A screening instrument to identify older community-dwellers at risk for death and hospitalization in Tuscany, Italy. The 'Assistenza Socio-Sanitaria in Italia' project

With targeted interventions, health status of frail older persons could be improved, yet many of these subjects remain undetected in the community. We aimed at validating a screening instrument to identify, in a primary care setting, older community-dwellers at an increased risk for death and hospitalization.The “Assistenza Socio-Sanitaria in Italia” (ASSI) project is a 2-phase prospective cohort study of older persons (65+ years), randomly selected from the lists of 98 general practitioners (GP) in Florence. At 2003 baseline, GP provided data on demographics and health status of 5,445 screenees, with a structured questionnaire that investigated the presence of: 1) need of help in performing Basic and 2) Instrumental Activities of Daily Living (BADL,IADL); 3) poor vision; 4) poor hearing; 5) weight loss; 6) use of homecare services; 7) self-perceived inadequacy of income. Two or more affirmative answers gave access to phase II of the study, based on personal interview. A record linkage procedure with Tuscany healthcare administrative databases allowed collection of follow-up data on mortality and hospitalizations through March, 2004. On a total of 6,590 person-years (p-y) of observations, 225 deaths were observed. Mortality was 2, 11, and 31 per 100 p-y in participants who scored 0-1, 2-3 and 4+ at the screening questionnaire, respectively (p<0.001). Compared with participants who scored 0-1, the hazard of death was 3.3 (95% CI 2.3-4.7) and 8.4 (5.7-12.3) in those who scored 2-3 and 4+ in age-, sex-, and place of residence adjusted Cox’s survival analysis, respectively. Through the end of the follow-up, 949 (17.6%) participants had been hospitalized, 15.4% of those who screened negative and 35.4% of those who screened positive (p<0.001); in the latter, the adjusted HR (95% CI) for hospitalization was 2.8 (2.1-3.7). In conclusion, frail older community dwellers, at risk for death and hospital admission, can be easily and validly identified at a primary care lev