External validation of the Hospital-patient One-year Mortality Risk (HOMR) model for predicting death within 1 year after hospital admission

Background:

Predicting long-term survival after admission to hospital is helpful for clinical, administrative and research purposes. The Hospital-patient One-year Mortality Risk (HOMR) model was derived and internally validated to predict the risk of death within 1 year after admission. We conducted an external validation of the model in a large multicentre study.

Methods:

We used administrative data for all nonpsychiatric admissions of adult patients to hospitals in the provinces of Ontario (2003–2010) and Alberta (2011–2012), and to the Brigham and Women’s Hospital in Boston (2010–2012) to calculate each patient’s HOMR score at admission. The HOMR score is based on a set of parameters that captures patient demographics, health burden and severity of acute illness. We determined patient status (alive or dead) 1 year after admission using population-based registries.

Results:

The 3 validation cohorts (n = 2 862 996 in Ontario, 210 595 in Alberta and 66 683 in Boston) were distinct from each other and from the derivation cohort. The overall risk of death within 1 year after admission was 8.7% (95% confidence interval [CI] 8.7% to 8.8%). The HOMR score was strongly and significantly associated with risk of death in all populations and was highly discriminative, with a C statistic ranging from 0.89 (95% CI 0.87 to 0.91) to 0.92 (95% CI 0.91 to 0.92). Observed and expected outcome risks were similar (median absolute difference in percent dying in 1 yr 0.3%, interquartile range 0.05%–2.5%).

Interpretation:

The HOMR score, calculated using routinely collected administrative data, accurately predicted the risk of death among adult patients within 1 year after admission to hospital for nonpsychiatric indications. Similar performance was seen when the score was used in geographically and temporally diverse populations. The HOMR model can be used for risk adjustment in analyses of health administrative data to predict long-term survival among hospital patients.The life expectancy of individual patients can be important for both medical decision-making and research. Patients with a short life expectancy may choose to defer preventive treatments, screening interventions or interventional procedures for conditions that are currently asymptomatic. An accurate assessment of risk of death, particularly if that risk is high, could motivate and inform discussions between patients and physicians regarding goals of care. In addition, accurate prognostications are essential for adjusting statistical models that have death as an outcome (or as a competing risk for other outcomes) in both research and administration.We recently derived and internally validated a model that predicts the risk of death from any cause at 1 year after admission to hospital.¹ The Hospital-patient One-year Mortality Risk (HOMR) model consists of covariates whose values are determined at admission using routinely collected health administrative data (Figure 1). These covariates include patient demographics (age, sex and living status); health burden (measured using the Charlson Comorbidity Index score, home oxygen status and the number of visits to emergency departments and admissions to hospital by ambulance in the previous year); and acuity of illness (admission urgency and hospital service, direct admission to an intensive care unit and whether the admission was an urgent readmission to hospital). The latter category was also gauged using the Diagnostic Risk Score, which quantifies risk of death for particular diagnoses beyond that explained by the other covariates (Appendix 1, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.150209/-/DC1).Open in a separate windowFigure 1:Covariates used to calculate a patient’s Hospital-patient One-year Mortality Risk (HOMR) score at the time of admission to hospital. The Diagnostic Risk Score (Appendix 1) quantifies risk of death for diagnostic groups beyond that explained by the other covariates. Points for the interacting covariates of age and Charlson Comorbidity Index score include the risk of patient age, comorbidity score and their interaction. In contrast, points for living status and admission urgency include the risk of these covariates and their interaction with admissions by ambulance in the previous year; points for the latter covariate are considered separately. See www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.150209/-/DC1)Discrete values for each covariate are given specific points, which are summed to create the HOMR score (Figure 1). In an internal validation population, the HOMR score accurately predicted the risk of death from any cause within 1 year after admission, with a C statistic of 0.92 and excellent calibration among adult residents of Ontario admitted to hospital for nonpsychiatric indications in 2011.¹Although these statistics are impressive, external validation is required to determine the true usefulness of any statistical model. External validation is necessary to prove that the model’s performance is not idiosyncratic to the patients, physicians, institutions or data systems used to derive and internally test it.^2,3 A prognostic model should remain accurate when retested with different patients (reproducibility), during different periods (historical transportability) and in different locations (geographic transportability).⁴ We conducted an external validation of the HOMR model in a multicentre study that included Canadian and American hospitals.     

