晚期慢性肾脏病成人患者衰弱的主观和客观测量：临床医生错误分类的横断面分析
Subjective and objectives measures of frailty among adults with advanced chronic kidney disease: a cross-sectional analysis of clinician misclassification.
作者信息
Kennard Alice, Rainsford Suzanne, Hamilton Kelly, Glasgow Nicholas, Pumpa Kate, Douglas Angela, Talaulikar Girish
机构信息
College of Health and Medicine, Australian National University, Canberra, Australian Capital Territory, Australia.
Department of Renal Medicine, Canberra Health Services, Canberra, Australian Capital Territory, Australia.
出版信息
Intern Med J. 2025 Apr;55(4):599-607. doi: 10.1111/imj.16630. Epub 2025 Jan 8.
BACKGROUND
Frailty is a recognisable clinical measure of impaired physiological reserve and vulnerability to adverse outcomes that is validated among patients with kidney disease. Practice patterns reveal inconsistent use of objective frailty measures by nephrologists, with clinicians prioritising subjective clinical impressions, possibly risking misclassification and discrimination.
AIMS
The aim of this study was to examine correlations between subjective and objective measures of frailty in a cohort of patients attending routine nephrologist review.
METHODS
Eighty-nine participants attending scheduled review with their primary treating nephrologist (n = 6) were included in cross-sectional analysis. Measured frailty based on Fried phenotype and subjective clinician impression were assessed for congruence using Pearson's correlation analysis and ĸ statistic. Ordinal logistic regression examined patient demographics associated with perceived frailty. Misclassification was explored using descriptive statistics and contingency table analysis.
RESULTS
Frailty and prefrailty were prevalent by both objective and subjective means of assessment with minimal correlation between clinician impression and measured Fried phenotype (r = 0.50, P = 0.00, ĸ = 0.25, P =& 0.00). Subjective clinician impression misclassified half of participants, influenced by surrogate frailty measures including female sex, comorbidity and reliance on a walking aid. Clinicians were equally likely to over-classify prefrailty as to under-recognise established frailty, with no evidence of systemic misclassification bias. Subjective clinican impression of frailty had a positive predictive value of 19.1% and a negative predictive value of 56.2%.
CONCLUSIONS
Nephrologists' reliance on subjective clinical impressions that overlook or misclassify prefrailty offers incomplete prognostic assessment and potentially misses opportunities for early intervention.
背景
衰弱是一种可识别的生理储备受损及易发生不良后果的临床指标，已在肾病患者中得到验证。实践模式显示，肾病学家对客观衰弱指标的使用并不一致，临床医生更看重主观临床印象，这可能会有错误分类和歧视的风险。
目的
本研究旨在探讨在接受肾病专家定期复查的患者队列中，主观和客观衰弱指标之间的相关性。
方法
纳入89名与其主治肾病专家（共6名）进行定期复查的参与者进行横断面分析。采用Pearson相关分析和κ统计量评估基于Fried表型的测量衰弱与临床医生主观印象的一致性。有序逻辑回归分析了与感知衰弱相关的患者人口统计学特征。使用描述性统计和列联表分析探讨错误分类情况。
结果
通过客观和主观评估方法均发现衰弱和衰弱前期普遍存在，但临床医生印象与测量的Fried表型之间相关性极小（r = 0.50，P = 0.00，κ = 0.25，P = 0.00）。临床医生的主观印象将一半的参与者错误分类，这受到包括女性、合并症和使用助行器等替代衰弱指标的影响。临床医生将衰弱前期过度分类与未充分认识到已确定的衰弱的可能性相同，没有系统性错误分类偏差的证据。临床医生对衰弱的主观印象的阳性预测值为19.1%，阴性预测值为56.2%。
结论
肾病学家依赖主观临床印象而忽视或错误分类衰弱前期，提供的预后评估不完整，可能错失早期干预的机会。
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