Predicting Mortality and Adverse Outcomes: Comparing the Frailty Index to General Prognostic Indices

J Gen Intern Med. 2020 May;35(5):1516-1522. doi: 10.1007/s11606-020-05700-w. Epub 2020 Feb 18.


Background: Mortality prediction models are useful to guide clinical decision-making based on prognosis. The frailty index, which allows prognostication and personalized care planning, has not been directly compared with validated prognostic models.

Objective: To compare the discrimination of mortality, disability, falls, and hospitalization between a frailty index and validated prognostic indices.

Design: Secondary Analysis of the National Health and Aging Trends Study.

Participants: Seven thousand thirty-three Medicare beneficiaries 65 years or older.

Measurements: We measured a deficit-accumulation frailty index, Schonberg index, and Lee index at the 2011 baseline assessment. Primary outcome was mortality at 5 years. Secondary outcomes were decline in activities of daily living (ADL), decline in instrumental activities of daily living (IADL), fall, and hospitalization at 1 year. We used C-statistics to compare discrimination between indices, adjusting for age and sex.

Results: The study population included 4146 (44.8%) with age ≥ 75 years, with a median frailty index of 0.15 (interquartile range 0.09-0.25). A total of 1385 participants died (14.7%) and 2386 (35.2%) were lost to follow-up. Frailty, Schonberg, and Lee indices predicted mortality similarly: C-statistics (95% confidence interval) were 0.78 (0.77-0.80) for frailty index; 0.79 (0.78-0.81) for Schonberg index; and 0.78 (0.77-0.80) for Lee index. The frailty index had higher C-statistics for decline in ADL function (frailty index, 0.80 [0.78-0.83]; Schonberg, 0.74 [0.72-0.76]; Lee, 0.74 [0.71-0.77]) and falls (frailty index, 0.66 [0.65-0.68]; Schonberg, 0.61 [0.58-0.63]; Lee, 0.61 [0.59-0.63]). C-statistics were similar for decline in IADL function (frailty index, 0.61 [0.59-0.63]; Schonberg, 0.60 [0.59-0.62]; Lee, 0.60 [0.58-0.62]) and hospitalizations (frailty index, 0.68 [0.66-0.70]; Schonberg, 0.68 [0.66-0.69]; Lee, 0.65 [0.63-0.67]).

Conclusions: A deficit-accumulation frailty index performs as well as prognostic indices for mortality prediction, and better predicts ADL disability and falls in community-dwelling older adults. Frailty assessment offers a unifying approach to risk stratification for key health outcomes relevant to older adults.

Keywords: disability; frailty; mortality; prediction; prognostication.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Activities of Daily Living
  • Aged
  • Frail Elderly
  • Frailty* / diagnosis
  • Geriatric Assessment
  • Humans
  • Independent Living
  • Medicare
  • Prognosis
  • United States / epidemiology