This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on ISI (196)  • Contact me when this article is cited  Related Content  • Similar articles in JAMA  Topic Collections  • Aging/ Geriatrics  • Alert me on articles by topic

Sharon K. Inouye, MD, MPH; Peter N. Peduzzi, PhD; Julie T. Robison, PhD; John S. Hughes, MD; Ralph I. Horwitz, MD; John Concato, MD, MS, MPH

JAMA. 1998;279:1187-1193.

Context.— Measures of physical and cognitive function are strong prognostic predictors of hospital outcomes for older persons, but current risk adjustment and burden of illness assessment indices do not include these measures.

Objective.— To evaluate and validate the contribution of functional measures to the ability of 5 standard burden of illness indices (Charlson, Acute Physiology and Chronic Health Evaluation [APACHE] II, Disease Staging, All Patient Refined Diagnosis Related Groups, and a clinician's subjective rating) in predicting 90-day and 2-year mortality among older hospitalized patients.

Design.— Two prospective cohort studies.

Setting.— General medicine service, university teaching hospital.

Patients.— For the development cohort, 207 consecutive patients aged 70 years or older, and for the validation cohort, 318 comparable patients.

Main Outcome Measure.— Death within 90 days and 2 years from the index admission.

Results.— In the development cohort, 29 patients (14%) and 81 patients (39%) died within 90 days and 2 years, respectively. A functional axis was developed using 3 independent risk factors: impairment in instrumental activities of daily living, Mini-Mental State Examination score of less than 20, and shortened Geriatric Depression Scale score of 7 or higher, creating low-, intermediate-, and high-risk groups with associated mortality rates of 20%, 32%, and 60%, respectively (P<.001); the C statistic for the final model was 0.69. The corresponding mortality rates in the validation cohort, in which 59 (19%) and 138 (43%) died within 90 days and 2 years, respectively, were 24%, 45%, and 60% (P<.001); the C statistic for the final model was 0.66. For each burden of illness index, the functional axis contributed significantly to the predictive ability of the model for both 90 days and 2 years. When the functional axis and each burden of illness measure were analyzed in cross-stratified format, mortality rates increased progressively from low-risk to high-risk functional groups within strata of burden of illness indices (double-gradient phenomenon). The contributions of functional and burden of illness measures were substantive and interrelated.

Conclusions.— Functional measures are strong predictors of 90-day and 2-year mortality after hospitalization. Furthermore, these measures contribute substantially to the prognostic ability of 5 burden of illness indices. Optimal risk adjustment for older hospitalized patients should incorporate functional status variables.

From the Departments of Internal Medicine (Drs Inouye, Peduzzi, Hughes, Horwitz, and Concato) and Epidemiology and Public Health (Drs Peduzzi and Robison), Yale University School of Medicine, New Haven, Conn, and the Department of Veterans Affairs Cooperative Studies Program Coordinating Center (Dr Peduzzi) and Medical Service (Drs Hughes and Concato), Veterans Affairs Connecticut Healthcare System, West Haven.

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Health-Related Quality of Life After Cardiac Surgery
Gorman Koch et al.
SEMIN CARDIOTHORAC VASC ANESTH 2008;12:203-217.
ABSTRACT  

Pneumonia: Criteria for Patient Instability on Hospital Discharge
Capelastegui et al.
Chest 2008;134:595-600.
ABSTRACT | FULL TEXT  

CRB-65 for the assessment of pneumonia severity: who could ask for more?
Ewig and Welte
Thorax 2008;63:665-666.
FULL TEXT  

Does a Geriatric Oncology Consultation Modify the Cancer Treatment Plan for Elderly Patients?
Girre et al.
J. Gerontol. A Biol. Sci. Med. Sci. 2008;63:724-730.
ABSTRACT | FULL TEXT  

Chronic Conditions and Mortality Among the Oldest Old
Lee et al.
Am. J. Public Health 2008;98:1209-1214.
ABSTRACT | FULL TEXT  

