title: Development of a prognostic model for six-month mortality in older adults with declining health.
abstract: BACKGROUND
  Estimation of six-month prognosis is essential in hospice referral decisions, but accurate, evidence-based tools to assist in this task are lacking.
  
  
  OBJECTIVE
  To develop a new prognostic model, the Patient-Reported Outcome Mortality Prediction Tool (PROMPT), for six-month mortality in community-dwelling elderly patients.
  
  
  METHODS
  We used data from the Medicare Health Outcomes Survey linked to vital status information. Respondents were 65 years old or older, with self-reported declining health over the past year (n=21,870), identified from four Medicare Health Outcomes Survey cohorts (1998-2000, 1999-2001, 2000-2002, and 2001-2003). A logistic regression model was derived to predict six-month mortality, using sociodemographic characteristics, comorbidities, and health-related quality of life (HRQOL), ascertained by measures of activities of daily living and the Medical Outcomes Study Short Form-36 Health Survey; k-fold cross-validation was used to evaluate model performance, which was compared with existing prognostic tools.
  
  
  RESULTS
  The PROMPT incorporated 11 variables, including four HRQOL domains: general health perceptions, activities of daily living, social functioning, and energy/fatigue. The model demonstrated good discrimination (c-statistic=0.75) and calibration. Overall diagnostic accuracy was superior to existing tools. At cut points of 10%-70%, estimated six-month mortality risk sensitivity and specificity ranged from 0.8% to 83.4% and 51.1% to 99.9%, respectively, and positive likelihood ratios at all mortality risk cut points ≥40% exceeded 5.0. Corresponding positive and negative predictive values were 23.1%-64.1% and 85.3%-94.5%. Over 50% of patients with estimated six-month mortality risk ≥30% died within 12 months.
  
  
  CONCLUSIONS
  The PROMPT, a new prognostic model incorporating HRQOL, demonstrates promising performance and potential value for hospice referral decisions. More work is needed to evaluate the model.
authors.affiliation: Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME 04105, USA. hanp@mmc.org
authors.forename: Paul K J
authors.initials: PK
authors.lastname: Han
authors.forename: Minjung
authors.initials: M
authors.lastname: Lee
authors.forename: Bryce B
authors.initials: BB
authors.lastname: Reeve
authors.forename: Angela B
authors.initials: AB
authors.lastname: Mariotto
authors.forename: Zhuoqiao
authors.initials: Z
authors.lastname: Wang
authors.forename: Ron D
authors.initials: RD
authors.lastname: Hays
authors.forename: K Robin
authors.initials: KR
authors.lastname: Yabroff
authors.forename: Marie
authors.initials: M
authors.lastname: Topor
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Feuer
mesh_terms: D000203:Activities of Daily Living; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D015897:Comorbidity; D005006:Ethnicity; D005260:Female; D006304:Health Status; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D009026:Mortality; D017063:Outcome Assessment, Health Care / Q000379:methods*; D011379:Prognosis; D011788:Quality of Life; D015203:Reproducibility of Results; D012737:Sex Factors; D012959:Socioeconomic Factors; D016019:Survival Analysis; D014481:United States / Q000453:epidemiology
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