Associations and predictions of readmission or death in acutely admitted older medical patients using self-reported frailty and functional measures. A Danish cohort study

https://doi.org/10.1016/j.archger.2018.01.013Get rights and content

Highlights

  • Acutely admitted frail older medical patients had higher risk of readmission or death.

  • The Tilburg Frailty Indicator is a robust self-report multicomponent questionnaire.

  • Frailty and lower functional status were associated with readmission or death.

  • Prediction models including frailty status and known risk factors performed mediocre.

  • A stronger model is warranted before considering implementation in clinical practice.

Abstract

Objective

To assess whether frailty in acutely admitted older medical patients, assessed by a self-report questionnaire and evaluation of functional level at discharge, was associated with readmission or death within 6 months after discharge. A second objective was to assess the predictive performance of models including frailty, functional level, and known risk factors.

Methods

A cohort study including acutely admitted older patients 65+ from seven medical and two acute medical units. The Tilburg Frailty Indicator (TFI), Timed-Up-and-Go (TUG), and grip strength (GS) exposure variables were measured. Associations were assessed using Cox regression with first unplanned readmission or death (all-causes) as the outcome. Prediction models including the three exposure variables and known risk factors were modelled using logistic regression and C-statistics.

Results

Of 1328 included patients, 50% were readmitted or died within 6 months. When adjusted for gender and age, there was an 88% higher risk of readmission or death if the TFI scores were 8–13 points compared to 0–1 points (HR 1.88, CI 1.38;2.58). Likewise, higher TUG and lower GS scores were associated with higher risk of readmission or death. The area under the curve for the prediction models ranged from 0.64 (0.60;0.68) to 0.72 (0.68;0.76).

Conclusion

In acutely admitted older medical patients, higher frailty assessed by TFI, TUG, and GS was associated with a higher risk of readmission or death within 6 months after discharge. The performance of the prediction models was mediocre, and the models cannot stand alone as risk stratification tools in clinical practice.

Introduction

Frailty is associated with higher risk of hospitalisation, re-hospitalisation, and death and, therefore, also with high healthcare-related costs (Clegg, Young, Iliffe, Rikkert, & Rockwood, 2013; Covinsky et al., 2003; Gill, Gahbauer, Han, & Allore, 2010; Gobbens & van Assen, 2012; Pilotto et al., 2012; Wong & Miller, 2008). The number of frail older people is increasing worldwide and underscores the necessity of prioritising and ensuring effective trajectories in and between healthcare sectors (OECD, 2013). Frailty is considered a manageable condition if identified, and it seems possible to prevent or delay adverse consequences of frailty (De Lepeleire, Iliffe, Mann, & Degryse, 2009; Morley et al., 2013).

