SummaryBackgroundOlder people are increasing users of health care globally. We aimed to establish whether older people with characteristics of frailty and who are at risk of adverse health-care outcomes could be identified using routinely collected data.MethodsA three-step approach was used to develop and validate a Hospital Frailty Risk Score from International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) diagnostic codes. First, we carried out a cluster analysis to identify a group of older people (≥75 years) admitted to hospital who had high resource use and diagnoses associated with frailty. Second, we created a Hospital Frailty Risk Score based on ICD-10 codes that characterised this group. Third, in separate cohorts, we tested how well the score predicted adverse outcomes and whether it identified similar groups as other frailty tools.FindingsIn the development cohort (n=22 139), older people with frailty diagnoses formed a distinct group and had higher non-elective hospital use (33·6 bed-days over 2 years compared with 23·0 bed-days for the group with the next highest number of bed-days). In the national validation cohort (n=1 013 590), compared with the 429 762 (42·4%) patients with the lowest risk scores, the 202 718 (20·0%) patients with the highest Hospital Frailty Risk Scores had increased odds of 30-day mortality (odds ratio 1·71, 95% CI 1·68–1·75), long hospital stay (6·03, 5·92–6·10), and 30-day readmission (1·48, 1·46–1·50). The c statistics (ie, model discrimination) between individuals for these three outcomes were 0·60, 0·68, and 0·56, respectively. The Hospital Frailty Risk Score showed fair overlap with dichotomised Fried and Rockwood scales (kappa scores 0·22, 95% CI 0·15–0·30 and 0·30, 0·22–0·38, respectively) and moderate agreement with the Rockwood Frailty Index (Pearson's correlation coefficient 0·41, 95% CI 0·38–0·47).InterpretationThe Hospital Frailty Risk Score provides hospitals and health systems with a low-cost, systematic way to screen for frailty and identify a group of patients who are at greater risk of adverse outcomes and for whom a frailty-attuned approach might be useful.FundingNational Institute for Health Research.
Background‘Frailty crises’ are a common cause of hospital admission among older people and there is significant focus on admission avoidance. However, identifying frailty before a crisis occurs is challenging, making it difficult to effectively target community services. Better longer-term outcome data are needed if services are to reflect the needs of the growing population of older people with frailty.AimTo determine long-term outcomes of older people discharged from hospital following short (<72 hours) and longer hospital admissions compared by frailty status.Design and settingTwo populations aged ≥70 years discharged from hospital units: those following short ‘ambulatory’ admissions (<72 hours) and those following longer inpatient stays.MethodData for 2-year mortality and hospital use were compared using frailty measures derived from clinical and hospital data.ResultsMortality after 2 years was increased for frail compared with non-frail individuals in both cohorts. Patients in the ambulatory cohort classified as frail had increased mortality (Rockwood hazard ratio 2.3 [95% confidence interval {CI} = 1.5 to 3.4]) and hospital use (Rockwood rate ratio 2.1 [95% CI = 1.7 to 2.6]) compared with those patients classified as non-frail.ConclusionIndividuals with frailty who are discharged from hospital experience increased mortality and resource use, even after short ‘ambulatory’ admissions. This is an easily identifiable group that is at increased risk of poor outcomes. Health and social care systems might wish to examine their current care response for frail older people discharged from hospital. There may be value in a ‘secondary prevention’ approach to frailty crises targeting individuals who are discharged from hospital.
Background The Hospital Frailty Risk Score (HFRS) has made it possible internationally to identify subgroups of patients with characteristics of frailty from routinely collected hospital data. Objective To externally validate the HFRS in France. Design A retrospective analysis of the French medical information database. Setting 743 hospitals in Metropolitan France. Subjects All patients aged 75 years or older hospitalised as an emergency in 2017 (n = 1,042,234). Methods The HFRS was calculated for each patient based on the index stay and hospitalisations over the preceding 2 years. Main outcome measures were 30-day in-patient mortality, length of stay (LOS) >10 days and 30-day readmissions. Mixed logistic regression models were used to investigate the association between outcomes and HFRS score. Results Patients with high HFRS risk were associated with increased risk of mortality and prolonged LOS (adjusted odds ratio [aOR] = 1.38 [1.35–1.42] and 3.27 [3.22–3.32], c-statistics = 0.676 and 0.684, respectively), while it appeared less predictive of readmissions (aOR = 1.00 [0.98–1.02], c-statistic = 0.600). Model calibration was excellent. Restricting the score to data prior to index admission reduced discrimination of HFRS substantially. Conclusions HFRS can be used in France to determine risks of 30-day in-patient mortality and prolonged LOS, but not 30-day readmissions. Trial registration: Reference ID on clinicaltrials.gov: ID: NCT03905629.