Subtle Neurological Abnormalities as Risk Factors for Cognitive and Functional Decline, Cerebrovascular Events, and Mortality in Older Community-Dwelling Adults
Inzitari et al.
Arch Intern Med 2008;168:1270-1276.
ABSTRACT | FULL TEXT  

Effect of race on patient expectations regarding their primary care physicians
Guerra et al.
Fam Pract 2008;0:cmn005v1-cmn005.
ABSTRACT | FULL TEXT  

Measuring case-mix and outcome for older people in acute hospital care across Europe: the development and potential of the ACMEplus instrument
Espallargues et al.
QJM 2008;101:99-109.
ABSTRACT | FULL TEXT  

Fat Mass But Not Fat-Free Mass Is Related to Physical Capacity in Well-Functioning Older Individuals: Nutrition as a Determinant of Successful Aging (NuAge) The Quebec Longitudinal Study
Bouchard et al.
J. Gerontol. A Biol. Sci. Med. Sci. 2007;62:1382-1388.
ABSTRACT | FULL TEXT  

Associations between comorbidities, treatment choice and outcome in the elderly with end-stage renal disease
Couchoud et al.
Nephrol Dial Transplant 2007;22:3246-3254.
ABSTRACT | FULL TEXT  

Comparison of the Health and Functional Status Between Older Inpatients With and Without Cancer Admitted to a Geriatric/Internal Medicine Unit
Retornaz et al.
J. Gerontol. A Biol. Sci. Med. Sci. 2007;62:917-922.
ABSTRACT | FULL TEXT  

Risk Factors for Delirium at Discharge: Development and Validation of a Predictive Model
Inouye et al.
Arch Intern Med 2007;167:1406-1413.
ABSTRACT | FULL TEXT  

A Practical Approach to Geriatric Assessment in Oncology
Rodin and Mohile
JCO 2007;25:1936-1944.
ABSTRACT | FULL TEXT  

Risk Factors for Mortality in Middle-aged Women
Tice et al.
Arch Intern Med 2006;166:2469-2477.
ABSTRACT | FULL TEXT  

Does Educational Attainment Contribute to Risk for Delirium? A Potential Role for Cognitive Reserve
Jones et al.
J. Gerontol. A Biol. Sci. Med. Sci. 2006;61:1307-1311.
ABSTRACT | FULL TEXT  

Colorectal cancer screening in young patients with poor health and severe comorbidity.
Sultan et al.
Arch Intern Med 2006;166:2209-2214.
ABSTRACT | FULL TEXT  

The impact of health status on physicians' intentions to offer cancer screening to older women.
Heflin et al.
J. Gerontol. A Biol. Sci. Med. Sci. 2006;61:844-850.
ABSTRACT | FULL TEXT  

Using clinical guidelines designed for older adults with diabetes mellitus and complex health status.
Durso
JAMA 2006;295:1935-1940.
ABSTRACT | FULL TEXT  

Prospective Study of Health Status Preferences and Changes in Preferences Over Time in Older Adults.
Fried et al.
Arch Intern Med 2006;166:890-895.
ABSTRACT | FULL TEXT  

Functional status is a confounder of the association of influenza vaccine and risk of all cause mortality in seniors
Jackson et al.
Int J Epidemiol 2006;35:345-352.
ABSTRACT | FULL TEXT  

Development and Validation of a Prognostic Index for 4-Year Mortality in Older Adults
Lee et al.
JAMA 2006;295:801-808.
ABSTRACT | FULL TEXT  

Pretreatment Quality of Life and Functional Status Assessment Significantly Predict Survival of Elderly Patients With Advanced Non--Small-Cell Lung Cancer Receiving Chemotherapy: A Prognostic Analysis of the Multicenter Italian Lung Cancer in the Elderly Study
Maione et al.
JCO 2005;23:6865-6872.
ABSTRACT | FULL TEXT  

Relationship Between Functional Loss Before Hospital Admission and Mortality in Elderly Persons With Medical Illness
Rozzini et al.
J. Gerontol. A Biol. Sci. Med. Sci. 2005;60:1180-1183.
ABSTRACT | FULL TEXT  

