Abstract

Background: Emergency departments are a last resort for some socially vulnerable patients without an acute medical illness (colloquially known as “socially admitted” patients), resulting in their occupation of hospital beds typically designated for patients requiring acute medical care. In this study, we aimed to explore the perceptions of health care providers regarding patients admitted as “social admissions.”

Methods: This qualitative study was informed by grounded theory and involved semistructured interviews at a Nova Scotia tertiary care centre. From October 2022 to July 2023, we interviewed eligible participants, including any health care clinician or administrator who worked directly with “socially admitted” patients. Virtual or in-person individual interviews were audio-recorded and transcribed, then independently and iteratively coded. We mapped themes on the 5 domains of the Quintuple Aim conceptual framework.

Results: We interviewed 20 nurses, physicians, administrators, and social workers. Most identified as female (n = 11) and White (n = 13), and were in their mid to late career (n = 13). We categorized 9 themes into 5 domains: patient experience (patient description, provision of care); care team well-being (moral distress, hierarchy of care); health equity (stigma and missed opportunities, prejudices); cost of care (wait-lists and scarcity of alternatives); and population health (factors leading to vulnerability, system changes). Participants described experiences caring for “socially admitted” patients, perceptions and assumptions underlying “social” presentations, system barriers to care delivery, and suggestions of potential solutions.

Interpretation: Health care providers viewed “socially admitted” patients as needing enhanced care but identified individual, institutional, and system challenges that impeded its realization. Examining perceptions of the people who care for “socially admitted” patients offers insights to guide clinicians and policy-makers in caring for socially vulnerable patients.

Emergency departments have become a destination of last resort for some patients who are made vulnerable by social circumstances, resulting in their occupying hospital beds typically designated for people with acute medical issues.1 “Social admission” is a colloquial, nondiagnostic label used to describe a person for whom no acute medical issues are recognized to be contributing to their seeking health care. However, many health care providers understand that patients who are admitted for social reasons face challenges such as a breakdown of care supports or an inability of the patient or family to cope with the demands of living at home.2 These patients often have lengthy stays in emergency departments or hospital wards, and frequently encounter barriers (e.g., housing or home support) delaying safe discharge from hospital. The colloquial terms “failure to cope,” “acopia,” “orphan patient,” or “home care impossible,” among others, are sometimes used to refer to these patients.3–5 Such terminology can be stigmatizing because it indicates a value judgment that patients require admission solely on “social” grounds, sometimes failing to account for underlying medical complexity.6

The “social admission” phenomenon is an under-researched area in health care. These patients, often categorized by health care providers as not being acutely ill, experience in-hospital death rates as high as 22.2%–34.9%.7,8 Explanations may include under-triaging in the emergency department owing to poor recognition of atypical clinical presentations and delays in timely assessments.5 Patients may be misdiagnosed or develop acute illness during their hospital stay. In 2 international studies, by the end of hospitalization, an admission diagnosis of “acopia” was no longer the discharge diagnosis in 88%–92.5% of cases.7,9 Diagnoses of falls, delirium, and mobility problems were common, but sepsis was initially undiagnosed in almost one-third of these patients.7 This raises questions about health care providers’ awareness of atypical presentations and decision-making for “social” presentations, which often require a nuanced understanding of both medical and social care needs.

Health care providers face challenges providing high-quality care to this patient population across Canada1,10 and internationally. 1,4,10–13 “Social admissions” may account for as many as 1 in 10 patients (0.57%–9.3%) presenting to the emergency department and 1 in 25 admissions to hospital, with increasing prevalence with age.14 A survey from Wales showed that 51.8% of hospital physicians consider that they frequently care for these patients, encountering them several times per week.15

Since “social admission” is a nondiagnostic label, its definition varies across regions and health care systems, meaning no guidelines exist to standardize approaches to meet medical or social care needs. Qualitative data evaluating how health care providers perceive and care for these patients are lacking. Therefore, we aimed to explore the perceptions of health care providers regarding patients admitted as “social admissions.”

