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Predicting Future Functional Status for Seriously Ill Hospitalized Adults: The SUPPORT Prognostic Model

Albert W. Wu, MD, MPH; Anne M. Damiano, MD, MA; Joanne Lynn, MS; Carlos Alzola, MS; Joan Teno, MD, MS; C. Seth Landefeld, MD; Norman Desbiens, MD; Joel Tsevat, MD, PhD; Alison Mayer-Oakes, MD; Frank E. Harrell, PhD; and William A. Knaus, MD
[+] Article and Author Information

From Johns Hopkins University, Baltimore, Maryland. Dartmouth Medical School, Hanover, New Hampshire. Duke University Medical Center, Durham, North Carolina. Case Western Reserve University School of Medicine, Cleveland, Ohio. Marshfield Medical Research Foundation, Marshfield, Wisconsin. Beth Israel Hospital, Boston, Massachusetts. The University of California, Los Angeles, School of Medicine. The George Washington University Medical Center, Washington, D.C. Requests for Reprints: Albert W. Wu, MD, MPH, Health Services Research and Development Center, the Johns Hopkins University, 624 North Broadway, Baltimore, MD 21205-1901. Disclaimer: The opinions and findings contained in this article are those of the authors and do not necessarily represent the views of the Robert Wood Johnson Foundation or their Board of Trustees. Acknowledgments: The authors thank the late Marilyn Bergner, PhD, for her contributions to this study. She inspired our efforts to assess and improve the health status of patients. Grant Support: In part by the Robert Wood Johnson Foundation.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1995;122(5):342-350. doi:10.7326/0003-4819-122-5-199503010-00004
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Objective: To develop a model estimating the probability of an adult patient having severe functional limitations 2 months after being hospitalized with one of nine serious illnesses.

Design: Prospective cohort study.

Setting: Five teaching hospitals in the United States.

Participants: 1746 patients (model development) who survived 2 months and completed an interview, selected from 4301 patients in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT); independent validation sample of 2478 patients.

Measurements and Main Outcomes: Patient function 2 months after admission categorized as absence or presence of severe functional limitations (defined as Sickness Impact Profile scores ≥ 30 or as activities of daily living scores ≥ 4 [levels that require near-constant personal assistance]). A logistic regression model was constructed to predict severe functional limitation.

Results: One third (n = 590) of patients who were interviewed at 2 months had severe functional limitations. Changes in functional status were common: Of those with no baseline dependencies (not dependent on personal assistance), 21% were severely limited at 2 months; of those with 4 or more baseline limitations, 30% had improved. The patient's ability to do activities of daily living was the most important predictor of functional status. Physiologic abnormalities, diagnosis, days in hospital, age, quality of life, and previous exercise capacity also contributed substantially. Model performance, assessed using receiver-operating characteristic curves, was 0.79 for the development sample and 0.75 for the validation sample. The model was well calibrated for the entire risk range.

Conclusions: Functional outcome varied substantially after hospitalization for a serious illness. A small amount of readily available clinical information can estimate the probability of severe functional limitations.

Figures

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Figure 2.
Calibration curves.Top.Bottom.

In both panels, the solid line denotes perfect calibration between observed frequency and predicted risk for severe functional limitations 2 months after hospitalization. The dotted line indicates actual calibration. Data for 1746 seriously ill patients in the model development sample. Data for 2478 seriously ill patients in the independent validation sample. The histogram provides the distribution of actual patients. ROC = receiver-operating characteristic.

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Figure 3.
Distribution of limitations in activities of daily living at 2 months with baseline limitations.

Numbers above the bars indicate the number of limitations at 2 months. Increases in the proportion of patients with four or more limitations at 2 months are associated with more baseline limitations. ADL = activities of daily living.

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Figure 4.
Phase II feedback form.

Sample format presenting prognostic information about survival and functional status to physicians in the intervention phase of SUPPORT. The patient is a 49-year-old man with liver cirrhosis (disease group), and the prognostic estimates are for day 7 of the study. The solid line indicates the predicted mortality rate with 95% CIs. The + sign is the probability of surviving with severe functional limitations 2 months after hospitalization. The probability of not being severely dysfunctional at 2 months if the patient survives is 0.12 (95% CI, 0.06 to 0.25).

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