The MDS-CHESS scale: a new measure to predict mortality in institutionalized older people
Abstract
OBJECTIVES: To develop a scale predicting mortality and other adverse outcomes associated with frailty. DESIGN: Observational study based on Minimum Data Set (MDS) 2.0 and mortality data. SETTING: Ontario chronic hospitals. PARTICIPANTS: All chronic hospital patients (N = 28,495) assessed with the MDS 2.0 after mandatory implementation in July 1996 followed until May 1999. MEASUREMENTS: MDS 2.0 assessments done as part of normal practice mainly by registered nurses or multidisciplinary teams in a chronic hospital. Mortality data are available from the accompanying discharge tracking form. RESULTS: The MDS‐Changes in Health, End‐stage disease and Symptoms and Signs (CHESS) score is a composite measure addressing changes in health, end‐stage disease, and symptoms and signs of medical problems. It is a strong predictor of mortality ( P < . 0001) independent of the effects of age, sex, activities of daily living impairment, cognition, and do‐not‐resuscitate orders. It is also strongly associated with physician activity, complex medical procedures, and pain ( P < . 001 for each dependent variable). CONCLUSIONS: The CHESS score provides a useful new MDS‐based test to predict mortality and to measure instability in health as a clinical outcome.
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Frail older people receiving inpatient CGA are more likely to return home, less likely to experience cognitive or functional decline, and have lower in-hospital mortality.
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Comprehensive geriatric assessment, provided it is closely linked to interventions, is associated with superior outcomes.
“The process, provided it is closely linked to interventions, is associated with superior outcomes (111)”
From Frailty in elderly people (2013) · cites this paper as [111]
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“…(morris et al. 1994), the depression Rating scale (dRs) (Burrows et al. 2000; Koehler et al. 2005; martin et al. 2008), the Changes in Health, End-stage disease, and signs and symptoms (CHEss) scale (Hirdes et al. 2003) and the method for Assigning Priority Levels (mAPLe) (Hirdes et al. 2008b).”
MethodSelf-citationDosa, D. M., Feng, Z., Hyer, K., Brown, L. M., Thomas, K. S., & Mor, V. (2010) · Disaster Medicine and Public Health Preparedness · doi:10.1001/dmp.2010.11 · Cited by 71 · see citing works
Predictors of Nursing Home Placement from Assisted Living Settings in Canada
Maxwell, C. J., Soo, A., Hogan, D. B., Wodchis, W. P., Gilbart, E., Amuah, J. E., Eliasziw, M., Hagen, B. F., & Strain, L. A. (2013) · Canadian Journal on Aging / La Revue canadienne du vieillissement · doi:10.1017/s0714980813000469 · Cited by 70 · see citing works
“A higher score has been shown to predict mortality, institutionalization, and hospitalization among seniors (Hirdes et al., 2003 , Hogan et al., 2012 ).”
BackgroundSeale, E., Reaume, M., Batista, R., Eddeen, A. B., Roberts, R. L., Rhodes, E., McIsaac, D. I., Kendall, C., Sood, M. M., Prud’homme, D., et al. (2022) · Canadian Medical Association Journal · doi:10.1503/cmaj.212155 · Cited by 69 · see citing works
The Effect of Wheelchair Use on the Quality of Life of Persons with Multiple Sclerosis
Devitt, R., Chau, B., & Jutai, J. W. (2004) · Occupational Therapy In Health Care · doi:10.1080/j003v17n03_05 · Cited by 69 · see citing works
Do hospital-owned skilled nursing facilities provide better post-acute care quality?
Rahman, M., Norton, E. C., & Grabowski, D. C. (2016) · Journal of Health Economics · doi:10.1016/j.jhealeco.2016.08.004 · Cited by 69 · see citing works
Pain among the oldest old in community and institutional settings
Życzkowska, J., Szczerbińska, K. E., Jantzi, M., & Hirdes, J. P. (2007) · Pain · doi:10.1016/j.pain.2006.12.009 · Cited by 68 · see citing works
“The CHESS scale (Changes in Health, End-stage disease, and Signs and Symptoms) identifies individuals at risk of mortality or serious decline in health using scores ranging from 0 to 5 to depict the level of instability in health (Hirdes et al., 2003).”
