Frailty and prehabilitation in lung transplant candidates: A cross-sectional UK survey of assessment,provision and barriers

Abstract

Objectives

Frailty is a multifactorial state of reduced physiological reserve and increased vulnerability, common in lung transplantation (LTx) candidates and associated with morbidity and mortality. There is no consensus on appropriate frailty instruments or optimal prehabilitation. Aims were to: (1) identify frailty measures in UK adult LTx candidates, (2) describe prescribed prehabilitation interventions, and (3) explore barriers to prehabilitation.

Methods

An anonymous online Qualtrics^XM survey was circulated via UK LTx coordinators and social media. Eligible respondents were professionals contributing to adult pre-operative assessment and listing decisions. Results were analysed using SPSS.

Results

Thirty-one respondents met criteria, representing all five UK LTx centres. Frailty was always assessed by 58.1% and sometimes by 25.8%, though comprehensive measurement tools were rarely used. Functional tools included the Short Physical Performance Battery and sit-to-stand tests. Assessments occurred pre-listing and during waitlisting. Frailty was discussed at all listing meetings and influenced transplant suitability. Outpatient prehabilitation included face to face, telephone, and local referrals, targeting exercise, nutrition, and psychosocial needs. Reported barriers were travel, funding, and limited space.

Conclusion

UK lung transplant services conceptually recognise frailty as multidimensional and clinically important, but operationally rely on pragmatic, largely physical proxy measures. Prehabilitation provision is variable and often externally delivered constrained by system-level resource and access barriers.

Keywords

frailty prehabilitation lung transplantation survey pulmonary rehabilitation

Introduction

Frailty is a multifactorial state characterised by a reduction in physiological reserves and an increase in vulnerability to stressors such as infections or surgical procedures.^1,2 It is common in chronic end-stage lung disease, particularly in those listed for lung transplantation (LTx).³ Frailty can lead to lack of independence, increased care requirements and hospital admissions.¹ It can be age related, disease related or both. Differentiation is a challenge in an era of increasing age of LTx candidates when trying to determine the potential impact of LTx and a candidate’s potential to thrive postoperatively.⁴

LTx is an effective treatment for patients with end-stage lung disease and increases both survival days and quality of life.⁵ LTx is performed in the United Kingdom (UK) through the National Health Service (NHS), a publicly funded service which provides clinical assessment, management, rehabilitation and medication services free at the point of use. LTx in adults in the UK is performed in only five tertiary centres. 205 patients were registered on the LTx waiting list in 2023-24 (3.0 per million population) and 140 LTx were performed (2.1 per million population), with a pre-COVID-19 pandemic peak of 210 in 2013-14. Median waiting time to transplant was 530 days from non-urgent registration.⁶ Prolonged waiting times for transplantation increase the risk of physical deconditioning, loss of functional capacity, and reduced physiological reserve, thereby contributing to the development or progression of frailty.⁷

Physical frailty, independent of chronological age, is associated with higher morbidity and mortality in LTx candidates both pre- and post-operatively.⁸ Frail recipients have longer hospital stays, more readmissions, greater disability, and reduced quality of life.^9,10 Rising numbers of older recipients and those with co-morbidities heighten concerns over reduced physiological reserve.^11,12 Consequently, frailty is increasingly considered when evaluating surgical suitability, balancing the risks and benefits of LTx in older individuals and in the design of prehabilitation programmes.^2,10,13 Reported prevalence of frailty in LTx candidates, and its association with adverse pre- and post-operative outcomes, varies considerably according to the measurement tool employed. For example, Venado et al. (2019) classified 43% of LTx candidates as frail using the Fried Frailty Phenotype (FFP), compared with only 23% when assessed using the Short Physical Performance Battery (SPPB).¹⁴ Similarly, Singer et al. (2015) identified frailty in 28% of their pre-LTx cohort using FFP, but in just 10% using SPPB.⁹ In addition to methodological differences, inter-study variation may also reflect differences in study populations, centre-specific clinical decision-making, referral pathways, and waiting-list duration, all of which may influence observed frailty prevalence and contribute to discrepancies across the literature.¹⁵ This may undermine confidence in frailty prevalence estimates, limiting their utility in clinical decision-making, particularly in borderline listing decisions.^5,14,15

