Ronen Bareket (1)(3) Mara A. Schonberg (2) Doron Comaneshter (1) Yochai Schonmann (1)(3) Michal Shani (1)(3) Arnon Cohen (1)(4) Shlomo Vinker (1)(3)

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1 Automated Prediction of Life Expectancy? Schonberg index to Predict 5-9-year Mortality of Community-Dwelling Adults Aged 65 and Older: Validation for use with Electronic Medical Records in Israel Ronen Bareket (1)(3) Mara A. Schonberg (2) Doron Comaneshter (1) Yochai Schonmann (1)(3) Michal Shani (1)(3) Arnon Cohen (1)(4) Shlomo Vinker (1)(3) (1) Clalit Health Services, Israel (2) Division of General Medicine and Primary Care, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA. (3) Department of Family Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel (4) Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheba, Israel.

2 Benefit Will the test/medicine/procedure help? NNT / NNS/ ARR When will it help? Time to benefit (TTB)

3 Time to benefit Cancer Screening (BMJ 346 (2013): e8441) FOBT / Mammography 1 live per 1,000 screened for 10 years Tight glycemic control (Brit J Diabetes & Vascular Dis 8, 5 (2008): ) UKPDS follow up all cause mortality 30 years RRR=13% Diabetic Nephropathy (Kidney Int. 2003;63(1):225-32) UKPDS - Microalbuminuria > ~10years > Macroalbuminuria > ~10years > Renal Failure

4 Guidelines Screening for Cancer stop screening for CRC at >75 or in adults with a life expectancy <10 (Ann of Int Med 156, 5 (2012): ) Mammography Should Stop When life expectancy is <5 to 7 years (J. Am College of Radiology 7, 1 (2010): 18 27) Don t recommend cancer screening in adults with life expectancy of less than 10 years (Choosing Wisely - Society of General Internal Medicine)

5 Prediction of Life Expectancy - When? During the clinical encounter When applying quality measures Automatic (sending FOBT test by mail) During visit

6 Prediction of Life Expectancy - Calculator Validated schonberg mortality index Developed using self-reported data from the US national health interview survey Community dwelling adults first 5 then 9 years J Gen Intern Med Oct;24(10): J Am Geriatr Soc Aug;59(8):

7 Schonberg mortality index Variable Age Gender Smoking BMI<25 Comorbidity Female Male Never Former Current COPD Diabetes Cancer Points J Gen Intern Med Oct;24(10): J Am Geriatr Soc Aug;59(8): Variable Overnight None 0 Hospitalizations Past Year One 1 Perceived Health Functional Measures Two or more Excellent / Very Good Good Fair / Poor Dependent in at least one IADL Difficulty walking several blocks Points

8 Schonberg mortality index J Gen Intern Med Oct;24(10): J Am Geriatr Soc Aug;59(8):

9 Study goals Validate schonberg score of predicted life expectancy using EHR data in israel

10 Methods

11 Data sources Clalit Health Services (CHS) data warehouse 4.3 million Patients - 52% of Israel Population Information on the utilization of health care services, drug purchases, laboratory and imaging tests a Wide-scale registry of chronic diagnoses

12 Study population Beginning of 2011 till end of 2015 All community dwelling HMO members ages 65-79

13 Proxies for subjective questions Variable Points Proxy Overnight None 0 Hospitalizations Past Year One 1 Two or more 3 Perceived Health Excellent / Very Good Good 0 1 Charlson score Annals of Fam Med 10, 2 (March 1, 2012): Fair / Poor 2 Functional Measures Dependent in at least one IADL 2 elderly nursing eligibility / Hx of a functional limitation Difficulty walking several blocks 3 positive Get up and Go / Norton >16 / home support J Gen Intern Med Oct;24(10): J Am Geriatr Soc Aug;59(8):

14 Can we trust data from 2011?

15 Results 341,187 - patients ages ,489 (4.2%) insufficient data for schonberg score 326,698 participants

16

17 Israel vs US by age group

18 Israel vs US by risk quintile 0.2

19 Israel vs US - distribution

20 Questionnaire vs Electronic Israel over estimation of morbidity by objective proxies? US under estimation of morbidity recall bias?

21 Health system differences Different life expectancy at 65 (OECD, Life expectancy at 65 (indicator) 2013 data) Access to care (Israel) Home care Free primary + secondaty care + hostpitalization Cheaper medications / tests / interventions Country Men Women Israel United States

22 Ethical consideration

23 Conclusion Israeli Modified Schonberg score 12 ~ US Schonberg Score 10 25% 5 years mortality 50% 9 years mortality 12% of Israeli population Next - Small cohort from 2006 Sufficient for Schonberg score calculation Examine If 25% 5 years mortality represents 50% 9 years mortality

24 Thank you