Magnitude and Patterns of Decline in Health and Function in 1 Year Affect Subsequent 5-Year Survival
Perera et al.
J. Gerontol. A Biol. Sci. Med. Sci. 2005;60:894-900.
ABSTRACT | FULL TEXT  

Outcomes of Elderly Survivors of Intensive Care: A Review of the Literature
Hennessy et al.
Chest 2005;127:1764-1774.
ABSTRACT | FULL TEXT  

The Burden of Symptoms Among Community-Dwelling Older Persons With Advanced Chronic Disease
Walke et al.
Arch Intern Med 2004;164:2321-2324.
ABSTRACT | FULL TEXT  

Comparing morbidity and mortality of HLA-matched unrelated donor hematopoietic cell transplantation after nonmyeloablative and myeloablative conditioning: influence of pretransplantation comorbidities
Sorror et al.
Blood 2004;104:961-968.
ABSTRACT | FULL TEXT  

Health-related quality of life after coronary artery bypass grafting: A gender analysis using the Duke Activity Status Index
Koch et al.
J. Thorac. Cardiovasc. Surg. 2004;128:284-295.
ABSTRACT | FULL TEXT  

Health Insurance Coverage And Mortality Among The Near-Elderly
McWilliams et al.
Health Aff (Millwood) 2004;23:223-233.
ABSTRACT | FULL TEXT  

Too Old to Care?
Penson et al.
The Oncologist 2004;9:343-352.
ABSTRACT | FULL TEXT  

Six month outcomes after emergency admission of elderly patients to a community or a district general hospital
Round et al.
Fam Pract 2004;21:173-179.
ABSTRACT | FULL TEXT  

Comparison of short-term mortality risk factors for valve replacement versus coronary artery bypass graft surgery
Gardner et al.
Ann. Thorac. Surg. 2004;77:549-556.
ABSTRACT | FULL TEXT  

Risk Factors for Early and Late Mortality in Hospitalized Older Patients: The Continuing Importance of Functional Status
Ponzetto et al.
J. Gerontol. A Biol. Sci. Med. Sci. 2003;58:M1049-1054.
ABSTRACT | FULL TEXT  

Depressive Symptoms and Risk of Mortality in Frail, Community-Living Elderly Persons
Yaffe et al.
AJGP 2003;11:561-567.
ABSTRACT | FULL TEXT  

Valuing the Outcomes of Treatment: Do Patients and Their Caregivers Agree?
Fried et al.
Arch Intern Med 2003;163:2073-2078.
ABSTRACT | FULL TEXT  

Priorities in Perioperative Geriatrics
Cook and Rooke
Anesth. Analg. 2003;96:1823-1836.
FULL TEXT  

Additive Effects of Cognitive Function and Depressive Symptoms on Mortality in Elderly Community-Living Adults
Mehta et al.
J. Gerontol. A Biol. Sci. Med. Sci. 2003;58:M461-467.
ABSTRACT | FULL TEXT  

Variation in mortality risk factors with time after coronary artery bypass graft operation
Gao et al.
Ann. Thorac. Surg. 2003;75:74-81.
ABSTRACT | FULL TEXT  

Sadness Predicts Death in Older People
Cooper et al.
J Aging Health 2002;14:509-526.
ABSTRACT  

Assessment of Patient Preferences: Integrating Treatments and Outcomes
Fried et al.
J. Gerontol. B Psychol. Sci. Soc. Sci. 2002;57:S348-354.
ABSTRACT | FULL TEXT  

Undernutrition and Risk of Mortality in Elderly Patients Within 1 Year of Hospital Discharge
Liu et al.
J. Gerontol. A Biol. Sci. Med. Sci. 2002;57:M741-746.
ABSTRACT | FULL TEXT  

Predictors of live hospice discharge: Data from the National Home and Hospice Care Survey (NHHCS)
Kutner et al.
AM J HOSP PALLIAT CARE 2002;19:331-337.
ABSTRACT  