MethodsStudy design

This qualitative study was informed by constructivist grounded theory, which uses inductive analysis of data collected from participants to generate new theories.16,17 We conducted semistructured interviews with clinicians and health care administrators between October 2022 and July 2023. Given that little is known about “social admissions,” grounded theory was best suited to our objective to generate an explanatory theory about this phenomenon.17

The research team included qualitative methods experts, geriatric medicine specialists, clinician scientists, primary care and emergency department clinicians, and members with administrative leadership roles. We also included nursing students, medical students, and internal medicine residents of diverse backgrounds.

We reported this study using the Consolidated Criteria for Reporting Qualitative Research Checklist (Appendix 1, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.231430/tab-related-content).18

Setting and participants

Studying “social admissions” can be challenging because of the variability in terminology and admission policies across different jurisdictions.19 The Orphan Patient Policy is a standardized “social admission” pathway used at the Queen Elizabeth II Health Sciences Centre, a tertiary care centre in Halifax, Nova Scotia. Halifax is the provincial capital and the largest city in the Atlantic region of Canada. In Nova Scotia, health care is provided through a publicly funded health care system.

Since March 2012, any patient, regardless of age or living situation, can be admitted to the Queen Elizabeth II Health Sciences Centre under the Orphan Patient Policy if they have undergone a medical assessment by a physician in the emergency department, are determined to have no acute or new medical conditions, and have been seen by a social worker or discharge planning nurse to exhaust all home care options. Inability to return home includes situations of homelessness, unavailable community supports, or waiting for transitions to long-term care. These patients are admitted to the first available inpatient bed, based on a rotating roster of all hospital admission services (e.g., medicine, psychiatry, surgery, subspecialty medicine or surgery, and hospitalist). The admitting service and its allied health care team become responsible for the patient’s care and disposition, with the expectation that discharge planning is the primary issue. Although these patients are locally called “orphan patients,” we use the terminology “social admission” throughout this paper.

Eligible participants included any clinical provider or administrator who worked directly with “socially admitted” patients. To identify potential participants for our study, we held initial interviews with hospital nursing bed flow managers who are responsible for administering the Orphan Patient Policy.

To recruit participants, we used snowball sampling: we emailed each health care provider or department that had been recommended by the initial interviewees (i.e., the nursing bed flow managers), and those suggested by study participants during their interviews or by key knowledge users with whom we shared preliminary findings (see Data analysis). Preliminary analyses also informed recruitment, and we used purposive and theoretical sampling20,21 to ensure that the perspectives of multiple health care professionals within the “social admission” care pathway were included, with the aim of data saturation. We approached several departments and individuals who declined to participate or did not respond to our requests for interviews. These included recreation therapy, physiotherapy, occupational therapy, some administrative positions, and several subspecialty medicine divisions.

Data collection

The interview guide (Appendix 2a, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.231430/tab-related-content) was based on our literature review of “social admissions”14 and informed by our chart reviews of more than 350 “social admissions” in Nova Scotia (unpublished data, 2021). The entire research team gave input on the interview guide through several iterative processes: multiple meetings to develop the guide, a pilot test with non-author colleagues, and a meeting after all interviewers had conducted at least 1 interview to discuss whether the guide was robust enough to elicit the information we were seeking. We revised the interview guide wording for clarity and understanding, and we added 2 major questions (interview guide questions 7 and 8) and several prompting questions.

Experienced qualitative researchers (C.S. and E.G.M.) provided training. We held 2 group and 1 individual interactive training and practice sessions, which provided methodological context, and practical approaches and techniques in qualitative interviewing. One research team member (J.C.M., L.E., G.A., or M.K.) administered individual interviews. Interviews occurred virtually (via Microsoft Teams) or in person in quiet rooms on hospital wards or participants’ offices. After interviews were completed, we contacted participants by email to provide self-identified demographic data. The survey was voluntary and anonymous, and participants selected from predefined categories or supplied free text for sex, gender, ethnicity, role, and profession (Appendix 2b).

Interviews were audio-recorded and transcribed verbatim. For additional rigour and contextualization during analysis, interviewers kept detailed field notes of their reflections during the interviews.