Current consensus recommendations from the International Society of Heart and Lung Transplantation (ISHLT) suggest pre-listing frailty assessment although frailty alone is not considered a complete contraindication to LTx due the potential for post-transplant reversibility.¹⁶ Frailty trajectories can improve after LTx with a structured rehabilitation programme¹⁷ although the varying frailty measures used prevent direct comparisons between studies. It is unclear which is the most appropriate measure to accurately quantify frailty when, for example, the FFP incorporates elements that are likely to be improved by LTx (e.g. slowness and weight loss) where cumulative deficits index tools may change less or worsen with any co-morbidity development after the initiation of immunosuppression (e.g. renal dysfunction or diabetes).² Heterogeneity in frailty measurement appears to reflect a fundamental disagreement over the conceptual definition of frailty in LTx, rather than simple methodological variation. Historically, most LTx institutions have used gerontologic models that assess physical strength.¹⁸ Formalising and standardising the assessment of frailty, recognising frailty as a phenomenon across the LTx pathway but with potential for reversibility with targeted intervention,² is needed to guide decision-making, optimise survival and function, and address the ethical challenge of allocating limited donor organs.^5,19

Despite numerous measures of frailty, and functional outcomes reported in the LTx literature,^3,5,15 no core outcome set for LTx prehabilitation exists, making suitable assessment tools for clinical or research use a matter of debate.^2,20,21 Frailty measurement is not universal, and the ISHLT advises caution in frailty-informed listing decisions due to the absence of an optimal measurement tool.¹⁶ Commonly cited functional measures and phenotypic frailty measures in the transplant literature include the SPPB and FFP,^3,15 whilst deficit accumulation models, (such as Rockwood’s) incorporates comorbidities, cognitive and mental health concerns, and functional decline.^22,23 Debate continues over which paradigm is most valid.¹⁵ Deficit accumulation models are rarely used in the LTx literature, potentially due to being deemed cumbersome in the context of a busy clinical practice.⁵ While phenotypic measures may be more sensitive to short-term physical change, their apparent responsiveness may overestimate reversibility, whereas deficit accumulation models may better capture long-term vulnerability but lack feasibility in clinical practice.¹⁵

Many LTx studies report functional outcomes as proxy measures of frailty¹⁵ with recognition that different models may address distinct points along the transplant pathway.^19,24 Most tools are validated in geriatric populations, complicating application in younger LTx candidates.²⁵ Whether UK centres routinely measure frailty, which models (or proxy/functional measures) are employed, and by whom within the multi-disciplinary team remains unclear.

Clinical deterioration while on the LTx waiting list may result in death, de-listing, or prolonged postoperative recovery. This prolonged waiting period nevertheless represents a critical window for targeted risk optimisation through early intervention.^12,26 Prehabilitation, defined as the physical, psychological, and social optimisation of individuals in preparation for surgery, is established across multiple surgical populations, with evolving evidence including renal and hepatic transplantation.^27,28 Emerging evidence suggests that frailty is modifiable in LTx candidates and should be addressed during the waiting list period.^14,16 Prehabilitation has been shown to improve selected measures of physical frailty and function in this population although studies using comprehensive, validated frailty tools are lacking and the strength of evidence is low.¹³ Schneeberger et al. (2020) reported significant improvements in physical performance, measured using the SPPB (p < 0.001), in a cohort of 28 lung transplant candidates (mean age 60) who completed an in-person pulmonary rehabilitation programme, although the duration of the intervention was not specified, limiting interpretation of dose–response effects.²⁹ Similarly, Wickerson et al. (2020) demonstrated improvements in frail and pre-frail candidates following a structured six-week, in-person group pulmonary rehabilitation programme (90 minutes, three times per week) incorporating aerobic and strength training (n = 62; median age 62), providing more clearly defined intervention parameters and a larger sample.³⁰ Singer et al. (2018) observed non-significant improvements in FFP scores in a small pilot study (n = 13; mean age 62.9) using a home-based programme combining daily walking, app-based aerobic and strength training three times per week, and nutritional advice, suggesting potential feasibility but insufficient power to demonstrate effectiveness.¹⁰

Optimising patients preoperatively and targeting frailty may also reduce postoperative hospital stay, disability and readmissions,³¹ offering potential cost savings.³² Consequently, multimodal prehabilitation is recommended by the European Society for Organ Transplantation for patients awaiting solid organ transplantation,³³ although the optimal format, content, and delivery models remain uncertain, and further robust randomised trials are required.¹³