Longitudinal Benefit of Positive Self-Perceptions of Aging on Functional Health
Levy et al.
J. Gerontol. B Psychol. Sci. Soc. Sci. 2002;57:P409-417.
ABSTRACT | FULL TEXT  

Using Quality of Life to Predict Hospitalization and Mortality in Patients With Obstructive Lung Diseases*
Fan et al.
Chest 2002;122:429-436.
ABSTRACT | FULL TEXT  

Health Status and Clinical Practice: When Will They Meet?
Rumsfeld
Circulation 2002;106:5-7.
FULL TEXT  

Understanding the Treatment Preferences of Seriously Ill Patients
Fried et al.
NEJM 2002;346:1061-1066.
ABSTRACT | FULL TEXT  

Co-morbidity adjustment for functional outcomes in community-dwelling older adults
Rigler et al.
Clin Rehabil 2002;16:420-428.
ABSTRACT  

2-Month Mortality and Functional Status of Critically Ill Adult Patients Receiving Prolonged Mechanical Ventilation
Chest 2002;121:549-558.
ABSTRACT | FULL TEXT  

Comprehensive Geriatric Assessment Adds Information to Eastern Cooperative Oncology Group Performance Status in Elderly Cancer Patients: An Italian Group for Geriatric Oncology Study
Repetto et al.
JCO 2002;20:494-502.
ABSTRACT | FULL TEXT  

Functional Disability and Health Care Expenditures for Older Persons
Fried et al.
Arch Intern Med 2001;161:2602-2607.
ABSTRACT | FULL TEXT  

The Association of Depression and Mortality in Elderly Persons: A Case for Multiple, Independent Pathways
Blazer et al.
J. Gerontol. A Biol. Sci. Med. Sci. 2001;56:M505-509.
ABSTRACT | FULL TEXT  

Development and Validation of a Prognostic Index for 1-Year Mortality in Older Adults After Hospitalization
Walter et al.
JAMA 2001;285:2987-2994.
ABSTRACT | FULL TEXT  

Cancer Screening in Elderly Patients: A Framework for Individualized Decision Making
Walter and Covinsky
JAMA 2001;285:2750-2756.
ABSTRACT | FULL TEXT  

Guest Editorial: Pinning Down Frailty
Gillick
J. Gerontol. A Biol. Sci. Med. Sci. 2001;56:134M-135.
FULL TEXT  

Management of Cancer in the Older Person: A Practical Approach
Balducci and Extermann
The Oncologist 2000;5:224-237.
ABSTRACT | FULL TEXT  

What Threshold for Adjuvant Therapy in Older Breast Cancer Patients?
Extermann et al.
JCO 2000;18:1709-1717.
ABSTRACT | FULL TEXT  

Outcome for Older Burn Patients
McGill et al.
Arch Surg 2000;135:320-325.
ABSTRACT | FULL TEXT  

Impact of Risk Adjusted Clinical Outcomes Methodology-Quality Measures on Hospital Mortality Data: A Statistical and Case Study Approach
Lied et al.
American Journal of Medical Quality 1999;14:255-261.
ABSTRACT  

Mechanical Ventilation in a Cohort of Elderly Patients Admitted to an Intensive Care Unit
Ely et al.
ANN INTERN MED 1999;131:96-104.
ABSTRACT | FULL TEXT  

Predictors of mortality in patients with Alzheimer's disease living in nursing homes
Gambassi et al.
J. Neurol. Neurosurg. Psychiatry 1999;67:59-65.
ABSTRACT | FULL TEXT  

The Minimum Data Set 2.0: A functional assessment to predict mortality in nursing home residents
Abicht-Swensen and Debner
AM J HOSP PALLIAT CARE 1999;16:527-532.
ABSTRACT  

Health-Related Quality of Life as a Predictor of Mortality Following Coronary Artery Bypass Graft Surgery
Rumsfeld et al.
JAMA 1999;281:1298-1303.
ABSTRACT | FULL TEXT  

Depressive Symptoms and 3-Year Mortality in Older Hospitalized Medical Patients
Covinsky et al.
ANN INTERN MED 1999;130:563-569.
ABSTRACT | FULL TEXT