Data analysis

Data collection and analysis occurred simultaneously. All participants were invited to review their transcripts before analysis (1 participant opted to). We used Dedoose software for data coding and organization.

Two team members independently coded interview transcripts using an inductive approach.16,17 Throughout the initial coding process, the coders (J.C.M., C.S., G.A., and M.K.) met regularly to refine, merge and expand codes, come to consensus about any disagreements and interpretations, add context to certain transcripts with their field notes from the interviews, and identify additional participants suggested by the participants. Using constant comparative and selective coding processes,16,17 we generated categories and subcategories to form themes to reflect participants’ perspectives on “social admissions.”

We used several strategies to ensure rigour and trustworthiness throughout the research process. As per the grounded theory approach, we incorporated reflexivity into our analytic process and acknowledged our dual roles as researchers and health care providers delivering care. Most members of the research team were affiliated with the research site and possessed an in-depth understanding of the local context and providers involved in “social admission” care. This intimate understanding enabled us to add context to the findings. However, we also challenged our preconceptions and biases by recruiting participants with diverse experiences and perspectives, and scheduling regular meetings among research team members to triangulate findings with our internal chart review, knowledge user feedback, and data analysis.22

We put participant narratives at the forefront by presenting the data (from preliminary interviews and after completion of interviews) to engaged key knowledge users within our hospital and university network (e.g., experienced researchers, clinicians, social workers, and administrators) in a variety of settings (e.g., individual communications, small group sessions, or internal department presentations). The knowledge users provided feedback and suggested further participants. The data were also triangulated with findings from our recent literature review.14

After data saturation was achieved, we mapped our findings on the Quintuple Aim conceptual framework at the suggestion of a knowledge user and as per consensus with the research group.23,24 This framework adequately organized and contextualized our findings and is a well-known approach to optimizing health system performance and defines 5 fundamental domains (definitions in Appendix 1) for transforming health care: enhance patient experience, better population health, optimize cost of care, improve care team well-being, and advance health equity.23,24

Ethics approval

Nova Scotia Health granted institutional research ethics approval (REB no. 1027628).

Results

We conducted 20 interviews (9 in person and 11 virtual) among hospital administrators and clinicians (Table 1). Clinicians were nurses (charge, discharge planning, and inpatient), physicians (residents and staff physicians), and social workers, representing the following services: emergency department, internal medicine, medical subspecialties (cardiology, neurology, and geriatric medicine), psychiatry, hospitalist, and surgical specialties (orthopedics, general surgery, cardiovascular surgery, and vascular surgery). Administrators included nursing bed managers and directors of hospital divisions and long-term care. The mean interview length was 38 (range 16–76) minutes.

Table 1:

Demographic information of hospital administrators and clinicians who were interviewed

We categorized 9 themes into each of the 5 domains of the Quintuple Aim framework as shown in Figure 1: patient experience (patient description, provision of care); care team well-being (moral distress, hierarchy of care); health equity (stigma and missed opportunities, prejudices); cost of care (wait-lists and scarcity of alternatives); and population health (factors leading to vulnerability, system changes for addressing “social admissions”). Additional illustrative quotations are presented in Appendix 3, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.231430/tab-related-content.

Figure 1:

Domains (in the circle) and themes (outside the circle) using the Quintuple Aim framework.23,24

Patient experienceParticipants’ description of patients

Participants provided diverse descriptions of these patients (Table 2). One cited financial precarity as a key problem faced by these patients. Another highlighted recurrent health care system interactions as being important. Some mentioned these patients had a mix of medical, mental health, and social problems. Most equated “social admissions” with older patients or those who were cognitively impaired. Some deemed them the most frail, vulnerable, or complex cases. Few considered that “socially admitted” patients had no medical conditions involved (Appendix 3) or that the medical conditions could wholly be managed at a primary care level.

