Associations and predictions of readmission or death in acutely admitted older medical patients using self-reported frailty and functional measures. A Danish cohort study
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.
References (51)
- et al.
Danish version of the tilburg frailty indicator–translation, cross-cultural adaption and validity pretest by cognitive interviewing
Archives of Gerontology and Geriatrics
(2014) - et al.
Content validation of the tilburg frailty indicator from the perspective of frail elderly. A qualitative explorative study
Archives of Gerontology and Geriatrics
(2015) - et al.
Frailty in elderly people
Lancet
(2013) - et al.
Using timed up and go and usual gait speed to predict incident disability in daily activities among community-dwelling adults aged 65 and older
Archives of Physical Medicine and Rehabilitation
(2014) - et al.
Frailty and its prediction of disability and health care utilization: The added value of interviews and physical measures following a self-report questionnaire
Archives of Gerontology and Geriatrics
(2012) - et al.
The tilburg frailty indicator: Psychometric properties
Journal of the American Medical Directors Association
(2010) - et al.
Frailty consensus: A call to action
Journal of the American Medical Directors Association
(2013) - et al.
A systematic review of the charlson comorbidity index using canadian administrative databases: A perspective on risk adjustment in critical care research
Journal of Critical Care
(2005) - et al.
The frailty dilemma. review of the predictive accuracy of major frailty scores
European Journal of Internal Medicine
(2012) - et al.
Setting and registry characteristics affect the prevalence and nature of multimorbidity in the elderly
Journal of Clinical Epidemiology
(2008)
The strengthening the reporting of observational studies in epidemiology (STROBE) statement: Guidelines for reporting observational studies
Preventive Medicine
Development and validation of the HOPE prognostic index on 24-month posthospital mortality and rehospitalization: Italian national research center on aging (INRCA)
Rejuvenation Research
Self-reported frailty at discharge is associated with readmission and mortality in older patients
Innovation in Aging
Performance-based functional impairment and readmission and death: A prospective study
BMJ Open
Comparing three different measures of frailty in medical inpatients: Multicenter prospective cohort study examining 30‐day risk of readmission or death
Journal of Hospital Medicine
Hand-grip dynamometry predicts future outcomes in aging adults
Journal of Geriatric Physical Therapy
Clinical characteristics and outcomes of hospitalized older patients with distinct risk profiles for functional decline: A prospective cohort study
PloS One
Physical function measurements predict mortality in ambulatory older men
European Journal of Clinical Investigation
Risk factors and screening instruments to predict adverse outcomes for undifferentiated older emergency department patients: A systematic review and meta‐analysis
Academic Emergency Medicine
The ability of frailty to predict outcomes in older people attending an acute medical unit
Acute Medicine
Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: Increased vulnerability with age
Journal of the American Geriatrics Society
Hospitalization-associated disability: “She was probably able to ambulate, but i’m not sure”
JAMA
Frailty: An emerging concept for general practice
The British Journal of General Practice: The Journal of the Royal College of General Practitionerss
Psychosocial factors modify the association of frailty with adverse outcomes: A prospective study of hospitalised older people
BMC Geriatrics
Short portable mental status questionnaire as a screening test for dementia and delirium among the elderly
Journal of the American Geriatrics Society
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