Availability of optimal‐sized prey affects global distribution patterns of the golden eagle Aquila chrysaetos

Climate and landscape change are expected to significantly affect trophic interactions, which will especially harm top predators such as the golden eagle Aquila chrysaetos. Availability of optimal prey is recognized to influence reproductive success of raptors on a regional scale. For the golden eagle, medium‐sized prey species between 0.5 and 5 kg are widely considered to be optimal prey during the breeding season, whereas smaller and larger species are deemed as energetically sub‐optimal. However, knowledge about the effects of optimal prey availability is still scarce on larger scales. To decrease this apparent knowledge gap, we combined biogeographical information on range margins with information about the foraging behaviour and reproductive success of golden eagles from 67 studies spanning the Northern Hemisphere. We hypothesized that availability of optimal prey will affect foraging behaviour and breeding success and, thus, distribution patterns of the golden eagle not only on a local but also on a continental scale. We correlated the diet breadth quantifying foraging generalism, breeding success and proportions of small (< 0.5 kg), medium (0.5–5 kg) and large‐sized (> 5 kg) prey species within the diet with the minimum distance of the examined eagles to the actual species distribution boundary. Closer to the range edge, we observed decreased proportions of medium‐sized prey species and decreasing breeding success of golden eagles. Diet breadth as well as proportions of small and large‐sized prey species increased, however, towards the range edge. Thus, availability of optimal‐sized prey species seems to be a crucial driver of foraging behaviour, breeding success and distribution of golden eagles on a continental scale. However, underlying effects of landscape characteristics and human influence on optimal prey availability has to be investigated in further large‐scale studies to fully understand the major threats facing the golden eagle and possibly other large terrestrial birds of prey.     

Testing assumptions of central place foraging theory: a study of Adélie penguins Pygoscelis adeliae in the Ross Sea

We investigated central place foraging (CPF) in the context of optimal foraging theory in Adélie penguins Pygoscelis adeliae of the southern Ross Sea by using satellite tracking and time‐depth recorders to explore foraging at two spatio‐temporal scales: within the day‐to‐day (sub‐mesoscale: single foraging trip, 10s of km²) and the entire breeding season (mesoscale: trips by multiple individuals across the collective foraging area, 100s of km²). Specifically, we examine whether three basic assumptions of the Orians–Pearson CPF model, shown to occur in other CPF species, are met: 1) within a patch, the rate of prey acquisition declines with time spent in that patch; 2) food is distributed in discrete patches and is not available between those patches; and 3) CPF species have knowledge of the potential (or average, at least) feeding rate within their universe of patches, and use this knowledge to determine their foraging strategy when planning or engaging in a foraging trip. We found that prey consumption rates did not decline with time spent in patches, and penguins foraged to some degree most of the time when at sea. Food availability, as measured by foraging dive rate, appeared to be predictable within the same day at the same location, but predictability broke down after 2 d at distances > 10 km away. We conclude that the assumptions of the Orians–Pearson CPF model are not a good fit to the circumstances of Ross Sea penguins, which clearly are central place foragers.     

Oxidative stress conditions increase the frequency of de novo formation of the yeast [PSI+] prion

Prions are self‐perpetuating amyloid protein aggregates which underlie various neurodegenerative diseases in mammals and heritable traits in yeast. The molecular basis of how yeast and mammalian prions form spontaneously into infectious amyloid‐like structures is poorly understood. We have explored the hypothesis that oxidative stress is a general trigger for prion formation using the yeast [PSI⁺] prion, which is the altered conformation of the Sup35 translation termination factor. We show that the frequency of [PSI⁺] prion formation is elevated under conditions of oxidative stress and in mutants lacking key antioxidants. We detect increased oxidation of Sup35 methionine residues in antioxidant mutants and show that overexpression of methionine sulphoxide reductase abrogates both the oxidation of Sup35 and its conversion to the [PSI⁺] prion. [PSI⁺] prion formation is particularly elevated in a mutant lacking the Sod1 Cu,Zn‐superoxide dismutase. We have used fluorescence microscopy to show that the de novo appearance of [PSI⁺] is both rapid and increased in frequency in this mutant. Finally, electron microscopy analysis of native Sup35 reveals that similar fibrillar structures are formed in both the wild‐type and antioxidant mutants. Together, our data indicate that oxidative stress is a general trigger of [PSI⁺] formation, which can be alleviated by antioxidant defenses.     

Native parasitoids and recovery of Spathius agrili from areas of release against emerald ash borer in eastern Tennessee,USA

The parasitoid Spathius agrili Yang, introduced in the USA to suppress populations of the emerald ash borer (EAB), Agrilus planipennis Fairmaire, has been recovered at a release site for the first time in eastern Tennessee after a single year of releases. Other native parasitoids, including Spathius floridanus Ashmead, undetermined species of Spathius (possibly Spathius elegans Matthews and Spathius parvulus Matthews) and Atanycolus cappaerti Marsh & Strazanac, also known to be associated with EAB, were recovered. These recoveries represent the first documentation of these four species, including the introduced S. agrili, associated with EAB in the southern USA. Implications for biological control efforts against EAB are discussed.     