Table 2:

Descriptions and illustrative quotations of the patient description and provision of care themes in the patient experience domain

Provision of care

Participants described “socially admitted” patients as receiving passive and hands-off care, contrasting this with active approaches for medical and surgical cases. Participants reported that patients, especially those who were older or confused, often received limited attention and workup, leaving their needs unaddressed (Table 2). The approach to care was characterized by patients being left in their beds, being the last person rounded on by the care team, and not being chosen to participate in rehabilitative programs or exercises. In short, these patients’ care needs were the last in the queue of nursing and physician priorities. Beyond direct provision of care, participants identified that hospital programs (e.g., recreation therapy) benefitting these patients had been discontinued or under-resourced (Appendix 3). Almost all clinical participants considered their ward was not the place to care for these patients.

Care team well-beingMoral distress

Health care providers described their roles as acute care or sub-specialized experts but said they felt helpless when they were unable to provide care for “socially admitted” patients, who often had complex, unrecognized, or chronic health issues. They often stated that better care should be offered yet described challenges when caring for “socially admitted” patients. These included a lack of appropriate training, struggles to arrange suitable care, and resistance when attempting to involve other services, allied health care, or social work, leading to delays in appropriate management (Table 3). As articulated by 1 participant (HC605): “I think that’s a lot to ask of different providers who may not have that skill set. So, sometimes I think it does cause, you know, moral distress and challenge for people sometimes, which then gets perhaps articulated as being ‘they shouldn’t be here.’” Many reported feeling negative toward the policy and labelling of these patients, and acknowledged it was used primarily to communicate with other health care providers. One participant suggested the policy prevented blame on clinicians for “admitting this [patient]” (HC840).

Table 3:

Descriptions and illustrative quotations of the moral distress and hierarchy of care themes in the care team well-being domain

Hierarchy of care

Participants highlighted a hierarchy in health care, prioritizing acute care patients over “social admissions.” One participant reflected on how hospitals rely on pathways with these patients not fitting into a clear “slot,” representing individuals not well differentiated, individuals with complexity, or individuals with issues that are not specialty specific. Consequently, “social admissions” were passed down the hierarchy, from physicians to residents, and sometimes to nursing assistants, implying they were less worthy of routine medical attention (Table 3).

Health equityStigma and missed opportunities

The term “social admission” led to incorrect assumptions about medical needs and cognitive abilities. Beliefs about behaviours were noted by several participants. These assumptions were propagated as early as handovers from paramedics to emergency nursing teams (Table 4). Participants highlighted instances where these patients were not medically stable and emphasized that social stressors did not exempt patients from becoming medically ill during the admission. The label was reported to be an impediment to opportunities to look for underlying treatable medical issues, compounded by the need to make timely decisions because of pressures to free up beds.

Table 4:

Descriptions and illustrative quotations of the stigma and missed opportunities, and prejudices themes in the health equity domain

Prejudices

Ageist beliefs underpinned assumptions about capacity, especially for older “socially admitted” patients. Some participants recognized that these patients could not effectively advocate for themselves, and others pointed out that older patients were often assumed to be cognitively or functionally impaired, and decisions were made without them. Participants provided examples of premature capacity determinations made without proper medical evaluation or consultation (Table 4). One participant described the invisibility of these patients, especially for women and minorities, and another noted how the care of “socially admitted” patients is undermined by negative attitudes similar to those encountered by individuals with substance use disorders (Appendix 3).

Cost of careWait-lists and scarcity of alternatives

Inadequate community support often resulted in emergency department visits and hospital admissions, with the perception that hospitals are the safest place. Participants noted lengthy wait-lists for community services like home care, physiotherapy, or occupational therapy, which led to deconditioning (Table 5). The transition to long-term care was described as “abysmal,” leaving patients in challenging situations for extended periods. Admissions were a “last resort” after all other options were exhausted, with patients and families struggling to access necessary care. The lack of alternatives contributed to participants’ distress when caring for “socially admitted” patients (Appendix 3).