Despite this growing evidence base, studies evaluating prehabilitation in LTx candidates demonstrate substantial heterogeneity in intervention design, frailty measurement, and outcome reporting, limiting reproducibility and clinical translation.^13,33 Furthermore, the literature is dominated by small, single-centre observational studies that are frequently underpowered to detect clinically meaningful outcomes and have limited applicability to publicly funded healthcare systems with prolonged waiting times, such as the UK.¹³

The absence of a core outcome set, an inconsistent operationalisation of frailty and lack of methodological rigour in prehabilitation studies¹³ have the potential to result in implementation uncertainty, limiting the translation of frailty research into routine LTx practice. It is unclear what frailty measures and prehabilitation interventions are used in the UK with LTx candidates. Factors influencing choice of prehabilitation interventions for LTx candidates are not well understood in the context of the NHS. The aims of this exploratory research were to a) identify the range of frailty (phenotypic, cumulative deficit or functional/proxy) measures being used, when measurement occurs prior to LTx in UK tertiary adult LTx centres, and by which members of the multidisciplinary team; b) assess if prehabilitation interventions are prescribed for individuals on the UK LTx waiting list; and c) describe barriers to this prehabilitation provision.

Methods

Study design

An online, anonymous, descriptive, cross-sectional survey was circulated to the multidisciplinary team members at each of the five UK LTx centres between July and September 2023. Participation was voluntary with no incentivisation. Participants provided informed consent by selecting an online consent statement before eligibility checks. They were then able to access the survey. Qualtrics^XM software supported secure data management and storage in university servers. The study was reviewed by The University of Manchester ethics committee which issued an ethics waiver. The study conforms to the principles of the Declaration of Helsinki.

Survey design

The survey was developed in Qualtrics^XM (Qualtrics, Provo, Utah) by researchers with clinical and non-clinical expertise to enhance face validity and minimise bias.³⁴ The survey collected respondent characteristics, including professional role and lung transplant centre, and examined current practices related to the assessment and use of all frailty and functional measures in the pre-operative evaluation of lung transplant candidates. Frailty was defined for respondents as a state of increased vulnerability to stressors, loss of physiological reserve, or reduced physical strength, speed, and function. Initial items used short, closed-response questions to minimise respondent burden and optimise completion,^34,35 followed by questions exploring whether frailty was assessed, which validated phenotypic and functional tools were personally used, and whether assessments were repeated over time, with free-text responses capturing the clinical circumstances for reassessment. Tool selection was explored using tick-box options informed by published lung transplantation literature, alongside an open “other” option. Further sections examined the role of frailty in clinical decision-making, including discussion at listing meetings and influence on transplant suitability, as well as prehabilitation practice, referral pathways, and perceived barriers to delivery. Fixed-choice and optional free-text items were combined to capture both structured data and unanticipated perspectives relevant to this exploratory study.³⁶ Adaptive questioning was used to learn more about the respondent’s use of each tool where selected. The respondents were not able to review their answers. Full details of questions are available in supplemental information.

The survey was piloted by one physiotherapist and one dietitian with experience in LTx from the Republic of Ireland. Feedback led to improvements in the clarity and format of the survey. Survey reporting is in accordance with the CHERRIES checklist for reporting web surveys (see supplemental information).³⁷

Inclusion and exclusion criteria

Inclusion criteria were registered healthcare professionals in adult UK LTx centres involved in pre-operative assessment and decisions on activating patients to the waiting list. Exclusion criteria were those working solely in paediatric services or without input to multidisciplinary listing discussions or decisions.

Sampling and recruitment

Sampling used a multistage purposeful design. Transplant coordinators at each UK LTx centre were contacted and distributed the survey via email to their LTx multidisciplinary team. The coordinators were contacted again after 14 days with a further request to circulate a survey reminder. The author’s UK professional networks were contacted directly via email and further advertisement was performed via social media (X, formerly Twitter) due to initial low response rates. Responses were encouraged from all staff members and multiple responses from each centre/profession were possible to explore as many different perspectives across professions and within and across centres within the UK.

Data analysis

Data were exported from Qualtrics^XM to SPSS. Data were checked for any missing or incomplete fields and Qualtrics^XM screened for duplicate submissions and other indicators of fraudulent activity. Numerical data are presented descriptively using counts and percentages. Free text responses were examined closely by one author to identify common themes, topics and frequency of these occurring using a content analysis approach.