Self-citationSzczerbińska, K. E., Hirdes, J. P., & Życzkowska, J. (2011) · American Journal of Geriatric Psychiatry · doi:10.1097/jgp.0b013e3182331702 · Cited by 66 · see citing works
Self-citationCOVID-19 excess mortality among long-term care residents in Ontario, Canada
Akhtar‐Danesh, N., Baumann, A. O., Crea‐Arsenio, M., & Antonipillai, V. (2022) · PLoS ONE · doi:10.1371/journal.pone.0262807 · Cited by 67 · see citing works
“The following variables were included in the analysis for each resident: result of last COVID19 test (positive or negative from March 2020); region of Ontario (Central, Southwest, East, North); income quintile based on postal code of the LTC home; frailty index (classified as robust, pre-frail, frail); ownership categ…”
MethodOgarek, J. A., McCreedy, E. M., Thomas, K. S., Teno, J. M., & Gozalo, P. L. (2018) · Journal of the American Geriatrics Society · doi:10.1111/jgs.15305 · Cited by 66 · see citing works
“In addition to updating the score to include items available in the current version of the MDS, our methods addressed 2 of the limitations previously identified.(1) First, the original scale was developed using a cohort of fewer than 30,000 people being treated in complex continuing care (CCCs) hospitals in Ontario, C…”
MethodInfluentialRehabilitation in Home Care Is Associated With Functional Improvement and Preferred Discharge
Cook, R. J., Berg, K., Lee, K., Poss, J. W., Hirdes, J. P., & Stolee, P. (2013) · Archives of Physical Medicine and Rehabilitation · doi:10.1016/j.apmr.2012.12.024 · Cited by 64 · see citing works
Self-citationLee, J. S. W., Chau, P. H., Hui, E., Chan, F. H.-W., & Woo, J. (2009) · European Journal of Public Health · doi:10.1093/eurpub/ckp006 · Cited by 63 · see citing works
Burn, R., Hubbard, R. E., Scrase, R. J., Abey‐Nesbit, R., Peel, N. M., Schlüter, P. J., & Jamieson, H. A. (2018) · BMC Geriatrics · doi:10.1186/s12877-018-1016-8 · Cited by 63 · see citing works
Hirdes, J. P., Freeman, S., Smith, T. F., & Stolee, P. (2012) · Palliative & Supportive Care · doi:10.1017/s1478951511000824 · Cited by 60 · see citing works
“The Changes in Health, End Stage disease, Signs and Symptoms (CHESS) scale is a measure of medical instability with scores ranging from 0 ¼ no instability to 5 ¼ highly unstable, and it has been shown to be highly predictive of mortality (Hirdes et al., 2003).”
BackgroundSelf-citationAkbar, U., McQueen, R. B., Bemski, J., Carter, J., Goy, E., Kutner, J. S., Johnson, M. J., Miyasaki, J. M., & Kluger, B. M. (2021) · Journal of Neurology Neurosurgery & Psychiatry · doi:10.1136/jnnp-2020-323939 · Cited by 59 · see citing works
Bliss, D. Z., Mathiason, M. A., Gurvich, O. V., Savik, K., Eberly, L. E., Fisher, J. M., Wiltzen, K. R., Akermark, H., Hildebrandt, A., Jacobson, M., et al. (2017) · Journal of Wound Ostomy and Continence Nursing · doi:10.1097/won.0000000000000313 · Cited by 59 · see citing works
Prevalence of Incontinence by Race and Ethnicity of Older People Admitted to Nursing Homes
Bliss, D. Z., Harms, S. L., Garrard, J. M., Cunanan, K. M., Savik, K., Gurvich, O. V., Mueller, C., Wyman, J. F., Eberly, L. E., & Virnig, B. A. (2013) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2013.03.007 · Cited by 58 · see citing works
Mortality in Nursing Homes Following Emergency Evacuation: A Systematic Review
Willoughby, M., Kipsaina, C., Ferrah, N., Blau, S., Bugeja, L. C., Ranson, D., & Ibrahim, J. (2017) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2017.02.005 · Cited by 58 · see citing works
Dosa, D. M., Skarha, J., Peterson, L. J., Jester, D. J., Sakib, N., Ogarek, J. A., Thomas, K. S., Andel, R., & Hyer, K. (2020) · JAMA Network Open · doi:10.1001/jamanetworkopen.2020.19460 · Cited by 58 · see citing works
Kim, H., Jung, Y., & Kwon, S. (2015) · Health Policy · doi:10.1016/j.healthpol.2015.07.009 · Cited by 54 · see citing works
Fehnel, C. R., Lee, Y., Wendell, L. C., Thompson, B., Potter, N., & Mor, V. (2015) · Journal of the American Heart Association · doi:10.1161/jaha.115.002145 · Cited by 54 · see citing works
