Abstract
ObjectivesTo develop and validate a prognostic model to predict deterioration in health-related quality of life (dHRQoL) in older general practice patients with at least one chronic condition and one chronic prescription. Study Design and SettingWe used individual participant data from five cluster-randomized trials conducted in the Netherlands and Germany to predict dHRQoL, defined as a decrease in EQ-5D-3 L index score of ≥5% after 6-month follow-up in logistic regression models with stratified intercepts to account for between-study heterogeneity. The model was validated internally and by using internal–external cross-validation (IECV). ResultsIn 3,582 patients with complete data, of whom 1,046 (29.2%) showed deterioration in HRQoL, and 12/87 variables were selected that were related to single (chronic) conditions, inappropriate medication, medication underuse, functional status, well-being, and HRQoL. Bootstrap internal validation showed a C-statistic of 0.71 (0.69 to 0.72) and a calibration slope of 0.88 (0.78 to 0.98). In the IECV loop, the model provided a pooled C-statistic of 0.68 (0.65 to 0.70) and calibration-in-the-large of 0 (−0.13 to 0.13). HRQoL/functionality had the strongest prognostic value. ConclusionThe model performed well in terms of discrimination, calibration, and generalizability and might help clinicians identify older patients at high risk of dHRQoL. RegistrationPROSPERO ID: CRD42018088129.
Highlights
In aging populations, the increased incidence and severity of multiple conditions leads to deterioration in health-related quality of life [1]
We harmonized individual participant data (IPD) from five cluster-randomized trials that were conducted in the Netherlands and Germany between 2009 and 2012 to optimize pharmacological treatment in older chronically ill patients (Supplemental Table 1)
Of all eligible 4,561 patients from the PROPERmed database for whom multiple imputation datasets were available, 3,582 patients with full data for all candidate prognostic variables were included in the complete-case population (Figure 1)
Summary
The increased incidence and severity of multiple (chronic) conditions (two or more) leads to deterioration in health-related quality of life (dHRQoL) [1]. Patients with multiple conditions usually have several drug prescriptions (five or more), which increases the risk of overuse, underuse and misuse of medications [2] Potential consequences, such as falls, cognitive decline, loss of autonomy, and hospital admissions, are often severe and may contribute to dHRQoL, a key patient-reported outcome and one of the most relevant in older life [3,4,5]. Complex drug regimens and high treatment burden make the management of multimorbidity a significant challenge for physicians [6]. They are expensive for health care systems worldwide because they lead to an increase of health care utilization and cost [7]. Risk stratification may help allocate resources to the high-risk patients that are expected to benefit most from targeted interventions [10,11,12]
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