Results

Response rate

Responses were received from staff across all five UK LTx centres. In total, 41 responses were submitted. Six respondents (14.6%) reported that they did not assess patients prior to lung transplantation within a UK LTx centre, and three respondents (8.6%) indicated that they were not involved in lung transplant listing decisions. Both groups were therefore ineligible and excluded from the analysis. 32 respondents (78.0%) met the predefined inclusion criteria and provided informed consent. One consenting respondent did not complete any survey questions and was therefore excluded from analysis. As a result, 31 respondents (76.0% of all responses) were included in the final analysis (See Figure 1).

Figure 1.

Respondent numbers and reasons for exclusion and inclusion.

Transplant coordinators circulated emails with survey links on our behalf, professional networks also shared the survey link alongside social media advertisement therefore response rate is unknown. Respondents included transplant coordinators (n=8), physiotherapists (n=7), nurses (n=4), LTx physicians (n=3), clinical psychologists (n=2), social workers (n=2), dietitians (n=1), anesthetists (n=1) and others (1 palliative care nurse, 1 heart transplant physician and 1 speech and language therapist). Notably there were no responses from surgeons or occupational therapists. Responses were welcomed from multiple individuals within each centre and professional group to ensure a comprehensive representation of multidisciplinary current practice and to illuminate variations that may exist.

Assessment of frailty

We asked if participants ever made an assessment or judgement of frailty. 18 reported that they always assess or judge frailty in LTx candidates, eight did so occasionally, and five never performed such assessments (Figure 2).

Figure 2.

Number of professionals measuring frailty at LTx assessment.

Physiotherapists, clinical nurse specialists and lung physicians were most likely to report preoperative assessment of frailty.

Measurement tools reported

Given the wide range of frailty and functional outcome measures reported in the lung transplantation literature,¹³ respondents were asked specifically about their use of frailty and functional assessment tools. A central finding was the near absence of well-established, cumulative, and validated frailty measures in current UK practice. With the exception of a single physician who reported using the Clinical Frailty Scale, no respondents described using multidimensional frailty tools such as the Frailty Index, despite their capacity to integrate multiple domains into a single measure of frailty.

In contrast, respondents frequently reported the use of single-domain functional and physical performance measures. The most commonly used tools were the Short Physical Performance Battery (SPPB), the five-times sit-to-stand test (5STS), and the 30- or 60-second sit-to-stand tests (see Table 1). One respondent reported selecting a sit-to-stand test during clinic appointments when other frailty assessments were unavailable, while another highlighted its suitability for virtual assessments due to ease of administration. Handgrip strength (HGS) was the only strength-based measure reported and was used by four respondents (two physiotherapists, one dietitian, and one nurse). Use of the SPPB was reported primarily by physiotherapists (n=7), representing four LTx centres.

Table 1.

Reported use of physical frailty measures by personnel in UK LTx centres.

Frailty/surrogate frailty tool sometimes/always using)	Respondents using tool n (%)^a	Other reported outcomes (sometimes/always using)	Respondents using tool n (%)^a
Clinical Frailty Scale (CFS)	1 (3.2)	Six Minute walk Test (6MWT)	5 (16.1)
Fried Frailty Phenotype (FFP)	0 (0.0)	Stamford Integrated Psychosocial Assessment Tool (SIPAT)	3 (11.1)
Short Physical Performance Battery (SPPB)	12 (38.7)	Montreal Cognitive Assessment (MOCA)	4 (14.8)
Timed Up and Go (TUG)	1 (3.2)	Hospital Anxiety and Depression Score (HADS)	13 (46.4)
Gait speed (4m/10m/15m)	3 (9.7)	Fiberoptic Endoscopic Evaluation of Swallow (FEES)	1 (3.2)
Handgrip strength (HGS)	4 (12.9)	Social support assessment	13 (50)
5 times sit to stand test (5STS)	9 (29.0)	Malnutrition Universal Screening Tool (MUST)	5 (18.5)
30sec/60sec sit to stand test	5 (16.1)	Duke Activity Status Index (DASI)	1 (3.2)
		Subjective Global Assessment (SGA)	1 (3.2)
		“End of the bed test”	1 (3.2)
		4AT (delirium screen)	1 (3.2)

^asome respondents reported using more than one tool therefore sum of % is not 100% and respondents per question varied (different denominator) therefore n=1 does not always equal same % response rate.

