title: Five-Year Risk of Mechanical Ventilation in Community-Dwelling Adults: The Framingham-Intermountain Anticipating Life Support Study.
abstract: OBJECTIVE
  To develop a quantitative tool for identifying outpatients most likely to require life support with mechanical ventilation within 5 years.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  Framingham Heart Study (FHS) 1991 to 2009 and Intermountain Healthcare clinics 2008 to 2013.
  
  
  METHODS
  FHS participants (n = 3,666; mean age 74; 58% female) in a derivation cohort and Intermountain Healthcare outpatients aged 65 and older (n = 88,302; mean age 73, 57% female) in an external validation cohort.
  
  
  METHODS
  Information on demographic characteristics and comorbidities collected during FHS examinations to derive a 5-year risk score for receiving mechanical ventilation in an intensive care unit, with external validation using administrative data from outpatients seen at Intermountain Healthcare. A sensitivity analysis investigating model performance for a composite outcome of mechanical ventilation or death was performed.
  
  
  RESULTS
  Eighty (2%) FHS participants were mechanically ventilated within 5 years after a FHS examination. Age, sex, diabetes mellitus, hypertension, atrial fibrillation, alcohol use, chronic pulmonary disease, and hospitalization within the prior year predicted need for mechanical ventilation within 5 years (c-statistic = 0.74, 95% confidence interval (CI) = 0.68-0.80). One thousand seven hundred twenty-five (2%) Intermountain Healthcare outpatients underwent mechanical ventilation. The validation model c-statistic was 0.67 (95% CI = 0.66-0.68). Approximately 1% of individuals identified as low risk and 5% to 12% identified as high risk required mechanical ventilation within 5 years. Sensitivity analysis demonstrated a c-statistic of 0.75 (95% CI = 0.75-0.75) for risk prediction of a composite outcome of mechanical ventilation or death.
  
  
  CONCLUSIONS
  A simple risk score using clinical examination data or administrative data may be used to predict 5-year risk of mechanical ventilation or death. Further study is necessary to determine whether use of a risk score enhances advance care planning or improves quality of care of older adults.
authors.affiliation: Pulmonary Center, School of Medicine, Boston University, Boston, Massachusetts.
authors.forename: Allan J
authors.initials: AJ
authors.lastname: Walkey
authors.affiliation: Mathematics and Statistics Department, School of Public Health, Boston University, Boston, Massachusetts.
authors.forename: Karol M
authors.initials: KM
authors.lastname: Pencina
authors.affiliation: Center for Humanizing Critical Care, Intermountain Medical Center, Murray, Utah.|Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah.|Department of Medicine, School of Medicine, University of Utah, Salt Lake City, Utah.
authors.forename: Daniel
authors.initials: D
authors.lastname: Knox
authors.affiliation: Homer Warner Center for Medical Informatics Research, Intermountain Healthcare, Salt Lake City, Utah.
authors.forename: Kathryn G
authors.initials: KG
authors.lastname: Kuttler
authors.affiliation: Mathematics and Statistics Department, School of Public Health, Boston University, Boston, Massachusetts.
authors.forename: Ralph B
authors.initials: RB
authors.lastname: D'Agostino
authors.affiliation: Sections of Cardiovascular Medicine, School of Medicine, Boston University, Boston, Massachusetts.|Sections of Preventive Medicine, School of Medicine, Boston University, Boston, Massachusetts.|Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts.
authors.forename: Emelia J
authors.initials: EJ
authors.lastname: Benjamin
authors.affiliation: Center for Humanizing Critical Care, Intermountain Medical Center, Murray, Utah.
authors.forename: Samuel M
authors.initials: SM
authors.lastname: Brown
mesh_terms: D000367:Age Factors; D000368:Aged; D000428:Alcohol Drinking / Q000453:epidemiology; D001281:Atrial Fibrillation / Q000453:epidemiology; D015331:Cohort Studies; D003920:Diabetes Mellitus / Q000453:epidemiology; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D006973:Hypertension / Q000453:epidemiology; D008020:Life Support Care / Q000706:statistics & numerical data*; D008171:Lung Diseases / Q000453:epidemiology; D008297:Male; D016016:Proportional Hazards Models; D012121:Respiration, Artificial / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D018570:Risk Assessment; D012737:Sex Factors; D014589:Utah / Q000453:epidemiology
keywords: advance care planning; end-of-life care; mechanical ventilation