“The cognitive performance scale is a 7-category hierarchical scale, which correlates closely with the Mini-Mental State Exam, as well as diagnoses of dementia.(37) The CHESS score is a 6-point ordinal scale ranging between 0 (no instability) to 5 and is an indicator of mortality and clinical stability among nursing ho…”
MethodFracture Risk in Nursing Home Residents Initiating Antipsychotic Medications
Rigler, S. K., Shireman, T. I., Cook‐Wiens, G., Ellerbeck, E. F., Whittle, J., Mehr, D. R., & Mahnken, J. D. (2013) · Journal of the American Geriatrics Society · doi:10.1111/jgs.12216 · Cited by 53 · see citing works
“Widely used, validated MDS scales were used to characterize cognitive performance (MDS Cognitive Performance Scale),(29) activities of daily living (the MDS hierarchical activities of daily living scale),(30) aggressive behavior (the MDS Aggressive Behavior Scale),(31) and mortality risk (the MDS CHESS mortality risk…”
MethodFreeman, S., Spirgienė, L., Martin‐Khan, M., & Hirdes, J. P. (2016) · Geriatrics and gerontology international/Geriatrics & gerontology international · doi:10.1111/ggi.12707 · Cited by 53 · see citing works
Self-citationArmstrong, J. J., Zhu, M., Hirdes, J. P., & Stolee, P. (2012) · Archives of Physical Medicine and Rehabilitation · doi:10.1016/j.apmr.2012.05.026 · Cited by 50 · see citing works
Self-citationAshworth, M., Hirdes, J. P., & Martin, L. (2008) · Research in Developmental Disabilities · doi:10.1016/j.ridd.2008.07.010 · Cited by 48 · see citing works
Self-citationThe Impact of Hospital‐Based Skilled Nursing Facility Closures on Rehospitalizations
Rahman, M., Zinn, J. S., & Mor, V. (2012) · Health Services Research · doi:10.1111/1475-6773.12001 · Cited by 48 · see citing works
“…stay in a SNF, including the outcome of rehospitalization and various MDS-based clinical characteristics (e.g., the CHESS comorbidity index) (Hirdes, Frijters, and Teare 2003), activity of daily living (ADL) score (Morris, Fries, and Morris 1999), and case mix index (CMI) using resource…”
Racial and ethnic disparities in the healing of pressure ulcers present at nursing home admission
Bliss, D. Z., Gurvich, O. V., Savik, K., Eberly, L. E., Harms, S. L., Mueller, C., Garrard, J. M., Cunanan, K. M., & Wiltzen, K. R. (2017) · Archives of Gerontology and Geriatrics · doi:10.1016/j.archger.2017.06.009 · Cited by 47 · see citing works
“Time-to-healing for pressure ulcers has been reported as ranging from a mean (sd) of 28 (20) days for Stage 2 pressure ulcers to 42 (Bergstrom et al., 2008) days for Stage 4 pressure ulcers (Horn et al., 2002).”
Urinary incontinence as a marker of higher mortality in patients receiving home care services
John, G., Gerstel, E., Jung, M., Dällenbach, P., Faltin, D. L., Petoud, V., Zumwald, C., & Rutschmann, O. (2013) · British Journal of Urology · doi:10.1111/bju.12359 · Cited by 46 · see citing works
Boström, A., Soest, D. V., Kolewaski, B., Milke, D. L., & Estabrooks, C. A. (2010) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2010.07.005 · Cited by 45 · see citing works
Elevated Hospitalization Risk of Assisted Living Residents With Dementia in Alberta, Canada
Maxwell, C. J., Amuah, J. E., Hogan, D. B., Cepoiu‐Martin, M., Gruneir, A., Patten, S. B., Soo, A., Clair, K. L., Wilson, K., Hagen, B. F., et al. (2015) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2015.01.079 · Cited by 45 · see citing works
Health status utilities and the impact of pressure ulcers in long-term care residents in Ontario
Thein, H., Gomes, T., Krahn, M. D., & Wodchis, W. P. (2009) · Quality of Life Research · doi:10.1007/s11136-009-9563-2 · Cited by 45 · see citing works
“CHESS, Changes in Health, End-stage disease and Symptoms and Signs—higher values indicate higher levels of clinical instability and risk of death [ 31 ] Qual Life Res (2010) 19:81–89 85”
Blekken, L. E., Nakrem, S., Vinsnes, A. G., Norton, C. S., Mørkved, S., Salvesen, Ø. O., & Gjeilo, K. H. (2016) · Gastroenterology Research and Practice · doi:10.1155/2016/1215746 · Cited by 43 · see citing works
“(iv) Patients’ instability in health/frailty was measured by the Changes in Health, End-Stage Disease, Signs, and Symptoms Scale (CHESS) [44].”