Table 5:

Description and illustrative quotations of the wait-list and scarcity of alternatives theme in the cost of care domain

Population healthFactors leading to vulnerability

Participants identified many issues that were associated with the “social admission” label, particularly for patients with cognitive impairment (Table 6). These included physical barriers (e.g., inaccessible homes), homelessness, and financial challenges. Social isolation left individuals unsupported, managing alone until emergencies, such as falls, catalyzed hospital admission. The inability to advocate for oneself was also a common observation.

Table 6:

Descriptions and illustrative quotations of factors leading to vulnerability and system changes for addressing “social admission” themes in the population health domain

System changes for addressing “social admissions”

Participants identified systemic barriers that they considered disadvantaged “socially admitted” patients. Participants were concerned that the health care system is currently in crisis (e.g., with a lack of primary care and home support), and emergency departments cannot function as intended, causing the acute care system to become the community system or “the [inter]mediate pathway between community and long-term care” (Table 6). Some called for specialized seniors’ care teams to address the unique needs of older adults. Participants emphasized the importance of understanding these patients’ situations holistically, with a multidisciplinary approach to assess medical history, social factors, and available resources; several examples of ideal approaches were shared. The system’s focus on individuals with higher functioning left “socially admitted” patients underserved, with emphases on services that are “organized from a provider lens, not from a patient-need lens” (HC605).

Interpretation

We sought to understand how health care providers perceive patients labelled as “socially admitted” in hospital, and we identified 9 key themes across the Quintuple Aim framework.23,24 The themes in the patient experience domain highlighted inconsistent definitions and passive care approaches for these patients, who are often seen as low priority in hospital. Under the care team well-being domain, themes of moral distress and hierarchy of care showed the challenges and dilemmas faced by health care providers. Issues of stigma (e.g., “they have dementia”), prejudices (e.g., ageism), wait-lists, and scarcity of alternatives underscored systemic challenges under the health equity and cost of care domains. Finally, factors leading to vulnerability and potential system changes were described by participants as ways to better the health of this population.

Our findings highlight the potential adverse effects on care when patients are labelled as “socially admitted” (or as “orphan patients” in the study hospital), such as incorrect assumptions about medical needs and cognitive abilities, which impedes opportunities to look for treatable medical issues. Despite a “social admission” pathway ostensibly designed to ensure there are no acute or new medical issues, patients were still perceived as having “multiple comorbidities” or being “the most frail … the most complex” (Table 2). This finding is in keeping with the results of a case–control study (in London, Ontario), in which medical comorbidity played a minimal role in the label of a “failure to cope” admission among adults aged 70 years or older. Instead, recent failed discharge from hospital was significantly associated with a “social admission” label, leading the authors to suggest blame was an important part of the use of this label in a system that prizes efficiency.3 This supports the viewpoint that it is more a system’s failure to cope than the patient’s.10

Our findings also demonstrate possible negative impacts on health care providers not addressed in previous research. Although similar patient populations (“failure to thrive” or “failure to cope”) in British Columbia25 and Ontario,3 and “acopia” admissions in the United Kingdom and Australia,7,9 have been researched, these studies did not consider the insights of providers directly caring for these patients. We highlight some structures (e.g., propagation of the label early in care) or cultures (e.g., ageism) in our health care systems, leading to system and individual tensions caring for “socially admitted” patients, especially in the context of few readily available alternatives. We observed that participants frequently reported feeling conflicted defining, prioritizing, and managing this patient population, yet unequivocally considered these patients deserved care — albeit care delivered by someone else. This latter finding contrasts with a survey of physicians in Wales in which two-thirds (62.7%) considered patients labelled as “social admissions/acopia” were a burden on national health resources, with 44.8% of physicians admitted to feeling that these patients were a burden on their time.15