Acutely admitted older medical patients are characterised by high age, serious illness, comorbidity, low functional status, poor nutritional status, and low quality of life (Buurman et al., 2012; Covinsky et al., 2003; Helvik, Engedal, & Selbaek, 2010; Oliveira, Fogaca, & Leandro-Merhi, 2009). Also, a large percentage of admitted older patients with acute illness are discharged with new hospitalisation-associated disabilities, increasing the risk of readmission (Covinsky, Pierluissi, & Johnston, 2011). A review by Garcia-Perez et al. (2011) concluded that morbidity, functional disability, number of prescribed drugs, length of stay, and prior admissions were risk factors predicting hospital readmission in the elderly, whereas age and gender were not associated with readmission (Garcia-Perez et al., 2011). However, the outcome was not accurately measured as only readmissions to the same hospital were registered (Garcia-Perez et al., 2011). A review by Kansagara et al. (2011) concluded that most readmission prediction models performed poorly and recommended that future studies should include psychosocial factors and functional tests and argued for studies to provide data to act on before the discharge. It is important to obtain data allowing for targeted interventions during and after hospitalisation (Kansagara et al., 2011). A self-report multidimensional assessment tool, including psychosocial factors, may be a feasible alternative for identifying acutely admitted older medical patients regardless of their specific diagnosis. This non-specialist approach will provide data that can be used immediately by health professionals in and between sectors. As many patients have more than one readmission, it is clinically relevant that the provided data are easily understandable for health professionals in both the primary and the secondary health sector. Shared non-specialist screening tools, which are easy to administer and robust in both community-dwelling and hospital settings, would be practical and informative for the involvement, care, and treatment of medical patients. Furthermore, the screening could provide a first indication of which targeted interventions to initiate for the patients at the hospital as well as in the transition phase or post-discharge seeking to reduce readmissions. A screening questionnaire showing better clinometric properties than other multidimensional self-reporting frailty questionnaires is the Tilburg Frailty Indicator (TFI) (Gobbens, van Assen, Luijkx, Wijnen-Sponselee, & Schols, 2010; Metzelthin et al., 2010; Pialoux, Goyard, & Lesourd, 2012). Recently, a systematic review assessed 38 multicomponent frailty tools and concluded, that the TFI was the most robust and extensively examined tool (Sutton et al., 2016). The TFI has been tested only in community-dwelling older people and has not previously been used when studying the association between frailty and readmission or death in a population of acutely admitted older patients. However, previous research, which did not include the TFI, indicated that frailty scores alone might not contain the discriminatory power to risk stratify in relation to readmissions and mortality (Pijpers, Ferreira, Stehouwer, & Nieuwenhuijzen Kruseman, 2012; Wou et al., 2013). As functional status assessed using TUG and GS is associated with disability and mortality, (Bohannon, 2008; Buyser et al., 2013; Donoghue, Savva, Cronin, Kenny, & Horgan, 2014; Kansagara et al., 2011), objective assessment of functional status may potentially strengthen or support the association. Combining the three frailty measures, the TFI, TUG, and GS with the known risk factors of morbidity, length of stay, and previous admissions may provide a prediction model with sufficient predictive power to be useful in clinical practice.

The aim of this study was to assess whether frailty in acutely admitted older medical patients, assessed by a self-report multidimensional questionnaire, TUG, and GS at discharge was associated with unplanned readmission or death within 6 months after discharge from hospital. The second aim was to investigate whether a constructed model including the TFI, TUG, and GS measurements together with information regarding morbidity, length of stay, and previous admissions predicts readmission or death within 6 months after discharge.

Section snippets

Study design

The study was a prospective cohort study including acutely admitted older patients who were consecutively included and tested at discharge from a hospital with follow-up in central registers for 6 months (182 days). The manuscript is presented in accordance with the STROBE guidelines (Von Elm et al., 2007). A conference abstract presenting preliminary results on a part of the data has been published. The adjusted (sex, age, and comorbidity) association of the total sample between TFI, TUG, and

Results

A total of 9003 patients aged 65 years or more were admitted during the 12-month period. Out of these, 2793 patients aged 65 years or more were consecutively screened for eligibility of which 1328 patients were included into the study (Fig. 1). Complete follow-up on outcomes was achieved for all patients. The median (10/90‰) age of the participants was 77.1 (67.5; 87.7) years; 50.4% were women, and the median (10/90‰) length of stay in hospital was 5 (1;15) days. Those discharged to their own

Overall findings

The self-reported multicomponent TFI-questionnaire, a TUG test, and GS were used as measures of frailty in acutely admitted older medical patients to assess the association with unplanned readmission or death within 6 months from discharge. Negative associations with readmission or death were consistently present for all three measures of frailty in the crude-, gender-, and age- and gender-, age-, and comorbidity-adjusted models. Furthermore, prediction models for readmission or death within 6

Conclusion

In conclusion, acutely admitted older medical patients’ frailty assessed using a self-reported multicomponent frailty questionnaire, The Tilburg Frailty Indicator (TFI), TUG, and GS at hospital discharge were associated with a higher risk of readmission or death within 6 months. However, the predictive performance of the models was poor to fair. Further research is needed to identify feasible measures or variables with clinical applicability, which more accurately can predict the risk of

Funding

The study was funded by the Danish Development and Research Fund.

Conflicts of interest

None of the authors has any conflicts of interest and have no relation to the funding organisation.

Acknowledgement

The authors would like to thank the staff at the participating medical and acute medical units.

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