Prediction value of the LACE index to identify older adults at high risk for all-cause mortality in South Korea: a nationwide population-based study

Association Between LACE+ Index Risk Category and 90-Day Mortality After Stroke

Background and Objectives

A higher LACE+ index risk category (defined as LACE+ score ≥78) typically calculated before hospital discharge has been associated with increased risk of unplanned 30-day hospital readmissions and early death after hospital discharge. However, its utility to predict poststroke mortality is unknown. Here, we examined whether the LACE+ index risk category assessed at both discharge (dLACE+) and admission (aLACE+) was associated with 90-day mortality after stroke.

Methods

We retrospectively analyzed 2,729 consecutive patients who presented with ischemic or hemorrhagic strokes, included in an institutional stroke registry between January 2018 and December 2021. The primary outcome of interest was 90-day mortality after the index hospitalization. Patients were categorized as high-risk (≥78), medium-to-high-risk (59-77), and low-to-medium-risk (0-58) according to the LACE+ as automatically calculated at admission and discharge. Analyses were performed on the entire cohort, as well as stratified according to acute ischemic stroke and hemorrhagic stroke diagnosis.

Results

Among patients who completed 90-day follow-up, the mortality rate was 24.3% (576/2368). In the Kaplan-Meier analysis, the high-risk aLACE+ group had the highest 90-day mortality rate as compared with low-to-medium-risk and medium-to-high-risk groups (p < 0.001). In a fully adjusted multivariable Cox-regression, the 90-day hazards of death were significantly greater among participants in a high-risk aLACE+ (aHR 1.7, 95% CI 1.080-2.742, p = 0.022) and medium-to-high-risk aLACE+ categories (aHR 1.4, 95% CI 1.141-1.778, p = 0.002) as compared with participants in the low-to-medium-risk aLACE+ category. Results were overall similar for dLACE+.

Discussion

The LACE+ calculated at both admission and discharge admission identified patients with stroke at increased risk for 90-day mortality. Future studies are warranted to determine whether LACE+ score-based risk stratification can be used to devise early interventions to mitigate the risk for death.

High LACE index scores are associated with disproportionate excess deaths in hospital amongst patients with COVID-19

Risk factors for COVID-19-related outcomes have been variably reported. We used the standardised LACE index to examine admissions and in-hospital mortality associated with COVID-19. Data were collected in the pre-pandemic period (01-04-2019 to 29-02-2020) from 10,173 patients (47.7% men: mean age ± standard deviation = 68.3 years ± 20.0) and in the pandemic period (01-03-2019 to 31-03-2021) from 12,434 patients. With the latter, 10,982 were without COVID-19 (47.4% men: mean age = 68.3 years ± 19.6) and 1452 with COVID-19 (58.5% men: mean age = 67.0 years ± 18.4). Admissions and mortality were compared between pre-pandemic and pandemic patients, according to LACE index. Admission rates rose disproportionately with higher LACE indices amongst the COVID-19 group. Mortality rates amongst the pre-pandemic, pandemic non-COVID-19 and COVID-19 groups with LACE index scores < 4 were 0.7%, 0.5%, 0%; for scores 4-9 were 5.0%, 3.7%, 8.9%; and for scores ≥ 10 were: 24.2%, 20.4%, 43.4%, respectively. The area under the curve receiver operating characteristic for predicting mortality by LACE index was 76% for COVID-19 and 77% for all non-COVID-19 patients. The risk of age and sex-adjusted mortality did not differ from the pre-pandemic group for COVID-19 patients with LACE index scores < 4. However, risk increased drastically for scores from 4 to 9: odds ratio = 3.74 (95% confidence interval = 2.63-5.32), and for scores ≥ 10: odds ratio = 4.02 (95% confidence interval = 3.38-4.77). In conclusion, patients with LACE index scores ≥ 4 have disproportionally greater risk of COVID-19 hospital admissions and deaths, in support of previous studies in patients without COVID-19. However, of importance, our data also emphasise their increased risk in patients with COVID-19. Because the LACE index has a good predictive power of mortality, it should be considered for routine use to identify high-risk COVID-19 patients.