Despite considering that “socially admitted” patients were deserving of care, our participants recounted how care was passed down to less-senior members of the health care team. This pattern of downgrading care can lead to situations in which “socially admitted” patients are looked after by team members who possess minimal experience recognizing evolving medical presentations or lack the authority to advocate strongly for clinical reassessments when needed. The implication that the care of “social admissions” should be delegated to others reflects an implicit attitude of hierarchy and detachment from the needs associated with this patient population. Not being able to provide the care that is warranted while at the same time believing that the needed care is beneath the care they provide is in keeping with cognitive dissonance literature in medicine (i.e., holding 2 or more inconsistent beliefs or behaving in a way that is inconsistent with core beliefs).26 Cognitive dissonance can trigger negative emotions and subsequent defensive reactions resulting in fault finding in others (e.g., blaming “social admissions”), reinforced commitment to wrong actions (e.g., propagating labels), and overlooked medical errors,26,27 offering some explanations for understanding how stigma and hierarchies of care can lead to missed acute medical illnesses (e.g., sepsis, malignancy, and strokes) in previous “social admission” populations.5,7,9

Existing literature indicates that “social admission” labelling may harm patients.14 Our findings suggest that the use of this label appears to have little benefit for the health care providers who care for this patient population. Moreover, no evidence exists to date that “social admissions” labelling or pathways help the health care system. Therefore, re-evaluating an approach to caring for “socially admitted” patients is imperative, and this may include abandoning the nondiagnostic label.

Better support for this patient population may be achieved through enhanced policies that propose feasible solutions to support these patients. To achieve this, further steps are required to define “social admissions,” and to highlight the importance and scope of the issues surrounding the patient population captured under this label.28 However, we found inconsistencies in how “social admissions” are described, which adds to the challenge in developing effective policies for these patients, and in comparing similar presentations across Canada.29 Developing a consistent definition for “social admissions” may also prompt clinical specialties to claim responsibility for this population, as champions are key to raising issues for prioritization in health care.30

“Social admissions” can be considered a “wicked problem” with no single easy solution.31 A previously proposed ecological approach can guide clinicians in managing “social” presentations.2,32 Participants in our study made suggestions about community- and institutional-level solutions such as home care and primary care teams that support social integration, more multidisciplinary care teams in and out of the hospital, and “geriatrizing” acute care. These suggestions reflect many of the same calls for action made by previous scholars and advocates,33,34 and are similar to solutions proposed by the National Institute on Ageing’s “Ageing in the Right Place” report.35 Scholars in France have proposed a societal-level solution involving the procedural and financial restructuring of ultraspecialized medicine, coupled with a revival of historic values combining medicine and social work to address the needs of an increasingly frail and socially complex population.36

Limitations

Our study was conducted in a single tertiary health centre in Nova Scotia, where “socially admitted” patients are admitted under an institution-specific Orphan Patient Policy, which likely limits the generalizability of our findings. Our participants were mainly White and female, which also limits the generalizability to other settings across the country and internationally. Furthermore, the participant sample did not include recreational therapists, volunteers, physiotherapists, or occupational therapists. In the study centre, recreation and volunteer programs had been discontinued or reduced following the COVID-19 pandemic, and there were no occupational or physiotherapists specifically assigned to this patient population. Another limitation of our study is that some interviewers had prior acquaintance with the participants they interviewed. This familiarity may introduce bias in the data collection and interpretation, although this should be balanced with constructivist grounded theory’s emphasis on researchers as co-participants in the research process.

Conclusion

Our research draws attention to health care providers’ challenges in managing care for “socially admitted” patients, and to perceptions regarding “social” presentations, perceived system barriers and resource shortages, and some potential solutions for better patient care. Overall, no consensus emerged as to what constitutes a “social admission” (who are the patients labelled as “socially admitted”?) or ownership for “social admissions” (who cares for these patients?), and participants reported inconsistencies in care delivered for such patients (how to care for “socially admitted” patients). To improve the patient experience and alleviate the moral distress of staff who care for “socially admitted” patients in hospital, the inherent structures of our health care system, such as hierarchies and stigmatization, should be reformed to better address the needs of patients with increasingly complex social problems who present to hospitals.