Multidisciplinary team members also used tools considering cognition, nutrition, depression and social support. Social support was the most consistent assessment across all professional groups in half of respondents. Other commonly employed tools included the Hospital Anxiety and Depression Scale, used by half of transplant coordinators (n=4) and both psychologists who responded (n=2).

Timing of assessments

We asked if an assessment was repeated and why. Assessments were conducted before listing and repeated mainly for surveillance of deterioration during waitlisting, either in clinics or via remote video. Additional triggers included hospital admissions, infections, or clinical concerns about deterioration and deconditioning. The most commonly repeated measure was the SPPB which was repeated for concerns in physical deterioration on the waiting list (n=7). Other tests repeated for concerns in physical deterioration included the 5STS (n=3), 6MWT (n=2) and Clinical Frailty Scale (n=1), with one lung transplant physician reportedly using a subjective “end of the bed test”. One psychologist reported repeating the Hospital Anxiety and Depression Score, Short Form-12 Health Survey and Stanford Integrated Psychosocial Assessment for Transplantation to evaluate improvements made during prehabilitation. This was the only mention of assessments being repeated to monitor the effects of an intervention. Assessments on the waiting list appear to be a reactive reassessment in relation to clinical concerns rather than routine protocolised measurement, although one participant reported routinely repeating the SPPB every six months on the waiting list.

Some outcome measures were repeated after transplant, including the SPPB, which was recorded during inpatient recovery (n = 1) and again at discharge (n = 4). Other measures were assessed at hospital discharge in small numbers, including gait speed (n = 1), grip strength (n = 1), and the five-times sit-to-stand test (5STS) (n = 1). In addition, the 5STS (n = 1) and 30- and 60-second sit-to-stand tests (n = 1) were reported as useful for video-based assessment, particularly when patients lived far from the centre or prior to virtual consultations.

Listing decisions

Frailty is reportedly discussed at listing meetings in all UK transplant centres, either always (n=25) or sometimes (n=5). It routinely influences suitability for LTx in most respondents (n=24) and occasionally in the remainder (n=6). However, how these opinions were formed, and whether measurement tools contributed, remains unclear.

Perceptions of the utility of measures prior to LTx

Respondents highlighted the need for more objective frailty assessment, moving beyond the “end of the bed test.” They reported considering environmental, cognitive, and social factors, recognising frailty as multifactorial, though no comprehensive frailty tool was used. Frailty was viewed as dynamic and potentially reversible pre- and post-LTx, with emphasis on identifying irreversible states that may hinder recovery. Whilst we didn’t specifically ask about barriers to frailty assessment, one respondent noted insufficient resources to assess all candidates routinely.

Provision of prehabilitation

Prehabilitation was defined for participants as the advice, treatment, or support to optimise patients for surgery, encompassing physical, psychological, and social preparation to enhance resilience, improve outcomes, and aid recovery.³⁸ We asked about prehabilitation in general, not about prehabilitation specifically for those deemed to be frail therefore we have assumed, where reported, that this service was available for all LTx candidates.

Just over a quarter of respondents (n=8) reported that they always provide this service. A similar number (n=7) sometimes provide prehabilitation and 13 respondents refer to other teams and services for their prehabilitation needs e.g. community dietitians or pulmonary rehabilitation (see Figure 3 for breakdown by centre). Of the seven physiotherapists who responded, only two reported that they provide prehabilitation, with a further five referring to other services for this service. Other transplant staff providing prehabilitation (always or sometimes) included transplant coordinators (n=4), dietitians (n=1), psychologists (n=2) and lung transplant physicians (n=2).

Figure 3.

Breakdown of prehabilitation provision by centre (anonymous).

Of the staff providing prehabilitation, interventions were mainly conducted face to face, but also included video or telephone reviews or the provision of written advice (Figure 4). Provision varied across health care professionals within the same centre therefore we can infer that Trusts were not operating with structured, protocolised prehabilitation services.

Figure 4.

Prehabilitation intervention provision by method (where provided by transplant professional).

