A Rapid Bedside Screen to Predict Unplanned Hospitalization and Death in Outpatients With Cirrhosis: A Prospective Evaluation of the Clinical Frailty Scale

Tandon, Puneeta; Tangri, Navdeep; Thomas, Lewis H.; Zenith, Laura; Shaikh, T.; Carbonneau, Michelle; Ma, Mang; Bailey, Robert J.; Jayakumar, Saumya; Burak, Kelly W.; Abraldes, Juan G.; Brisebois, Amanda; Ferguson, Thomas; Majumdar, Sumit R.

doi:10.1038/ajg.2016.303

Cited by 155 publications

(178 citation statements)

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“…The ease of utility of the KPS is very similar to the Clinical Frailty Scale, (36) another 1-minute to 2-minute, nine-category, health care provider- administered screen which we have recently found to be highly reproducible and prognostic in outpatients with cirrhosis, even when compared to more "objective" frailty assessments such as the Fried Frailty Scale and the Short Physical Performance Battery. (21) The majority of KPS scores in our patient cohort were abnormal and consistent with or below those seen in patients with metastatic cancer. (37)(38)(39) As expected of a hospitalized population, the scores in our cohort were considerably worse than those noted in the transplant waiting list study by Orman et al (19) At 1 week post-hospital discharge, 17% of patients had low KPS scores, consistent with an inability to care for oneself and the need for the equivalent of institutional care.…”

Section: Discussionsupporting

confidence: 76%

“…The mean age 6 standard deviation of the cohort was 57 6 10 years. Sixty-three percent of the cohort were men, with a median MELD score of 17 (interquartile range [13][14][15][16][17][18][19][20][21]. Alcohol was the most common cause of cirrhosis (44%).…”

Section: Patient and Admission Characteristicsmentioning

confidence: 99%

“…(8)(9)(10) One of these is its inability to account for an individual's performance status. Performance status and the linked concept of frailty are known robust predictors of adverse outcomes in diverse populations (11)(12)(13)(14)(15)(16)(17) including cirrhosis, (18)(19)(20)(21) often outperforming traditional prognostic markers. (22,23) Developed in 1948, the Karnofsky Performance Status (KPS) is one of the oldest performance status scales.…”

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confidence: 99%

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A Karnofsky performance status–based score predicts death after hospital discharge in patients with cirrhosis

et al. 2016

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Identification of patients with cirrhosis at risk for death within 3 months of discharge from the hospital is essential to individualize postdischarge plans. The objective of the study was to identify an easy-to-use prognostic model based on the Karnofsky Performance Status (KPS). The North American Consortium for the Study of End-Stage Liver Disease consists of 16 tertiary-care hepatology centers that prospectively enroll nonelectively admitted cirrhosis patients. Patients enrolled had KPS assessed 1 week postdischarge. KPS was categorized into low (score 10-40), intermediate , and high (80-100). Of 954 middle-aged patients (57 6 10 years, 63% men) with a median Model for End-Stage Liver Disease (MELD) score of 17 (interquartile range 13-21), the mortality rates for the low, intermediate, and high performance status groups were 23% (36/ 159), 11% (55/489), and 5% (15/306), respectively. Low, intermediate, and high performance status was seen in 17%, 51%, and 32% of the cohort, respectively. Low performance status was associated with older age, dialysis, hepatic encephalopathy, longer length of stay, and higher white blood cell count or MELD score at discharge. A model was derived using the three independent predictors of 3-month mortality: KPS, age, and MELD score. This score had better discrimination (area under the receiver operating characteristic curve 5 0.74) than a model using MELD (area under the receiver operating characteristic curve 5 0.62) or MELD and age (area under the receiver operating characteristic curve 5 0.67) to predict 3-month mortality. Conclusions: Cirrhosis patients at risk for 3-month postdischarge mortality can be identified using a novel KPS-based score; this score may be adopted in practice to guide postdischarge early interventions, including the integrated provision of active and palliative management strategies. (HEPATOLOGY 2017;65:217-224).P atients with cirrhosis can experience sudden deteriorations in health that lead to increased morbidity, repeated hospitalizations, and mortality. (1)(2)(3) Hospitalization is a marker for a variety of poor outcomes including readmission and death. Although we are gaining a better understanding of risk factors for readmission in discharged patients, (1,(4)(5)(6) we lack a practical prognostic model to identify those at highest risk for 3-month postdischarge mortality.Identifying this group would facilitate interventions that include more intensive follow-up and consideration of early liver transplant when available. Moreover, an estimation of the probability of survival can help to inform the type of integrated palliative support that is provided to patients.To date, mortality prediction in patients with cirrhosis has been predominated by liver-specific and kidney-specific prognostic indicators such as the Abbreviations: AUC, area under the receiver operating characteristic curve; CI, confidence interval; HE, hepatic encephalopathy; KAM, KPS, age, MELD (model); KPS, Karnofsky Performance Status; MELD, Model for End-Stage Liver Disease; OR, odd...