Footnotes

Competing interests: Jasmine Mah receives scholarships supporting her PhD research from the Department of Medicine at Dalhousie University, Dalhousie Medical Research Foundation, Dr. Patrick Madore Traineeship, and the Pierre Elliott Trudeau Foundation. Kenneth Rockwood has asserted copyright of the Clinical Frailty Scale through Dalhousie University’s Industry, Liaison, and Innovation Office. In addition to academic and hospital appointments, Kenneth Rockwood is cofounder of Ardea Outcomes, which (as DGI Clinical) in the last 3 years has contracts with pharmaceutical and device manufacturers (Danone, Hollister, INmune, Novartis, Takeda) on individualized outcome measurement. In 2020, he attended an advisory board meeting with Nutricia on dementia and chaired a Scientific Workshop & Technical Review Panel on frailty for the Singapore National Research Foundation. He is associate director of the Canadian Consortium on Neurodegeneration in Aging, itself funded by the Canadian Institutes for Health Research, the Alzheimer Society of Canada, and several other charities. He holds the Kathryn Allen Weldon Chair in Alzheimer Research, funded by the Dalhousie Medical Research Foundation. Kenneth Rockwood also reports personal fees from Ardea Outcomes, the Chinese Medical Association, Wake Forest University Medical School Centre, the University of Nebraska Omaha, the Australia and New Zealand Society for Geriatric Medicine, Atria Institute, Fraser Health Authority, McMaster University, and EpiPharma. In addition, Dr. Rockwood has licensed the Clinical Frailty Scale to Enanta Pharmaceuticals, Synairgen Research, Faraday Pharmaceuticals, KCR S.A., Icosavax, BioAge Labs, Biotest AG, Qu Biologics, AstraZeneca UK, Cellcolabs AB, Pfizer, W.L. Gore & Associates, pending to Cook Research Incorporated, Renibus Therapeutics, and, as part of Ardea Outcomes, has a pending patent for Electronic Goal Attainment Scaling. He also reports permission for the Pictorial Fit-Frail Scale licensed to Congenica. Use of both the Clinical Frailty Scale and Pictorial Fit-Frail Scale is free for education, research, and nonprofit health care with completion of a permission agreement stipulating users will not change, charge for, or commercialize the scales. For-profit entities pay a licensing fee, 15% of which is is retained by the Dalhousie University Office of Commercialization and Industry Engagement. The remainder of the licence fees are donated to the Dalhousie Medical Research Foundation. Melissa Andrew reports grants from Sanofi, grants and support to attend meetings from GSK, grants from Pfizer, grants from Canadian Frailty Network, personal fees from Sanofi, personal fees from Pfizer, personal fees from Seqirus, grants from Merck, grants from Public Health Agency of Canada, and grants from Canadian Institutes of Health Research, outside the submitted work. Dr. Andrew is a volunteer board member for the Alzheimer Society of Nova Scotia and the National Advisory Committee on Immunization. Sheliza Khan declares leadership in the patient flow department at Queen Elizabeth II Hospital. No other competing interests were declared.

This article has been peer reviewed.

Contributors: Jasmine Mah and Christie Stilwell contributed equally as co–first authors. Jasmine Mah contributed to the conceptualization and design, procurement of data, analysis of data, drafting of the original manuscript, and review of the manuscript. Christie Stilwell and Emily Marshall contributed to the conceptualization and design, analysis of data, drafting of the original manuscript, and review of the manuscript. Madeline Kubiseski and Gaurav Arora contributed to the conceptualization and design, procurement of data, analysis of data, and review of the manuscript. Karen Nicholls, Sheliza Khan, Jonathan Veinot, Lucy Eum, Susan Freter, Katalin Koller, Maia von Maltzahn, Kenneth Rockwood, Samuel Searle, and Melissa Andrew contributed to the conceptualization and design, analysis of data, and drafting of the original manuscript or review of manuscript drafts. All authors approved the final version to be published and agreed to be accountable for its accuracy and integrity.

Data sharing: Anonymized data from our study may be available on request. Interested parties are encouraged to contact the lead author via email to access these data or to obtain a copy of the Orphan Patient Policy. The data will be shared under terms that ensure the protection of participant privacy and compliance with relevant data protection regulations.

Funding: This study is supported by Nova Scotia Health, through a grant from the Nova Scotia Health Research Fund. Nova Scotia Health is the provincial health authority.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/