homr model accurately predicts 1-year mortality in older … · systematic review of prognostic...
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C U R T I N D , O ’ D O N N E L L D , D O Y L E D , G A L L A G H E R P , O ’ M A H O N Y D .
U N I V E R S I T Y C O L L E G E C O R K , I R E L A N D
E U G M S , S E P T E M B E R 2 1 , 2 0 1 7
HOMR model accurately predicts 1-year mortality in older
hospitalized patients
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Background
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George
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Estimating prognosis
doctors are inaccurate and overly optimistic
1. Parkes CM. Accuracy of predictions of survival in later stages of cancer. BMJ 1972;ii: 29-31. [PMC free article][PubMed] 2. Christakis N, Lamont E. Extent and determinants of error in doctors' prognoses. BMJ 2000;320: 469-73. [PMC free article][PubMed] 3. Vigano A, Dorgan M, Buckingham J, Bruera E, Suarez-Alzamor ME. Survival prediction in terminal cancer patients: a systematic review of the
medical literature. Palliat Med 2000;14: 363-74. [PubMed] 4. Christakis NA, Lamont ER. Extent and determinants of error in physicians' prognoses in terminally ill patients. West J Med. 2000 May; 172(5):
310–313.
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Prediction Models
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Prediction Models
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Assessing Performance of Prediction models
Discrimination (C Statistic)
Calibration
Transportability
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Assessing Performance of Prediction models
Discrimination (C Statistic)
Calibration
Transportability
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Discrimination (C Statistic)
C statistic
≥0.9 Excellent
0.8 -0.89 Very good
0.7-0.79 Good
0.6-0.69 Fair
0.5-0.59 Poor
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Discrimination (C Statistic)
C statistic
≥0.9 Excellent
0.8 -0.89 Very good
0.7-0.79 Good
0.6-0.69 Fair
0.5-0.59 Poor
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Discrimination (C Statistic)
C statistic
≥0.9 Excellent
0.8 -0.89 Very good
0.7-0.79 Good
0.6-0.69 Fair
0.5-0.59 Poor
>
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Assessing Performance of Prognostic models
Discrimination (C Statistic)
Calibration
Transportability
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Calibration
Agreement between observed and predicted outcomes
<10% difference indicates good calibration
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Assessing Performance of Prognostic models
Discrimination (C Statistic)
Calibration
Transportability
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Transportability
Different population
Different location
Different investigators
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Systematic Review of Prognostic Models
“testing of transportability was limited”
“insufficient evidence at this time to recommend the widespread use..”
JAMA, 2012
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The Hospital-patient One-year Mortality Risk (HOMR) Model (2014)
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HOMR model
Predicts 1 year mortality after hospitalization
Cohort >3 million; Adults of all ages
C statistic 0.9
<1% difference between observed and expected mortality
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HOMR model
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HOMR model
HOMR score
Predicted risk
47 70%
46 63%
45 58%
44 53%
43 50%
42 46%
41 43%
40 37%
39 32%
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Assessment of the performance of the HOMR model in an older Irish cohort
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Methods
Adult inpatients ≥65 under care of geriatric medicine service
January 2013 –March 2015
Primary outcome: death within 1 year after discharge from hospital
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Results
Characteristic Male 43%
Mean age 82
Emergency admission 94%
Independent 67%
Home care 21.3%
Nursing home 7.7%
1409 patients
1150 alive
259 Dead
(18.4%)
Baseline
...........................................................................
1 year
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Results
C statistic 0.79
(95% CI 0.75 -0.82)
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Results
Calibration:
Deaths: 259 (18.4%)
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Results
Calibration:
Deaths: 259 (18.4%)
Predicted deaths 403 (28.8%)
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Results
Calibration:
Deaths: 259 (18.4%)
Predicted deaths 403 (28.8%)
Odds ratio for death: Irish population = North American population
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Calibration
0
10
20
30
40
50
60
70
80
90
100
25 27 29 31 33 35 37 39 41 43 45 47 49 51
Predicted Observed
% dead at one year
HOMR score
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Calibration
0
10
20
30
40
50
60
70
80
90
100
25 27 29 31 33 35 37 39 41 43 45 47 49 51
Predicted Observed
Medium risk
% dead at one year
HOMR score
Low risk
High risk
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Re-calibration
0
10
20
30
40
50
60
70
80
90
100
25 27 29 31 33 35 37 39 41 43 45 47 49 51
Predicted Observed
% dead at one year
HOMR score
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Discussion
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Discussion
Model Descrip-on C-‐Sta-s-c: Deriva-on Valida-on Independent valida-on
HELP, 2000 Pa$ents ≥80 years, emergency admissions
C= 0.73 (N=1266)
C=0.74 (N=150)
-‐
Walter et al, 2001 Pa$ents ≥70 years, discharged from general medicine service
C=0.75 (N=1495)
C=0.79 (N=1427)
C=0.72 (N=122; pa$ents ≥75; 5 year mortality predic$on )
BISEP, 2003 Pa$ents ≥70 years, admiJed under general medicine service
C=0.83 (N=525)
C=0.77 (N=1246)
C=0.73 (N=122; pa$ents ≥75; 5 year mortality predic$on )
Levine et al, 2007 Pa$ents ≥65 years discharged from general medicine service
C=0.67 (N=2739)
C=0.65 (N=3643) -‐
MPI, 2008
Pa$ents ≥65 years admiJed to geriatric unit
C=0.75 C=0.75 -‐
Silver Code, 2010 Pa$ents ≥75 admiJed through the emergency department
C=0.66 (N=5457)
C=0.64 (N=5456)
-‐
HOMR, 2014 Adult pa$ents admiJed under non-‐psychiatric hospital services
C=0.92 (N=319 531)
C=0.89 -‐0.92 (N= 2 862 996)
C=0.79 (N=1409; pa$ents ≥65 years discharged from geriatric service)
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Discussion
Model Descrip-on C-‐Sta-s-c: Deriva-on Valida-on Independent valida-on
HELP, 2000 Pa$ents ≥80 years, emergency admissions
C= 0.73 (N=1266)
C=0.74 (N=150)
-‐
Walter et al, 2001 Pa$ents ≥70 years, discharged from general medicine service
C=0.75 (N=1495)
C=0.79 (N=1427)
C=0.72 (N=122; pa$ents ≥75; 5 year mortality predic$on )
BISEP, 2003 Pa$ents ≥70 years, admiJed under general medicine service
C=0.83 (N=525)
C=0.77 (N=1246)
C=0.73 (N=122; pa$ents ≥75; 5 year mortality predic$on )
Levine et al, 2007 Pa$ents ≥65 years discharged from general medicine service
C=0.67 (N=2739)
C=0.65 (N=3643) -‐
MPI, 2008
Pa$ents ≥65 years admiJed to geriatric unit
C=0.75 C=0.75 -‐
Silver Code, 2010 Pa$ents ≥75 admiJed through the emergency department
C=0.66 (N=5457)
C=0.64 (N=5456)
-‐
HOMR, 2014 Adult pa$ents admiJed under non-‐psychiatric hospital services
C=0.92 (N=319 531)
C=0.89 -‐0.92 (N= 2 862 996)
C=0.79 (N=1409; pa$ents ≥65 years discharged from geriatric service)
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Discussion
Model C statistic
HOMR 0.79
CHA2DS2-VASc 0.68
HAS-BLED 0.69
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Discussion
Can the model be used to predict 1-year mortality in older hospitalized patients?
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Conclusion
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Conclusion
Prognostic models are important
HOMR model is robust
Compares favourably to other prognostic models
Re-calibrated model needs to be tested
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Thank you