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External validation of the Hospital Frailty Risk Score and comparison with the Hospital-patient One-year Mortality Risk Score to predict outcomes in elderly hospitalised patients: a retrospective cohort study
  1. Finlay McAlister1,
  2. Carl van Walraven2
  1. 1 Department of Medicine, University of Alberta, Edmonton, Canada
  2. 2 Department of Epidemiology & Community Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
  1. Correspondence to Dr Finlay McAlister; finlay.mcalister{at}


Objective Frailty is an important prognostic factor in hospitalised patients but typically requires face-to-face assessment by trained observers to detect. Thus, frail patients are not readily apparent from a systems perspective for those interested in implementing quality improvement measures to optimise their outcomes. This study was designed to externally validate and compare two recently described tools using administrative data as potential markers for frailty: the Hospital Frailty Risk Score (HFRS) and the Hospital-patient One-year Mortality Risk (HOMR) Score.

Design Retrospective cohort study.

Setting Ontario, Canada.

Participants All patients over 75 with at least one urgent non-psychiatric hospitalisation between 2004 and 2010.

Main outcome measures Prolonged hospital length of stay (>10 days), 30-day mortality after admission and 30-day postdischarge rates of urgent readmission or emergency department (ED) visits.

Results In 452 785 patients (25.9% with intermediate or high-risk HFRS), increased HFRS was associated with higher Charlson scores, older age and decreased likelihood of baseline independence. Patients with high or intermediate HFRS had significantly increased risks of prolonged hospitalisation (70.0% (OR 8.64, 95%  CI 8.30 to 8.99) or 49.7% (OR 3.66, 95%  CI 3.60 to 3.71) vs 21.3% in low-risk HFRS group) and 30-day mortality (15.5% (OR 1.27, 95% CI 1.20 to 1.33) or 16.8% (OR 1.39, 95%  CI 1.36 to 1.41) vs 12.7% in low-risk), but decreased risks of 30-day readmission (10.0% (OR 0.74, 95%  CI 0.69 to 0.79) and 11.2% (OR 0.84, 95%  CI 0.82 to 0.86) vs 13.1%) or ED visit (7.3% (OR 0.41, 95%  CI 0.38 to 0.45) and 11.1% (OR 0.66, 95%  CI 0.38 to 0.45) vs 16.0%). Although only loosely associated (Pearson correlation coefficient 0.265, p<0.0001), both the HFRS and HOMR Score were independently associated with each outcome—HFRS was more strongly associated with prolonged length of stay (C-statistic 0.71) and HOMR Score was more strongly associated with 30-day mortality (C-statistic 0.71). Both poorly predicted 30-day readmissions (C-statistics 0.52 for HFRS and 0.54 for HOMR Score).

Conclusions The HFRS best identified hospitalised older patients at higher risk of prolonged length of stay and the HOMR score better predicted 30-day mortality. However, neither score was suitable for predicting risk of readmission or ED visit in the 30 days after discharge. Thus, a single score is inadequate to prognosticate for all outcomes associated with frailty.

  • frailty
  • risk model
  • risk score
  • hospitalization
  • validation

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  • Contributors Both authors contributed equally to the planning, conduct and reporting of the work described herein and (anonymised for blinded peer review) is responsible for the overall content as guarantor. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Funding This project was unfunded although McAlister receives salary support from the Alberta Health Services Chair in Cardiovascular Outcomes.

  • Disclaimer The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred. Parts of this material are based on data and information compiled and provided by Canadian Institute for Health Information (CIHI). However, the analyses, conclusions, opinions and statements expressed herein are those of the author and not necessarily those of CIHI.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval Sunnybrook Hospital, Toronto.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement We are unable to release the databases used for this study as they are held by the Institute for Clinical Evaluative Sciences (ICES) on behalf of the Ontario Ministry of Health and Long-Term Care. Individuals can submit data access requests to ICES with appropriate ethics board approval.

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