Association between frailty and 30-day outcomes after discharge from hospital

Kahlon, Sharry; Pederson, Jenelle L.; Majumdar, Sumit R.; Belga, Sara; Lau, Darren; Fradette, Miriam; Boyko, Debbie; Bakal, Jeffrey A.; Johnston, Curtis; Padwal, Raj; McAlister, Finlay A.

doi:10.1503/cmaj.150100

Cited by 179 publications

(153 citation statements)

References 29 publications

(44 reference statements)

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“…We also conducted a post hoc sensitivity analysis excluding patients who underwent cancer surgery. We considered the Clinical Frailty Scale as a dichotomized variable, applying a well-balanced cut-off score of 4 (rather than 5, as used previously 5,22,23 ), because our cohort excluded patients with scores of 7 or higher. Finally, we disaggregated composite outcomes to identify whether readmission or death was driving the relation.…”

Section: Discussionmentioning

confidence: 99%

Impact of frailty on outcomes after discharge in older surgical patients: a prospective cohort study

Pederson

Churchill

et al. 2018

CMAJ

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Frailty is a state of vulnerability to diverse stressors. We assessed the impact of frailty on outcomes after discharge in older surgical patients. METHODS:We prospectively followed patients 65 years of age or older who underwent emergency abdominal surgery at either of 2 tertiary care centres and who needed assistance with fewer than 3 activities of daily living. Preadmission frailty was defined according to the Canadian Study of Health and Aging Clinical Frailty Scale as "well" (score 1 or 2), "vulnerable" (score 3 or 4) or "frail" (score 5 or 6). We assessed composite end points of 30-day and 6-month all-cause readmission or death by multivariable logistic regression. (n = 3 [4.2%]). By 6 months, the degree of frailty independently and dose-dependently predicted readmission or death: 56 (33.3%) of the vulnerable patients (adjusted OR 2.15, 95% CI 1.01-4.55) and 37 (54.4%) of the frail patients (adjusted OR 3.27, 95% CI 1.32-8.12) were readmitted or had died, compared with 11 (15.3%) of the patients who were well. INTERPRETATION:Vulnerability and frailty were prevalent in older patients undergoing surgery and unlikely to trigger specialized geriatric assessment, yet remained independently associated with greater risk of readmission for as long as 6 months after discharge. Therefore, the degree of frailty has important prognostic value for readmission. Trial registration for primary study: ClinicalTrials. gov, no. NCT02233153

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Section: Discussionmentioning

confidence: 99%

Impact of frailty on outcomes after discharge in older surgical patients: a prospective cohort study

Pederson

Churchill

et al. 2018

CMAJ

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“…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%

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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“…The studies were geographically distributed worldwide: 4 in the North America (41,163,166,167), Canada (36,(168)(169)(170)(171) There was variation in sample size, with the 3 large outliers unsurprisingly utilising secondary analysis of previous data (43,172,178) as methodology within single secondary care centres in the general internal medicine and elderly care setting. The observational studies were of relatively modest size ( Figure 3).…”

Section: General Features and Quality Assessmentmentioning

confidence: 99%

“…Some studies excluded patients with significant cognitive impairment (36,160,166,168,169,171), critically unwell patients (41,177,180,181) or patients residing in a long term care facility (163,171,174). 3 studies based in the Emergency Department setting excluded patients who were subsequently admitted to hospital during the assessment episode (166,168,169).…”

Section: Na Not Applicablementioning

confidence: 99%

Frailty Assessment in Acute Care

2015

The Gerontologist

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IntroductionFor some people, ageing is associated with the experience of increased co-morbidity, functional impairment, poor resilience and heightened vulnerability to external stressors, resulting in reduced lifespan as well as health-span. This frailty phenomenon poses challenges to health care systems in the form of increased patient complexity and resource utilisation. The acute care setting, characterised by time-pressure and high patient turn-over, is under strain and struggles to recognise and subsequently reliably intervene, to prevent, reverse or halt the decline of this vulnerable cohort. MethodsThis mixed-methods study probes existing evidence and 'real-world' processes with a systematic review of frailty assessments developed or validated in the acute care setting and a survey of contemporaneous clinical practice in London Acute Medical Units. Content validation and understanding of contextual factors for ideal frailty assessment in acute care is explored using Delphi consensus and Focus Group methodology respectively. The resultant model is developed on existing retrospective national Hospital Episode Statistics data, and prospectively tested on observational data in a local Acute Medical Unit setting. ResultsExisting frailty scores are preponderantly biophysical in nature, and have poor predictive power for adverse outcomes in the acute care setting. In clinical practice, single-dimension assessment tools predominate. Frailty syndromes and previous high resource utilisation in the form of a simple, clinically relevant tool useful to the multidisciplinary team gain consensus as optimal assessment for the setting. Retrospective testing of the frailty model displays moderate predictive powers for adverse events (inpatient mortality, emergency readmission and institutionalisation) and prospective testing provides concurrent (Frailty Index, Age, Co-Morbidity) and comparative predictive validity (Frailty Index, Co-Morbidity, 2 admission National Early Warning Score) with existing risk stratification models in this setting. ConclusionsA risk prediction model based on frailty syndromes and previous high resource utilisation is a valid, feasible and useful for the acute care setting.

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Association between frailty and 30-day outcomes after discharge from hospital

Cited by 179 publications

References 29 publications

Impact of frailty on outcomes after discharge in older surgical patients: a prospective cohort study

Impact of frailty on outcomes after discharge in older surgical patients: a prospective cohort study

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

Frailty Assessment in Acute Care

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