Prehabilitation primarily involved organization of social support and exercise prescription for patients to complete independently although it is unclear if any further assessment of progress, advice or exercise prescription was offered routinely. Where reported, other interventions included swallowing exercises, education and support to manage breathlessness including the Managing Breathlessness Toolkit, compassion focused therapy, acceptance and commitment therapy, financial and environmental support (see Table 2).

Table 2.

Prehabilitation interventions provided in UK lung transplant centres.

Prehabilitation interventions provided	n
Supervised exercise	2
Nutritional advice	3
Nutritional supplements	2
Cognitive behavioural therapy (CBT)	3
Organisation of social support	7
Optimisation/rationalisation of medication	2
Exercise prescription for patient to complete independently	5
Other (swallowing exercises, education and support to manage breathlessness including the Managing Breathlessness Toolkit, compassion focused therapy (CFT), acceptance and commitment therapy (ACT), financial and environmental support)	5

Barriers to prehabilitation at transplant centres in the UK

Reported barriers included lack of funding for staff (n=20), a shortage of suitable space (n=12) and travel distance for patients (n=23). Barriers to patient engagement were deemed to be the patient perception of being too unwell to participate (n=1), poor understanding of who could benefit from a nutritional intervention (n=1) and poor understanding of the speech and language therapist role (n=1).

Discussion

Summary of main findings

This survey is the first to investigate current practices and opinions of frailty measurement and prehabilitation provision in UK LTx centres. Responses were received from all five UK centres and although the majority of respondents were physiotherapists and transplant coordinators, a wide range of professions report to be considering the impact of frailty in LTx candidates. UK LTx teams are assessing physical, nutritional, psychological and social aspects of frailty but staff did not report the use of standardized, comprehensive frailty measurement tools. There are barriers to transplant-centre led prehabilitation including lack of space and staff therefore patients are mostly referred to local or community services close to their homes.

Standardisation of frailty measurement

Responses suggest UK LTx health care professionals are considering individual constituents of frailty and proxy measures of frailty in their candidate evaluation demonstrated by the heterogeneity of assessment measures reported. The LTx literature mainly discusses physical frailty measurement¹⁵ (e.g., FFP or SPPB) which is described as “a more circumscribed, subtype of frailty”³⁹ and therefore fails to consider factors such as social or cognitive vulnerability.² The lack of utilization of a multi-dimensional, validated frailty tool in UK clinical practice is notable yet clinicians report considering frailty in their overall assessment for candidacy. There is therefore a possible risk of subjective variation between centres. The cumulative deficit approach to measuring frailty in LTx candidates (e.g. a frailty index measurement) has previously been linked to worse health-related quality of life, increased rate of hospital admissions and lower transplant-free survival in individuals with ILD.⁴⁰ Wilson et al. (2016) demonstrated that pre-transplant frailty by Frailty Index had an independent correlation with lower survival rates following lung transplantation with an increased risk of death remaining significant even after adjusting for factors such as age and sex.⁴¹ No respondents to this survey reported it’s clinical use in the UK however.

Frailty is recognised as problematic in LTx candidates, yet its measurement in candidacy assessment appears to be inconsistent, clinicians preferring to use proxy or functional measures. Definition, validity and conceptualisation of frailty requires further refinement and standardisation.^23,33 Without clearer practices and evidence to determine the most appropriate tools across the LTx pathway, reliance on subjective “eyeball assessment” may persist.^19,23 Literature heavy in the physical frailty paradigm, wide variation in outcome measures, with no consensus in clinical or research outcome sets, continues to challenge transplant clinicians.⁴²

Operational definition of frailty in LTx

The variability in assessment tools utilised in LTx pathways may reflect the lack of agreement of the operational definition of frailty in the context of LTx. In addition to outcome assessment prior to transplant listing, reasons given for re-assessment in the pre-transplant period included to monitor for deterioration after infections or readmissions and if a physical deterioration was suspected. The dynamic nature of pre-operative outcome scores was valued as an important marker of clinical trajectory by several respondents. Previous publications have highlighted the importance in choosing an appropriate measure that can quantify risk for a specific outcome of interest.^2,43 This will vary across the LTx pathway. Phenotypic measures such as the FFP are likely to be improved after LTx, whereas cumulative deficit frailty models may worsen due to immunosuppression-induced comorbidities such as diabetes, renal dysfunction and hypertension.^2,23

Differentiating reversible frailty in younger LTx candidates from irreversible frailty in older co-morbid patients remains challenging,²⁵ highlighting the need for context-specific tools sensitive to clinical purpose and change with prehabilitation or transplantation—an issue not yet comprehensively addressed.^23,42

Clinician preferences

Apart from a 2019 US consensus report,² no studies have explored clinician preferences for frailty measurement in LTx. In that survey, all multidisciplinary members considered frailty relevant to candidacy, though 42% lacked standardised assessments. Similarly, five of 31 UK respondents reported not assessing frailty pre-transplant, and only one respondent used a comprehensive frailty tool, yet all considered it in listing decisions. This disparity may reflect differing team roles or limited awareness and confidence in available tools and their psychometric properties.

