Technology applied to geriatric medicine
The MPI_AGE European Project: Using Multidimensional Prognostic Indices (MPI) to improve cost-effectiveness of interventions in multimorbid frail older persons. Background, aim and design

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Abstract

Purpose

The MPI_AGE project is a multicenter project co-funded by the Executive Agency for Health and Consumers in the frame of Active and Healthy Ageing 2nd-Health Programme 2008–2013. Aim of the project is to implement Multidimensional Prognostic Indices (MPI) that predict survival, based on the Comprehensive Geriatric Assessment, in order to improve the cost-effectiveness of health interventions in frail older individuals with multimorbidity and polypharmacy.

Materials and methods

The project is divided in seven Work Packages (WP). WP1, WP2 and WP3 include the activities of coordination, evaluation and dissemination, respectively. WP4 is a retrospective analysis of clinical, functional and administrative data carried out in order to develop and validate MPI in community-dwelling older subjects. In WP5, the best cost-effective profile of different therapeutic interventions in older individuals with different MPI-based mortality risk profile will be identified. WP6 is a multicenter prospective study with a follow-up of 12 months carried out in 11 geriatric clinical centres with the aim of evaluating the usefulness of the MPI in the clinical decision making in patients with different mortality risk. In WP7, a systematic process of recommendations will be carried out through the wide involvement of partners, external experts and stakeholders in meetings and web diffusion.

Conclusions

Mortality risk may influence the effectiveness of specific treatments and interventions in frail older subjects with multimorbidity and polypharmacy. Clinicians and health policy makers need to consider the prognostic information obtained through the MPI to identify those setting-specific profiles of older subjects who may better benefit from interventions.

Introduction

Recent epidemiologic changes and the current economic crisis are challenging health-care systems to find innovative strategies and guarantee effective and appropriate health-care service delivery to older individuals with multimorbidity and polypharmacy. The clinical, functional and economic consequences of disability and multimorbidity are of great concern for older citizens, health professionals and policy makers. Innovative approaches, in fact, are needed in order to foster better efficiency of health-care systems while ensuring their accessibility and long-term financial sustainability. In this context, the prognosis of ill older individuals may assume a central role in identifying which kind of intervention is needed at best according to subject and his/her specific ambient setting. Indeed, the alignment of the metric used to assess prognosis with recommendations in clinical guidelines is strongly recommended to facilitate clinical decision making, especially in multimorbid frail older subjects [1]. Therefore, validated indices that predict mortality for older persons rigorously assessed for generalizability, accuracy, calibration and potential bias in different settings are urgently needed in public health systems.

Section snippets

The Multidimensional Prognostic Index (MPI)

The Multidimensional Prognostic Index (MPI) is a predictive tool for short- and long-term mortality initially developed and validated in hospitalized older subjects [2]. The development of the MPI bases upon a large body of evidence showing that the final prognosis of the older subject is mainly related to biological, clinical, functional, and social variables, i.e. to the multidimensional impairment of the individual [3]. The underpinning of the MPI is information collected during a standard

The MPI-SVaMA

Very recently, a modified MPI (MPI-Scheda per la Valutazione Multidimensionale delle persone adulte e anziane [MPI-SVaMA]) was developed and validated in over 12,000 community-dwelling older patients requiring care assistance (home services and/or nursing home admission) from an Italian Regional Health-Care System (HCS) [4]. To calculate the MPI-SVAMA, the following domains of the SVaMA were considered: (1) age, (2) sex, (3) main diagnosis, (4) Nursing Care Needs (VIP) evaluated according to a

MPI and MPI-SVaMA in clinical practice

The MPI has been successfully validated in over 15,000 older hospitalized patients suffering from major clinical conditions leading to death including gastrointestinal bleeding and liver cirrhosis [5], pneumonia [6], heart failure [7], chronic kidney disease [8], dementia [9], transient ischemic attack [10] and cancer [11]. In all these different clinical conditions, the MPI showed good accuracy in identifying older patients at different mortality risk with a mean Area Under Curve (AUC) or

Project objectives

The MPI_Age project aims to use setting-specific MPIs that predict mortality, based on a standard CGA, to improve the cost-effectiveness of health interventions in older individuals with multimorbidity and polypharmacy across a broad range of European Countries. To do so, an international consortium of geriatrics experts was summoned which is presented in detail below and is responsible for the performance of different tasks ultimately leading to the main scope of the project. A preliminary

Strategic relevance for the European Union

The strategic relevance of the project is related to it's potential impact in decreasing health-related costs while increasing cost-effectiveness of interventions, in order to assure an appropriate distribution of health resources according to the health needs of the older subjects. According to the Innovation Union Communication (IUC) launched by the European Commission (EU) in 2010, the multidimensional, multidisciplinary and predictive strategies proposed by the project give relevant

Partnership

The international partners were chosen on the basis of the presence of complementary skills within established international relationships and previous experience with EU funded projects as well as extensive clinical and research experiences. In this project, nine European countries with a homogeneous distribution (south, north, centre and east Europe) are directly involved as Associated Partners (APs) to assure a high level of representation in term of results and statistical power. The

Project design

The project has started in February 2014 and is being carried out in a period of three years. It is structurally divided in 7 work packages (WP) (Fig. 1). The WP1 “Coordination” and WP3 “Evaluation” include the activities of administration and monitoring throughout the project, while the WP2 “Dissemination” has the objectives to spread the results and the state of the project developing also the MPI_AGE website. This WP is done in cooperation with the European Union Geriatric Medicine Society

Expected outcomes

To address the project's general objective the following outcomes have been identified as target objective of the MPI_AGE project in five specific topics:

  • clinical decision making process, i.e. which interventions, identified according to the individual MPI-based prognostic risk profile, are the most effective to the individual older subjects;

  • health-care direct impacts, i.e. improvement of interdisciplinary interaction and collaboration to share integrated care pathways of intervention between

Summary

Retrospective data on hospitalized and community-dwelling subjects have shown that there are great differences among treatment strategies of older subjects with different risk of mortality [21]. Similarly, and as a consequence, the effectiveness of therapies may be significantly different in subjects displaying different risk of mortality [1]. Several studies demonstrate that interventions based on the CGA in older residents at home, in nursing homes or while hospitalized are effective in

Disclosure of interest

The authors declare that they have no conflicts of interest concerning this article.

Acknowledgements

The contributions of each authors are the following: Alberto Pilotto, Maria Cristina Polidori, Alfonso Cruz-Jentoft and Stefania Maggi: Study design, writing and reviewing the manuscript. Daniele Sancarlo: literature search and writing the manuscript. Francesco Mattace-Raso, Marc Paccalin, Eva Topinkova and Anna-Karin Welmer: reviewing process.

Funding source: This work was supported by the MPI_AGE European project co-funded by the Executive Agency for Health and Consumers (EAHC) in the frame of

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