Real-World Implementation of PRISMA-7 and Clinical Frailty Scale for Frailty Identification and Integrated Care Activation: A Cross-Sectional Study in Northern Italian Primary Practice

Abstract

Background/Objectives: Frailty screening is crucial for identifying vulnerable older adults who may benefit from interventions. However, the implementation of screening in primary care and integration into personalised care pathways remains limited. This study examined the feasibility of a two-step frailty screening approach combining PRISMA-7 and the Clinical Frailty Scale (CFS). The study assessed PRISMA-7 cut-offs' impact on frailty classification, CFS agreement, and activation of integrated domiciliary care. Methods: This cross-sectional study was conducted in Northern Italy. General practitioners screened patients aged ≥75 years using the PRISMA-7 tool; if the result was positive (score ≥ 3), the Clinical Frailty Scale (CFS) was subsequently applied. Descriptive statistics, group comparisons, correlation analyses, and logistic regression models were employed to evaluate the predictors of frailty and activation of integrated domiciliary care. Comparisons were made for PRISMA-7 cut-off values ≥3 and ≥4. Results: Among the 18,658 patients evaluated using PRISMA-7, 46.0% were identified as frail with a threshold of ≥3 and 28.8% with ≥4. In a subset of 7970 patients assessed using both PRISMA-7 and the Clinical Frailty Scale (CFS), CFS confirmed frailty (score ≥ 5) in 48.3% of the patients at a PRISMA-7 cut-off of three and 68.2% at a cut-off of four. The female sex predicted frailty by CFS, whereas the male sex was correlated with frailty at the PRISMA-7 cut-off of three. Rural location was correlated with frailty by PRISMA-7 but showed an inverse relationship with frailty by CFS. Integrated domiciliary care began in 14.2% of the patients meeting the clinical criteria, with a higher frequency in rural areas. Concordance between PRISMA-7 and CFS increased with patient age, and at a cut-off of four. Conclusions: Two-step frailty screening using PRISMA-7 and CFS is viable for primary care. Using a PRISMA-7 cut-off score of ≥4 may reduce frailty overestimation, enhance congruence with clinical assessments, and reduce sex-related bias. These findings support incorporating structured screening into personalised care planning and refining frailty tools to improve equity and effectiveness.

Keywords: Clinical Frailty Scale; PRISMA-7; frailty screening; integrated domiciliary care; personalised medicine; primary care.

Figure 1

Distribution of the PRISMA-7 and CFS scores by age, sex, and GP office location. Bar charts showing the distribution of PRISMA-7 (left panels) and the Clinical Frailty Scale (CFS, right panels) scores among patients aged ≥75 years stratified by (top) age group (75–84 vs. ≥85 years), (middle) sex, and (bottom) rural vs. urban location of the general practitioner) office. Most patients aged 75–84 years scored ≤2 on PRISMA-7 and ≤4 on CFS, whereas those aged ≥85 years scored ≥4 on PRISMA-7 and ≥5 on CFS. Female patients showed higher frequencies of CFS scores ≥ 5, while male patients were more likely to score 3 on PRISMA-7. Urban–rural differences in score distributions were modest but suggested slightly higher CFS scores in urban populations. Abbreviations: CFS, Clinical Frailty Scale; GP, general practitioner.

Figure 2

Age of frailty onset by sex, Kaplan–Meier analysis for PRISMA-7 and the Clinical Frailty Scale. Kaplan–Meier curves displaying cumulative frailty prevalence by patient age stratified by sex and frailty assessment tool: PRISMA-7 (cut-offs 3 and 4) and the Clinical Frailty Scale (CFS). With a PRISMA-7 cut-off of 3, men became frail earlier than women (mean age: 85.7 vs. 87.6 years; p < 0.001). This difference narrowed at a cut-off of 4 (88.1 vs. 89.2 years; p < 0.001). In contrast, CFS showed no significant sex difference in the age of frailty onset (89.2 vs. 88.8 years; p = 0.013). These findings highlight how cut-off selection affects sex-specific frailty classification in older adults. Abbreviations: CFS, Clinical Frailty Scale.