Avelino-Silva Thiago J, Lee Sei J, Covinsky Kenneth E, Walter Louise C, Deardorff W James, Boscardin John, Campora Flavia, Szlejf Claudia, Suemoto Claudia K, Smith Alexander K
Division of Geriatrics, School of Medicine, University of California San Francisco.
Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas (HCFMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
JAMA Netw Open. 2025 Jan 2;8(1):e2455475. doi: 10.1001/jamanetworkopen.2024.55475.
The Walter Index is a widely used prognostic tool for assessing 12-month mortality risk among hospitalized older adults. Developed in the US in 2001, its accuracy in contemporary non-US contexts is unclear.
To evaluate the external validity of the Walter Index in predicting posthospitalization mortality risk in Brazilian older adult inpatients.
DESIGN, SETTING, AND PARTICIPANTS: This prognostic study used data from a cohort of adults aged 70 years or older admitted to the geriatric unit of a university hospital in Brazil from January 1, 2009, to February 28, 2020. Participants underwent comprehensive geriatric assessments at admission, were reevaluated at discharge, and were subsequently followed up for 48 months. Data were analyzed from March to July 2024.
The Walter Index, a score based on 6 risk factors (male sex, dependent activities of daily living at discharge, heart failure, cancer, high creatinine level, and low albumin level), was calculated to assess its predictive accuracy for 12-month mortality as well as 6-, 24-, and 48-month mortality. The study investigated whether incorporating delirium, frailty, or C-reactive protein level enhanced accuracy. Performance was assessed using discrimination, calibration, and clinical utility measures.
In total, 2780 participants (mean [SD] age, 81 [7] years; 1795 [65%] female) were included, with 89 (3%) lost to follow-up. The 12-month posthospitalization mortality rate was 23% (646 participants). Mortality was 7% (47 of 634) in the lowest-risk group (0-1 point), 17% (111 of 668) for 2 to 3 points, 25% (198 of 803) for 4 to 6 points, and 43% (290 of 675) in the highest-risk group (≥7 points). The index demonstrated an area under the receiver operating characteristic curve (AUC) of 0.714 (95% CI, 0.691-0.736) for predicting 12-month posthospitalization mortality (AUCs were 0.75 and 0.80 in the original derivation and validation cohorts, respectively). Comparable results were observed for mortality at 6 months (AUC, 0.726; 95% CI, 0.700-0.752), 24 months (AUC, 0.711; 95% CI, 0.691-0.730), and 48 months (AUC, 0.719; 95% CI, 0.700-0.738). Adding delirium modestly increased the index's discrimination (AUC, 0.723; 95% CI, 0.702-0.749); additionally including frailty and C-reactive protein level did not improve discrimination further (AUC, 0.723; 95% CI, 0.701-0.744).
In this prognostic study of hospitalized older adults in Brazil, the Walter Index showed similar discrimination in predicting postdischarge mortality as it did 2 decades ago in the US. These findings highlight the need for continuous validation and potential modification of established prognostic tools to improve their applicability across settings.
沃尔特指数是一种广泛用于评估住院老年人12个月死亡风险的预后工具。该指数于2001年在美国开发，其在当代非美国背景下的准确性尚不清楚。
评估沃尔特指数在预测巴西老年住院患者出院后死亡风险方面的外部有效性。
设计、设置和参与者：这项预后研究使用了2009年1月1日至2020年2月28日期间入住巴西一家大学医院老年科的70岁及以上成年人队列的数据。参与者在入院时接受了全面的老年评估，出院时进行了重新评估，随后进行了48个月的随访。数据于2024年3月至7月进行分析。
计算基于6个风险因素（男性、出院时日常生活依赖、心力衰竭、癌症、高肌酐水平和低白蛋白水平）的沃尔特指数得分，以评估其对12个月死亡率以及6个月、24个月和48个月死亡率的预测准确性。该研究调查了纳入谵妄、衰弱或C反应蛋白水平是否能提高准确性。使用区分度、校准度和临床效用指标评估性能。
总共纳入了2780名参与者（平均[标准差]年龄为81[7]岁；1795名[65%]为女性），其中89名（3%）失访。出院后12个月的死亡率为23%（646名参与者）。最低风险组（0 - 1分）的死亡率为7%（634名中的47名），2至3分的死亡率为17%（668名中的111名），4至6分的死亡率为25%（803名中的198名），最高风险组（≥7分）的死亡率为43%（675名中的290名）。该指数在预测出院后12个月死亡率时的受试者工作特征曲线下面积（AUC）为0.714（95%置信区间，0.691 - 0.736）（在原始推导队列和验证队列中的AUC分别为0.75和0.80）。在6个月（AUC，0.726；95%置信区间，0.700 - 0.752）、24个月（AUC，0.711；95%置信区间，0.691 - 0.730）和48个月（AUC，0.719；95%置信区间，0.700 - 0.738）的死亡率方面观察到了类似的结果。加入谵妄适度提高了该指数的区分度（AUC，0.723；95%置信区间，0.702 - 0.749）；另外纳入衰弱和C反应蛋白水平并未进一步提高区分度（AUC，0.723；95%置信区间，0.701 - 0.744）。
在这项针对巴西住院老年人的预后研究中，沃尔特指数在预测出院后死亡率方面显示出与20年前在美国时相似的区分度。这些发现凸显了持续验证和对既定预后工具进行潜在修改以提高其在不同环境中的适用性的必要性。