A survey of the health of South American camelids in the United Kingdom was carried out between December 1992 and June 1993; 123 members of the British Camelid Owners and Breeders Association and 19 non-members were sent questionnaires and usable responses were received from 84 (59 per cent). In total 689 camelids were included, and in 1992, 66 per cent were Ilama, 21 per cent alpaca and 13 per cent guanaco. Their ages ranged from less than six months to over 10 years, with animals aged two to five years constituting the largest proportion. The mortality rates between 1990 and 1992 were 2.7 to 3.3 per cent for Ilama, 3.5 to 6.9 per cent for alpaca and 0 to 11.4 per cent for guanaco. The highest mortality was in animals less than six months and more than 10 years old; 4 to 11 per cent of Ilama deaths and 17 to 33 per cent of alpaca deaths were in animals aged less than six months and a high proportion of these occurred during the first week of life. In the cases for which a cause was reported, accidents and injury accounted for 20 per cent of Ilama deaths, and perinatal deaths accounted for 22 per cent of alpaca deaths. A third of the deaths were reported as being of unknown cause, and a veterinary diagnosis was reported in less than half of the cases. These data suggest that attention to the environment and housing conditions of Ilama, the neonatal care of alpaca and improvements in diagnosis are priorities for reducing the mortality and improving the health of South American camelids in the UK.
Background The aim of this study was to provide high-quality evidence on delivering hospital-wide Comprehensive Geriatric Assessment (CGA). Objective(s) (1) To define CGA, its processes, outcomes and costs in the published literature, (2) to identify the processes, outcomes and costs of CGA in existing hospital settings in the UK, (3) to identify the characteristics of the recipients and beneficiaries of CGA in existing hospital settings in the UK and (4) to develop tools that will assist in the implementation of hospital-wide CGA. Design Mixed-methods study combining a mapping review, national survey, large data analysis and qualitative methods. Participants People aged ≥ 65 years in acute hospital settings. Data sources Literature review – Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, MEDLINE and EMBASE. Survey – acute hospital trusts. Large data analyses – (1) people aged ≥ 75 years in 2008 living in Leicester, Nottingham or Southampton (development cohort, n = 22,139); (2) older people admitted for short stay (Nottingham/Leicester, n = 825) to a geriatric ward (Southampton, n = 246) or based in the community (Newcastle, n = 754); (3) people aged ≥ 75 years admitted to acute hospitals in England in 2014–15 (validation study, n = 1,013,590). Toolkit development – multidisciplinary national stakeholder group (co-production); field-testing with cancer/surgical teams in Newcastle/Leicester. Results Literature search – common outcomes included clinical, operational and destinational, but not patient-reported, outcome measures. Survey – highly variable provision of multidisciplinary assessment and care across hospitals. Quantitative analyses – in the development cohort, older people with frailty diagnoses formed a distinct group and had higher non-elective hospital use than older people without a frailty diagnosis. Patients with the highest 20% of hospital frailty risk scores had increased odds of 30-day mortality [odds ratio (OR) 1.7], long length of stay (OR 6.0) and 30-day re-admission (OR 1.5). The score had moderate agreement with the Fried and Rockwood scales. Pilot toolkit evaluation – participants across sites were still at the beginning of their work to identify patients and plan change. In particular, competing definitions of the role of geriatricians were evident. Limitations The survey was limited by an incomplete response rate but it still provides the largest description of acute hospital care for older people to date. The risk stratification tool is not contemporaneous, although it remains a powerful predictor of patient harms. The toolkit evaluation is still rather nascent and could have meaningfully continued for another year or more. Conclusions CGA remains the gold standard approach to improving a range of outcomes for older people in acute hospitals. Older people at risk can be identified using routine hospital data. Toolkits aimed at enhancing the delivery of CGA by non-specialists can be useful but require prolonged geriatrician support and implementation phases. Future work could involve comparing the hospital-based frailty index with the electronic Frailty Index and further testing of the clinical toolkits in specialist services. Funding The National Institute for Health Research Health Services and Delivery Research programme.
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