Interview with Patrick Page, MD

Patrick Page is a family physician with Western Colorado Physicians Group in Grand Junction, Colo.,
where he has practiced for the past 35 years. One of Dr. Page’s abiding interests is advancing care for
aging patients. He introduced an electronic frailty index to his practice to evaluate patients and their
risks for ongoing health problems. He has worked with experts on frailty both in the United States and
the United Kingdom. Dr. Page, who will be a presenter at the 2018 PCMH Congress in San Diego in
September, believes that medical homes should introduce a frailty index into their practices and
diversify away from primarily a disease-focused treatment model. He recently spoke with Medical
Home News Editor Ron Shinkman.

Interviewer: How did you become interested in frailty?

Page: At the request of a family I was asked to attend a rehabilitation stay discharge meeting. It concerned a problematic disposition. I became curious about that setting as it seemed that recurrent admissions often were related to unresolved conflicts at the time of discharge. I’ve been to about 200 of these family meetings over the last 15 years. Acute care after discharge occurs frequently when needed support is lacking. I found that a family physician who knows both the patient and the families can often assist with information that improves the discharge plan.

After a literature search, I reached out to (Canadian physician and geriatric researcher) Ken Rockwood. He had completed the Cross-Canadian Study on Health and Aging, which led to what’s known as the Rockwood Frailty index, which was derived from Comprehensive Geriatric Assessment, 92 data points of symptoms and functions and care needs. Using mathematical modeling he coined the accumulated deficit theory (of frailty).

He put me in touch with (geriatrician) Stephen Evans in Buffalo and they repeated the work in Buffalo. His protégé, Steven Busulovich started a company known as Patient Pattern, a software product which includes a risking score, a care plan and a way to assess how frailty levels imply varied care plan needs. Our Frailty Workgroup (an ad hoc group of providers of frailty care across the continuum of care) adopted this software because health systems can derive the index from existing data bases….OASIS from home health and Minimum Data Set from skilled nursing and long term care.

Interviewer: And what is a frailty index specifically?

Page: There are several types of measurement of frailty:
The Rockwood Frailty index is a numerical score based on the percent of deficits from a number of types of assessments, symptoms, functions, use of devices, abnormal lab results or accumulation of diseases.

Frailty can be defined as the loss of homeostatic reserve. The accumulation of deficits objectively measures that loss on a continuum. When you get to a 67 percent deficit level, end of life is approaching rapidly, and only 40 percent of patients live longer than four months. It’s the most potent predictor of poor outcomes, hospitalization, re-hospitalization, institutionalization
and death available. This work added granularity to Dr. Fried’s phenotype theory of frailty, defined by slowing, exhaustion, weight loss, loss of motor strength, and inactivity. Drs. Andrew Clegg and John Young in the United Kingdom have used the accumulated deficit model to guide their national implementation for frailty care, guiding their hospital physicians, general practitioners and the community of care to accept that frailty is a unique condition requiring a specific pathway of care with varying strategies as frailty naturally progresses. Those strategies might obviate disease state management guidelines, yet improve quality of life.

Interviewer: And can you provide context regarding frailty as a social determinant of health?

Page: Aging is an unavoidable social determinant of health, but if you compare a frailty index to an age-related survival score, you get a high degree of predictability for poor outcomes as frailty progresses. Think of frailty as physiologic age or vulnerability or lack of resilience, which varies by the individual. It’s not just the number of chronic diseases they have. What if they have a high degree of motivation? What if they have a supportive family? And what if they have recovered from multiple (health) insults?
They may not be vulnerable or frail. Other social determinants affect this: genetics, income, happiness, motivation, depression. The comprehensive geriatric assessment measures the current status of the patients reserve and recovery. Use of the CGA takes time, yet is useful to extend functional life and independence.

If we can tap data bases to save that time and produce actionable data, we can make our care of the elderly more efficient and patient centered.

Interviewer: Are there warning signs for a manifestation of frailty?

Page: Any evidence of decreased function or reserve, following an emergency room visit for a fall, or when a concerned family member whose relative hasn’t been seen in a few years and is shocked by their decline. Most home health admissions, skilled nursing stays, or hospitalizations where there is a disposition concern.

Frailty sensitive care can also assist palliative care, hospice and as a pre-operative safety threshold for elective surgery or as a standardized performance measure for advanced cancers, or to track patients undergoing orthopedic procedures. You don’t have to be co-morbid or disabled to be frail, but you’re more likely to be frail if you are co- morbid or disabled.

Interviewer: How does frailty relate to medical homes?

Page: This concept inverts the primacy of the patient rather than the diseases. The frailty assessment is asking you to assess that patient; what is their unique risk and vulnerability for a bad outcome? It also requires that care plans and assessments follow the patients as they encounter the hospital, ER, primary or specialty care or other settings. We need to have a different
paradigm that’s allows information and care planning to follow the patient along the continuum of care.

 Interviewer: So, are frail patients good candidates for a medical home, or should there be some hybrid model?

Page: I think the (term) patient-centered medical home fits frailty to a ‘T.’ That is why we started a Frailty Work Group with our HIE and local university which trains nurse practitioners.

We need to re-engineer the care of the frail population as it accounts for 30% of the Medicare budget. A frailty index provides specific information and highlights care needs. If a patient fell because they didn’t have a walker, or they needed more support at home, it’s the right care at the right time to the right person. That’s patient-centered in my view. Some incentives and bureaucratic rules will have to change as we learn what works better.

Interviewer: Tell us something about yourself people would not necessarily know.

Page: After three years at Colorado University, I went to Lancaster University (in the UK), and I applied to medical school on the way. And I was planning to be a psychiatrist. But my best friend’s stepfather was a general practitioner in Brighton, England. He asked me why I wanted to be a psychiatrist. I had told him I had a lot of interest in humanity and literature. He said, because of that, you are going to have a much more enjoyable career in general practice.