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Clinical Decisionmaking

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New risk index can identify elderly people at increased risk for death within a year after hospital discharge

Many elderly people die within a year after they have been hospitalized for an acute medical illness. A newly developed risk index can be used at the bedside to help doctors assess the risk of hospitalized elderly patients dying within a year of discharge. This in turn can help guide their clinical strategy and counseling of patients and their families about needs for long-term care, home care, or other supportive services. The index was developed by researchers at the VA Medical Center and the University of California, San Francisco, Indiana University School of Medicine, the Cleveland Clinic, and the University of Connecticut. Their work was supported in part by the Agency for Healthcare Research and Quality (K02 HS00006).

The researchers initially developed the index by correlating medical factors with death 1 year after discharge in 1,495 elderly patients at one hospital and validated it in 1,427 elderly patients discharged from a different hospital. They identified six independent risk factors for postdischarge death, which they weighted according to level of risk: male sex (1 point); number of limitations in activities of daily living (ADLs), such as dressing or toileting oneself (one to four ADLs, 2 points; all five ADLs, 5 points; congestive heart failure (2 points); cancer (solitary, 3 points; metastatic, 8 points); creatine level higher than 3.0 mg/dL (2 points), indicative of renal dysfunction; and low albumin level (3.0-3.4 g/dL, 1 point; less than 3.0 g/dL, 2 points), which is a marker of both malnutrition and general disease severity. The researchers added these risk scores for a total risk score.

In the group of patients from which they derived the score, 13 percent in the lowest risk group (0-1 point), 20 percent in the group with 2 or 3 points, 37 percent in the group with 4 to 6 points, and 68 percent in the highest risk group (more than 6 points) died within 1 year of hospital discharge. In the validation group, 1-year mortality was 4 percent in the lowest risk group, 19 percent in the group with 2 or 3 points, 34 percent in the group with 4 to 6 points, and 64 percent in the highest risk group. This index performed better in predicting 1-year mortality than other prognostic indexes that focus only on coexisting illnesses or physiologic measures, conclude the researchers.

More details are in "Development and validation of a prognostic index for 1-year mortality in older adults after hospitalization," by Louise C. Walter, M.D., Richard J. Brand, Ph.D., Steven R. Counsell, M.D., and others, in the June 20, 2001 Journal of the American Medical Association 285(23), pp. 2987- 2994.

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