Improvement of pea biomass and seed productivity by simultaneous increase of phloem and embryo loading with amino acids

The development of sink organs such as fruits and seeds strongly depends on the amount of nitrogen that is moved within the phloem from photosynthetic‐active source leaves to the reproductive sinks. In many plant species nitrogen is transported as amino acids. In pea (Pisum sativum L.), source to sink partitioning of amino acids requires at least two active transport events mediated by plasma membrane‐localized proteins, and these are: (i) amino acid phloem loading; and (ii) import of amino acids into the seed cotyledons via epidermal transfer cells. As each of these transport steps might potentially be limiting to efficient nitrogen delivery to the pea embryo, we manipulated both simultaneously. Additional copies of the pea amino acid permease PsAAP1 were introduced into the pea genome and expression of the transporter was targeted to the sieve element‐companion cell complexes of the leaf phloem and to the epidermis of the seed cotyledons. The transgenic pea plants showed increased phloem loading and embryo loading of amino acids resulting in improved long distance transport of nitrogen, sink development and seed protein accumulation. Analyses of root and leaf tissues further revealed that genetic manipulation positively affected root nitrogen uptake, as well as primary source and sink metabolism. Overall, the results suggest that amino acid phloem loading exerts regulatory control over pea biomass production and seed yield, and that import of amino acids into the cotyledons limits seed protein levels.     

Introgression between invasive and native blue mussels (genus Mytilus) in the central California hybrid zone

The ecological and genetic factors determining the extent of introgression between species in secondary contact zones remain poorly understood. Here, we investigate the relative importance of isolating barriers and the demographic expansion of invasive Mytilus galloprovincialis on the magnitude and the direction of introgression with the native Mytilus trossulus in a hybrid zone in central California. We use double‐digest restriction‐site‐associated DNA sequencing (ddRADseq) to genotype 1337 randomly selected single nucleotide polymorphisms and accurately distinguish early and advanced generation hybrids for the first time in the central California Mytilus spp. hybrid zone. Weak levels of introgression were observed in both directions but were slightly more prevalent from the native M. trossulus into the invasive M. galloprovincialis. Few early and advanced backcrossed individuals were observed across the hybrid zone confirming the presence of strong barriers to interbreeding. Heterogeneous patterns of admixture across the zone of contact were consistent with the colonization history of M. galloprovincialis with more extensive introgression in northern localities furthest away from the putative site of introduction in southern California. These observations reinforce the importance of dynamic spatial and demographic expansions in determining patterns of introgression between close congeners, even in those with high dispersal potential and well‐developed reproductive barriers. Our results suggest that the threat posed by invasive M. galloprovincialis is more ecological than genetic as it has displaced, and continues to displace the native M. trossulus from much of central and southern California.     

Phylogeographic structure and deep lineage diversification of the red alga Chondrus ocellatus Holmes in the Northwest Pacific

A major goal of phylogeographic analysis using molecular markers is to understand the ecological and historical variables that influence genetic diversity within a species. Here, we used sequences of the mitochondrial Cox1 gene and nuclear internal transcribed spacer to reconstruct its phylogeography and demographic history of the intertidal red seaweed Chondrus ocellatus over most of its geographical range in the Northwest Pacific. We found three deeply separated lineages A, B and C, which diverged from one another in the early Pliocene–late Miocene (c. 4.5–7.7 Ma). The remarkably deep divergences, both within and between lineages, appear to have resulted from ancient isolations, accelerated by random drift and limited genetic exchange between regions. The disjunct distributions of lineages A and C along the coasts of Japan may reflect divergence during isolation in scattered refugia. The distribution of lineage B, from the South China Sea to the Korean Peninsula, appears to reflect postglacial recolonizations of coastal habitats. These three lineages do not coincide with the three documented morphological formae in C. ocellatus, suggesting that additional cryptic species may exist in this taxon. Our study illustrates the interaction of environmental variability and demographic processes in producing lineage diversification in an intertidal seaweed and highlights the importance of phylogeographic approaches for discovering cryptic marine biodiversity.     

Improving Phenotypic Prediction by Combining Genetic and Epigenetic Associations

We tested whether DNA-methylation profiles account for inter-individual variation in body mass index (BMI) and height and whether they predict these phenotypes over and above genetic factors. Genetic predictors were derived from published summary results from the largest genome-wide association studies on BMI (n ∼ 350,000) and height (n ∼ 250,000) to date. We derived methylation predictors by estimating probe-trait effects in discovery samples and tested them in external samples. Methylation profiles associated with BMI in older individuals from the Lothian Birth Cohorts (LBCs, n = 1,366) explained 4.9% of the variation in BMI in Dutch adults from the LifeLines DEEP study (n = 750) but did not account for any BMI variation in adolescents from the Brisbane Systems Genetic Study (BSGS, n = 403). Methylation profiles based on the Dutch sample explained 4.9% and 3.6% of the variation in BMI in the LBCs and BSGS, respectively. Methylation profiles predicted BMI independently of genetic profiles in an additive manner: 7%, 8%, and 14% of variance of BMI in the LBCs were explained by the methylation predictor, the genetic predictor, and a model containing both, respectively. The corresponding percentages for LifeLines DEEP were 5%, 9%, and 13%, respectively, suggesting that the methylation profiles represent environmental effects. The differential effects of the BMI methylation profiles by age support previous observations of age modulation of genetic contributions. In contrast, methylation profiles accounted for almost no variation in height, consistent with a mainly genetic contribution to inter-individual variation. The BMI results suggest that combining genetic and epigenetic information might have greater utility for complex-trait prediction.