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Section: Discussionsupporting

confidence: 76%

Section: Patient and Admission Characteristicsmentioning

confidence: 99%

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confidence: 99%

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A Karnofsky performance status–based score predicts death after hospital discharge in patients with cirrhosis

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“…Through two original articles including 673 cirrhotics from two North American centers, we learn that frailty – measured by the performance-based gait speed or clinician-assessed Clinical Frailty Scale – is associated with an increased risk of hospitalizations. 1,2 Specifically, Dunn et al report that every 0.1 meter/second decrease in gait speed (i.e., slower) was associated with 22% greater inpatient days. This is an enormous effect size for a minimally significant change in gait speed.…”

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confidence: 99%

“…1 In the report by Tandon et al , cirrhotics rated as “mildly frail”, “moderately frail”, or “severely frail” on the Clinical Frailty Scale (i.e., score >4 out of 9) experienced nearly double the rate of unplanned hospital admissions as compared to patients with a Clinical Frailty Scale score ≤4 (39% versus 21%; p=0.005). 2 …”

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Editorial: Advancing Adoption of Frailty to Improve the Care of Patients with Cirrhosis: Time for a Consensus on a Frailty Index

Lai

2016

American Journal of Gastroenterology

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Frailty is a key determinant of outcomes in patients with cirrhosis. Two papers in this issue of the American Journal of Gastroenterology advance our understanding of the mechanism by which frailty impacts mortality -by increasing the risk of hospitalization for liver-related complications. We now have overwhelming justification to incorporate frailty into clinical practice, but this should be done in a systematic way to foster multi-center collaboration to accelerate research in this field. It's time for consensus on single frailty index to unify decision-making surrounding frailty and equalize outcomes for all cirrhotics across all centers.

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A practical approach to nutritional screening and assessment in cirrhosis

Tandon

Raman

Mourtzakis³

et al. 2017

Hepatology

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Malnutrition is one of the most common complications of cirrhosis, associated with an increased risk of morbidity and mortality. As a potentially modifiable condition, it is of particular importance to identify malnourished patients so that nutritional therapy can be instituted. Nutrition screening and assessment are infrequently performed in patients with cirrhosis. The reasons for this are multifactorial, including the absence of a validated "rapid" screening tool, multiple definitions of what constitutes malnutrition, and challenges with interpreting body composition and laboratory results in the setting of volume overload and liver dysfunction. This article summarizes the clinically relevant evidence and presents key issues, tools, and clinical options that are applicable to patients with cirrhosis. The definition, etiology, and clinically relevant outcomes associated with malnutrition are reviewed. Rapid nutritional screening is differentiated from more detailed nutritional assessment. Nutritional assessment in special populations, including women and the obese, and the role of inflammation are discussed. Multicenter studies using a common nutritional screening/assessment strategy are the next steps to fast-track adoption and implementation of nutrition-related evaluations into routine clinical practice. (Hepatology 2017;65:1044-1057).

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A Rapid Bedside Screen to Predict Unplanned Hospitalization and Death in Outpatients With Cirrhosis: A Prospective Evaluation of the Clinical Frailty Scale

Abstract: Frailty is strongly and independently associated with an increased risk of unplanned hospitalization or death in outpatients with cirrhosis. The CFS is a rapid screen that could be easily adopted in liver clinics to identify those at highest risk of adverse events.

Cited by 155 publications

References 39 publications

A Karnofsky performance status–based score predicts death after hospital discharge in patients with cirrhosis

A Karnofsky performance status–based score predicts death after hospital discharge in patients with cirrhosis

Editorial: Advancing Adoption of Frailty to Improve the Care of Patients with Cirrhosis: Time for a Consensus on a Frailty Index

A practical approach to nutritional screening and assessment in cirrhosis

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