The frequent use of the SPPB (n=12; all seven physiotherapists) likely reflects its simplicity and minimal resource demands. It has shown utility as a frailty screening tool in older adults.⁴⁴ The SPPB and FFP are increasingly applied in LTx studies, both are reliable and validated tools¹⁵ and linked to higher pretransplant mortality and delisting.¹⁹ However, the SPPB reflects only the physical components of frailty and no recommendation exists for its preferred use.¹⁵ UK staff reported no use of the FFP or cumulative deficit models, and only one physician used the Clinical Frailty Scale, despite its clinical adoption in other specialities.²⁰ One respondent cited limited resources as a barrier, possibly explaining reliance on short physical or proxy tools over multidimensional models such as the The Lung Transplant Frailty Scale.³⁹ The lack of published reports of more comprehensive tools such as the Clinical Frailty Scale or Lung Transplant Frailty Scale within LTx candidates may influence clinicians in their choice of tool.

Lung transplant specific frailty tools

Respondents in this survey did not report the use of frailty tools designed specifically for the LTx population.³⁹ The Lung Transplant Frailty Scale has better predictive validity than SPPB or FFP in predicting waiting list death or delisting but is complex to administer and requires multiple laboratory tests alongside other measurements, increasing the costs associated with staff time and facilities. The Lung Transplant Frailty Scale also fails to consider the domains of cognition or social isolation.³⁹

The addition of cognitive and depressive variables to physical frailty measurement (FFP) did not strengthen the association of frailty to waiting list mortality in a study of 363 LTx candidates however, mild cognitive impairment (Montreal Cognitive Assesment <26/30) and hypoalbuminaemia were linked to physical frailty and found to be independent predictors of waiting list mortality.³ Measurement of albumin levels were not reported by UK survey respondents.

The FFP, used in the geriatric and LTx literature, is both reliable and has predictive validity of waiting list mortality^3,15 yet was not identified as being used clinically within the UK. Barriers to clinical application of the FFP in non-LTx populations are the inclusion of measurements not routinely used in patient assessment such as HGS.²⁰

HGS was inconsistently reported in UK centres despite its correlation with quadriceps strength in LTx candidates⁴⁵ and prior consensus recommendation.⁸ Its reliability, simplicity, and association with functional performance make it appealing as a marker of physical frailty, though lack of consensus on interpretation and cut-off values remains a barrier.⁴⁶

Social support assessment was commonly reported, reflecting international LTx standards.¹⁶ Lack of support is linked to disability, poor outcomes, and post-LTx non-adherence with increased mortality,^16,47 though one study found no association with short-term outcomes in 515 LTx recipients.²⁴ Its routine assessment across UK centres suggests optimisation of social factors is prioritised, and socioeconomic status alone is not seen as grounds for exclusion.¹⁶ Despite this, no specific tools for social frailty were reported, likely reflecting the absence of recommended, validated screening instruments in transplant literature.^16,47

Barriers to provision of prehabilitation by LTx centres

Prehabilitation provision in the UK is limited by space and staffing, with similar barriers of funding and personnel reported in Canada.⁴⁸ Phone consultations or referral to local pulmonary rehabilitation reflect recognition that travel to transplant centres is a barrier, though the ability of local teams, less experienced with LTx candidates, to address frailty and optimise LTx candidates remains unclear. Such teams may nonetheless improve accessibility, particularly for frail patients or those with high oxygen requirements. Without data on uptake, adherence, or effectiveness, these remote programmes appear a pragmatic means to promote equity of access and reduce barriers for minoritised or socioeconomically disadvantaged groups.⁴⁹

