1.-Identify new variables related to the patient (quality of life, functional dependency, social support, substance abuse) and the caregiver (caregiver burden, social support), which are linked to the probability of re-admission and mortality within the period until the subject is discharged and up to one year after the index event.
2.- Create and internally validate rules for predicting re-admissions and mortality in the transition period until the subject is discharged and up to one year after the index event, based on the variables previously identified in addition to clinical variables. Assess its external validity in an independent cohort of patients.
3.- Identify differences between patients who are re-admitted and those who are not, within the transition period until the subject is discharged (one month after the index event).
Qualitative-quantitative mix in which 5 hospitals from 3 Autonomous Communities (Andalusia, Catalonia, and the Basque Country) will participate.
Patients who meet two or more of Ollero’s criteria will be included. Variables will be identified by means of nominal groups of professionals and focal groups including patients and caregivers. These will be included in the final models together with clinical variables, PROMS (health-related quality of life, caregiver burden, social support). Logistic/Cox regression models will be developed and internally validated to identify the risk of re-admission and death, which will be validated in an external cohort
We hope to provide the healthcare system with multimorbid patient stratification tools to help identify those patients who are in the greatest need of individualised interventions.