MethodInfluentialTjam, E. Y., Heckman, G. A., Smith, S., Arai, B., Hirdes, J. P., Poss, J. W., & McKelvie, R. S. (2011) · International Journal of Cardiology · doi:10.1016/j.ijcard.2011.01.031 · Cited by 44 · see citing works
“In addition, the CHESS scale has been shown to predict increased physician activity and the use of medical procedures, such as the use of suctioning, parenteral intravenous (IV) access, and the use of IV antibiotics in LTC residents, and is therefore considered a reliable and valid measure of health instability in suc…”
BackgroundMethodInfluentialSelf-citationDevelopment and Psychometric Properties of a Standardized Assessment for Adults who are Deaf-Blind
Dalby, D. M., Hirdes, J. P., Stolee, P., Strong, J. G., Poss, J. W., Tjam, E. Y., Bowman, L. C., & Ashworth, M. (2009) · Journal of Visual Impairment & Blindness · doi:10.1177/0145482x0910300103 · Cited by 44 · see citing works
Self-citationOsteoporosis management among residents living in long-term care
Giangregorio, L., Jantzi, M., Παπαϊωάννου, Α., Hirdes, J. P., Maxwell, C. J., & Poss, J. W. (2009) · Osteoporosis International · doi:10.1007/s00198-009-0837-x · Cited by 43 · see citing works
“Our analyses also included four health index measures previously developed and validated for use with the RAI 2.0 tool: (1) the Activities of Daily Living (ADL) self-performance hierarchy scale (range 0–6) [26]; (2) the Changes in Health, End-stage disease and Signs and Symptoms (CHESS) score (range 0–5) [ 27 ]; (3) t…”
MethodInfluentialSelf-citationChan, C., Slaughter, S. E., Jones, C. A., & Wagg, A. (2015) · Healthcare · doi:10.3390/healthcare3030503 · Cited by 42 · see citing works
Teresi, J. A., Ramirez, M. M., Remler, D. K., Ellis, J. M., Boratgis, G. D., Silver, S. A., Lindsey, M., Kong, J., Eimicke, J. P., & Dichter, E. (2011) · International Journal of Nursing Studies · doi:10.1016/j.ijnurstu.2011.07.003 · Cited by 42 · see citing works
Doran, D. M., Hirdes, J. P., Blais, R., Baker, G. R., Poss, J. W., Li, X., Dill, D., Gruneir, A., Heckman, G. A., Lacroix, H., et al. (2013) · BMC Health Services Research · doi:10.1186/1472-6963-13-227 · Cited by 42 · see citing works
Self-citationEmergency Department Use by Nursing Home Residents: Effect of Severity of Cognitive Impairment
Stephens, C. E., Newcomer, R., Blegen, M., Miller, B. L., & Harrington, C. A. (2011) · The Gerontologist · doi:10.1093/geront/gnr109 · Cited by 42 · see citing works
Effect of Bisphosphonates on Fracture Outcomes Among Frail Older Adults
Zullo, A. R., Zhang, T., Lee, Y., McConeghy, K. W., Daiello, L. A., Kiel, D. P., Mor, V., & Berry, S. D. (2018) · Journal of the American Geriatrics Society · doi:10.1111/jgs.15725 · Cited by 42 · see citing works
Seow, H. Y., Sutradhar, R., Burge, F., McGrail, K. M., Guthrie, D. M., Lawson, B. J., Oz, U. E., Chan, K., Peacock, S. J., & Barbera, L. C. (2021) · BMJ Open · doi:10.1136/bmjopen-2020-041432 · Cited by 42 · see citing works
- Authors
- Hirdes, J. P., Frijters, D. H., & Teare, G. F.
- Affiliations
- University of Waterloo (CA)
- Vrije Universiteit Amsterdam (NL)
- University of Toronto (CA)
- Corresponding author
- Hirdes, John P.
- Venue
- Journal of the American Geriatrics Society
- Publisher
- Wiley
- Published
- 2003-01
- Volume
- 51
- Issue
- 1
- Pages
- 96-100
- ISSN
- 0002-8614 (ISSN-L)
- 1532-5415
- OpenAlex
- W1997637125
- Cited by
- 477
- References
- 20
- Citations by year
- 2026: 22 · 2025: 22 · 2024: 32 · 2023: 18 · 2022: 22 · 2021: 24 · 2020: 41 · 2019: 23 · 2018: 24 · 2017: 26 · 2016: 29 · 2015: 23 · 2014: 28 · 2013: 26 · 2012: 17
- FWCI
- 4.44
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of the American Geriatrics Society (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Geriatrics and Gerontology › Frailty in Older Adults
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
- Health Sciences › Health Professions › General Health Professions › Geriatric Care and Nursing Homes
- Keywords
- mortality prediction, frailty, institutionalized elderly, end-stage disease, symptoms and signs, activities of daily living, do-not-resuscitate orders, pain, nursing assessment
- MeSH terms
- Activities of Daily Living, Aged, Aged, 80 and over, Canada, Chronic Disease, Female, Humans, Institutionalization, Male, Middle Aged, Mortality, Severity of Illness Index, Geriatric Assessment, Comorbidity, Proportional Hazards Models, Frail Elderly
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