The European Society of Transplantation and the ISHLT recommend multi-modal, patient-tailored prehabilitation during waitlisting, though evidence on optimal delivery is lacking^12,33; further research is needed to identify optimal setting and content, demonstrate benefits for frailty and post-LTx outcomes and to explore candidates’ experiences, preferences, and engagement in preoperative optimisation in the context of the UK health system. The lack of face to face delivery of prehabilitation by LTx teams could pose an obstacle to the close and ongoing monitoring of functional status and rehabilitation potential; the lack of both being absolute contraindications to LTx.¹⁶

Limitations

Survey distribution via transplant coordinators and social media may have missed some staff, limiting the respondent pool. Those more interested in frailty or prehabilitation may have been more likely to reply, potentially overestimating its reported consideration. Unequal centre representation by number and profession also reflected the sampling method. Multiple respondents were received from most centres in our attempt to reflect views from multiple professional groups. Our aim was not to compare professional groups, or practice by centre, but to explore the breadth of practice and opinions across the UK LTx in this age of uncertainty around frailty measures and their role within pre-transplant assessment and optimisation. The inclusion of only UK centres limits the transferability of findings to international practice.

Barriers to frailty measurement were not explored but require further study to inform tool development and a core outcome set. This exploratory study provides preliminary evidence that prehabilitation provision in the UK is limited; however, further in-depth qualitative research is required to enable a more detailed understanding of the factors underpinning this limited provision.

Social support was assessed only at a broad level, without capturing key components of social frailty such as living arrangements, social participation, economic factors, or neighbourhood interaction.⁵⁰ Furthermore, the survey questions did not explore the specific contributors to limited social support, nor whether these factors are identified or addressed within prehabilitation, thereby limiting the depth and interpretability of the findings in this domain.

Content analysis of short text qualitative data was performed by one team member alone due to time constraints of a fixed term research contract. This has the potential to introduce bias to the findings.

Conclusion

UK centres mainly use physical assessment tools as surrogate frailty measures, with teams acknowledging frailty’s multidimensional nature but rarely employing comprehensive, validated instruments. This is consistent with previous publications discussing frailty and function in LTx candidates.¹⁵ Considerable heterogeneity exists in the tools applied. An operational definition of frailty for LTx candidates is needed to guide appropriate evaluation of transplant urgency, modifiability through intervention, and surgical risk. Although the negative perception of frailty’s impact on outcomes was recognised, supervised exercise and teleprehabilitation were uncommon, with referrals instead made to local services. Reported barriers to LTx centre-based prehabilitation included funding, travel distance, and limited space. These findings should underpin further research to explore barriers and facilitators for patients, carers, and staff, ideally in an in-depth interview study. Further research should focus on informing multidisciplinary team-led frailty measurement and management strategies that emphasise clinical feasibility and focus on improving outcomes.

Supplemental material

Supplemental material - Frailty and prehabilitation in lung transplant candidates: A cross-sectional UK survey of assessment, provision and barriers

Supplemental material for Frailty and prehabilitation in lung transplant candidates: A cross-sectional UK survey of assessment, provision and barriers by Laura McGarrigle, Gill Norman, Helen Hurst, Chris Todd in Chronic Respiratory Disease

Supplemental material

Supplemental material - Frailty and prehabilitation in lung transplant candidates: A cross-sectional UK survey of assessment, provision and barriers

Footnotes

Acknowledgements

The authors thank the transplant coordinators who circulated the survey, the clinicians who completed the pilot questionnaire and provided feedback alongside those who shared their experiences within the final survey.

ORCID iDs

Laura McGarrigle

Gill Norman

Helen Hurst

Chris Todd

Ethical considerations

The study was reviewed by The University of Manchester ethics committee which issued an ethics waiver. The study conforms to the principles of the Declaration of Helsinki.

Consent to participate

Participation was voluntary and informed consent gained from all participants.

Author contributions

LM developed the concept for the study, collected and analysed the data and drafted the manuscript. GN, HH and CT contributed to survey concept, content and design and commented substantively on the manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: LM is partially funded by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration Greater Manchester (ARC-GM) (Grant award number NIHR200174). CT is a CI and partially funded by NIHR ARC-GM. GN was funded by NIHR ARC-GM and is now funded by the NIHR Innovation Observatory. The views expressed in this publication are those of the authors and not necessarily those of the National Institute for Health and Care Research or the Department of Health and Social Care.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.*

Supplemental material

Supplemental material for this article is available online.

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