Metric definitions and calculations

Set out below are the metric definitions and calculations for the 11 indicators used in the Frailty Care Heatmaps that form part of the analysis undertaken as part of the "One small step for older people with frailty, one giant leap for frailty care?" report.  

Links to the data sources are also provided at the end.   Further information on the calculation of the estimated diagnosis rate is available here.

Metric definitions and calculations

  1. Registered list population aged 65 and over - this is based on GP Contract Services data indicator CCDCCC03 "The number of registered patients aged 65 years or over at the end of the reporting period.”
  2. % of total population aged 65 and over - this is calculated from GP Contract Services data indicator CCDCCC03 divided by CCDCCC01 "The number of registered patients on the GP practice list as at 31 March 2018.”
  3. % of Patients aged 65 years or over who have had a frailty assessment - this is calculated from GP Contract Services data indicator (CCDCMI10) "Registered patients aged 65 years or over, who have had a frailty assessment using the appropriate tool" divided by  CCDCCC03 "The number of registered patients aged 65 years or over at the end of the reporting period.”
  4. % of Patients aged 65 years or over with a diagnosis of moderate or severe frailty - this is calculated from GP Contract Services data indicators (CCDCMI12) "Registered patients aged 65 years or over, who have a diagnosis of moderate frailty, diagnosed using the appropriate tool" (CCDCMI13) "...diagnosis of severe frailty..." added together and divided by  CCDCCC03 "The number of registered patients aged 65 years or over at the end of the reporting period."  
  5. Estimated diagnosis rate (% of 'expected' prevalence based on eFI) - this is calculated from GP Contract Services data indicators (CCDCMI12) "Registered patients aged 65 years or over, who have a diagnosis of moderate frailty, diagnosed using the appropriate tool" (CCDCMI13) "...diagnosis of severe frailty..." added together and divided by the 'expected' number of moderate and severe frailty diagnoses based on  5-year age-band specific prevalence rates generated from applying eFI to Kent Integrated Dataset (KID) which are then applied to practice specific demographic profile and converted to a % by multiplying by 100.  See page 5 & 6 for more detail.
  6. Ratio of moderate to severe frailty diagnoses - this measure of case mix is calculated from GP Contract Services data indicators (CCDCMI12) "Registered patients aged 65 years or over, who have a diagnosis of moderate frailty, diagnosed using the appropriate tool" divided by (CCDCMI13) "Registered patients aged 65 years or over, who have a diagnosis of severe frailty, diagnosed using the appropriate tool". The 'expected' ratio based on eFI development work is around 4.  A lower ratio indicates that there may be under-diagnosis of moderate frailty, particularly if there is a significant overall diagnosis gap.  A higher ratio may indicate under-diagnosis of severe frailty. 
  7. Ratio of moderate and severe frailty diagnoses to dementia register for 65+ population - this measure of case mix is calculated from GP Contract Services data indicators (CCDCMI12) "Registered patients ...who have a diagnosis of moderate frailty" and (CCDCMI13) "...diagnosis of severe frailty" combined and divided by the number of patients on the 65 years and over dementia register as reported at 31 Mar 2018.  The 'expected' ratio is 2.5 - 3.0 assuming no diagnosis gap from expected prevalence for either frailty or dementia.  A lower ratio indicates that there may be under-diagnosis of frailty relative to dementia. A higher ratio potentially indicates the reverse.
  8. % of patients with a diagnosis of severe frailty who have received annual medication review - this is calculated from GP Contract Services data indicator (CCDCMI14) "Registered patients aged 65 years or over, who have a diagnosis of severe frailty and have received an annual medication review on or after their severe frailty diagnosis." divided by indicator (CCDCMI13)  "Registered patients aged 65 years or over, who have a diagnosis of severe frailty, diagnosed using the appropriate tool”
  9. % of patients aged 65 years or over with a diagnosis of moderate or severe frailty, who have had a fall - this is calculated from GP Contract Services data indicator (CCDCMI16) "Registered patients aged 65 years or over, who have a diagnosis of either moderate or severe frailty, diagnosed using the appropriate tool up to the end of the reporting period and who have had a fall." divided by the sum of indicators (CCDCMI12)  "Registered patients aged 65 years or over, who have a diagnosis of moderate frailty, diagnosed using the appropriate tool" and (CCDCMI13) "...diagnosis of severe frailty...”
  10. Referral to ‘falls clinic’ as % of patients with a diagnosis of either moderate or severe frailty and a fall - this is calculated from GP Contract Services data indicator (CCDCMI17) "Registered patients aged 65 years or over, who have a diagnosis of either moderate or severe frailty, diagnosed using the appropriate tool up to the end of the reporting period and who have had a referral to ‘falls clinic’, as clinically appropriate." divided by (CCDCMI16) "Registered patients aged 65 years or over, who have a diagnosis of either moderate or severe frailty, diagnosed using the appropriate tool up to the end of the reporting period and who have had a fall.”
  11. % patients with a diagnosis of moderate or severe frailty, who have given consent to activate their enriched Summary Care Record (SCR) - this is calculated from GP Contract Services data indicator (CCDCMI18) "Registered patients aged 65 years or over, who have a diagnosis of moderate or severe frailty, diagnosed using the appropriate tool, who have given consent to activate their enriched Summary Care Record (SCR)." divided by the sum of indicators (CCDCMI12) "Registered patients aged 65 years or over, who have a diagnosis of moderate frailty, diagnosed using the appropriate tool" and (CCDCMI13) "...diagnosis of severe frailty...”

Data sources

Other links