty-three differing frailty assessment tools were identified. One-third of these failed to assess frailty as a multidomain deficit and there was a reliance on assessing function and presence of comorbidity. Substantial methodological variability in data analysis and lack of methodological description was also identified. Published psychometric and/or clinimetric assessment was available for only 4 of the 10 most commonly used frailty tools. The Clinical Frailty Scale (CFS) was most studied and demonstrated good clinimetric properties within a surgical population.

Research aim 2: A total of 150 patients were recruited. Most were young, male and from areas of greatest social deprivation. Seventy-six (51%) were frail (CFS 5+). Frailty was significantly associated with age, polypharmacy and comorbidity. Clinicians were more likely to consider women frail on end-of bed, this was not replicated in remaining instruments. Compared to CFS, there was excellent agreement with end-of-bed assessment and moderate agreement with HIS FRAIL. The mFI-11 and FiND demonstrated poor agreement and correlation with the remaining frailty assessment instruments which suggests these tools measure different constructs. Due to small numbers, no significant differences were observed on 30-day follow-up, including: mortality, morbidity, length of stay, readmission rate, or nonhome discharge.

Research aim 3: A total of 160 questionnaires were distributed with 60 (37.5%) responses. Respondents were primarily consultant or trainee vascular surgeons but contributions were comprehensive and involved most members of vascular surgery multidisciplinary team members. Responses were received from ten of fourteen Scottish regional health boards. A total of 20 respondents volunteered for follow-up interviews/focus groups across four regional health boards and totalling over 8 hours of recorded interview time. Healthcare workers recognise the importance of identifying and treating frailty. However, assessment lacks a unified approach with clinicians primarily performing subjective assessments. A call for standardising the approach to frailty assessment was made primarily due to a feeling that this would assist in unifying the necessary, and currently, disjointed services into a collaborative multidisciplinary approach to improving health outcomes for patients living with frailty.

Conclusion: Despite frailty being recognised by vascular healthcare professionals as a relevant construct with important clinical considerations, there is substantial heterogeneity in approaches to frailty assessment within vascular surgery research and clinical practice. This might be associated with variability in diagnostic and prognostic accuracy and has generated uncertainty around tool selection. For this reason, a call has been made for adopting a standardised approach to frailty assessment. To support such a movement, the work in this thesis presents data supporting the feasibility of routine frailty screening using standardised tools in an outpatient setting. Surgeons prioritise a prognostic role for such tools while allied healthcare professionals consider frailty in a broader sense, recognising the need for collaborative multidisciplinary approaches to its management as part of improving health care outcomes. Introducing a standardised approach to frailty identification is felt supportive in this movement primarily through guiding unification of language, awareness of a growing problem and to redirect the attention and priorities of multidisciplinary services. As part of achieving shared care goals, a deepened understanding of early-onset frailty and the interplay with mobility-limiting pathology, particularly in considering frailty phenotypically, is recommended.

• Item Type: Thesis (MD)
• Qualification Level: Doctoral
• Subjects: R Medicine > R Medicine (General); R Medicine > RA Public aspects of medicine; R Medicine > RD Surgery
• Colleges/Schools: College of Medical Veterinary and Life Sciences > School of Cardiovascular & Metabolic Health
• Supervisor's Name: Quinn, Professor Terry and Orr, Mr. Douglas
• Date of Award: 2025
• Depositing User: Theses Team
• Unique ID: glathesis:2025-85617
• Copyright: Copyright of this thesis is held by the author.
• Date Deposited: 24 Nov 2025 15:32
• Last Modified: 24 Nov 2025 15:39
• Thesis DOI: 10.5525/gla.thesis.85617
• URI: https://theses.gla.ac.uk/id/eprint/85617

Related URLs

• Article DOI
• Article DOI
• Article DOI
• Article DOI
• Article DOI
• Article DOI
• Article DOI