Predicting death in home care users: derivation and validation of the Risk Evaluation for Support: Predictions for Elder-Life in the Community Tool (RESPECT)

• Published in: Canadian Medical Association journal (CMAJ) 2021-07, Vol.193 (26), p.E997-E1005
• Main Authors: Hsu, Amy T, Manuel, Douglas G, Spruin, Sarah, Bennett, Carol, Taljaard, Monica, Beach, Sarah, Sequeira, Yulric, Talarico, Robert, Chalifoux, Mathieu, Kobewka, Daniel, Costa, Andrew P, Bronskill, Susan E, Tanuseputro, Peter
• Format: Article
• Language: English
• Subjects: Activities of daily living; Advance Care Planning; Aged; Aged patients; Canada; Cancer; Cardiovascular disease; Care and treatment; Chronic illnesses; Death; Geriatric Assessment - methods; Health aspects; Health risk assessment; Home care; Humans; Kaplan-Meier Estimate; Medical care; Medical prognosis; Methods; Middle Aged; Mortality; Needs assessment; Older people; Palliative care; Patient outcomes; Planning; Population; Primary care; Proportional Hazards Models; Risk Assessment - methods; Sociodemographics; Terminal Care; Variables
• ISSN: 0820-3946; 1488-2329
• DOI: 10.1503/cmaj.200022

Prognostication tools that report personalized mortality risk and survival could improve discussions about end-of-life and advance care planning. We sought to develop and validate a mortality risk model for older adults with diverse care needs in home care using self-reportable information - the Risk Evaluation for Support: Predictions for Elder-Life in the Community Tool (RESPECT). Using a derivation cohort that comprised adults living in Ontario, Canada, aged 50 years and older with at least 1 Resident Assessment Instrument for Home Care (RAI-HC) record between Jan. 1, 2007, and Dec. 31, 2012, we developed a mortality risk model. The primary outcome was mortality 6 months after a RAI-HC assessment. We used proportional hazards regression with robust standard errors to account for clustering by the individual. We validated this algorithm for a second cohort of users of home care who were assessed between Jan. 1 and Dec. 31, 2013. We used Kaplan-Meier survival curves to estimate the observed risk of death at 6 months for assessment of calibration and median survival. We constructed 61 risk groups based on incremental increases in the estimated median survival of about 3 weeks among adults at high risk and 3 months among adults at lower risk. The derivation and validation cohorts included 435 009 and 139 388 adults, respectively. We identified a total of 122 823 deaths within 6 months of a RAI-HC assessment in the derivation cohort. The mean predicted 6-month mortality risk was 10.8% (95% confidence interval [CI] 10.7%-10.8%) and ranged from 1.54% (95% CI 1.53%-1.54%) in the lowest to 98.1% (95% CI 98.1%-98.2%) in the highest risk group. Estimated median survival spanned from 28 days (11 to 84 d at the 25th and 75th percentiles) in the highest risk group to over 8 years (1925 to 3420 d) in the lowest risk group. The algorithm had a c-statistic of 0.753 (95% CI 0.750-0.756) in our validation cohort. The RESPECT mortality risk prediction tool that makes use of readily available information can improve the identification of palliative and end-of-life care needs in a diverse older adult population receiving home care.