• Finlay McAlister and Carl van Walraven.
• Department of Medicine, University of Alberta, Edmonton, Canada finlay.mcalister@ualberta.ca.
• BMJ Qual Saf. 2019 Apr 1; 28 (4): 284-288.

ObjectiveFrailty 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.DesignRetrospective cohort study.SettingOntario, Canada.ParticipantsAll patients over 75 with at least one urgent non-psychiatric hospitalisation between 2004 and 2010.Main Outcome MeasuresProlonged hospital length of stay (>10 days), 30-day mortality after admission and 30-day postdischarge rates of urgent readmission or emergency department (ED) visits.ResultsIn 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).ConclusionsThe 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.© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.

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