{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"institution":[{"name":"Research Square"}],"indexed":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T01:03:03Z","timestamp":1790643783746,"version":"4.1.0"},"posted":{"date-parts":[[2026,9,29]]},"group-title":"In Review","reference-count":27,"publisher":"Springer Science and Business Media LLC","license":[{"start":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T00:00:00Z","timestamp":1790640000000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"accepted":{"date-parts":[[2026,8,13]]},"abstract":"<title>Abstract<\/title>\n                <p>Background\n Functional decline can increase care needs at the same time that out-of-pocket spending constrains continued treatment and rehabilitation. Existing studies usually predict these outcomes separately and therefore cannot identify older adults moving into joint functional and financial vulnerability. We developed a multistate model and tested whether its predictions remained informative in later CHARLS waves.\nMethods\n We used 2011\u20132018 Harmonized China Health and Retirement Longitudinal Study data. Adults aged at least 60 years contributed adjacent-wave observations. Four living states combined basic-activity difficulty and household catastrophic health expenditure, defined as out-of-pocket health spending at least 40% of non-food expenditure; death was the fifth state. Penalized multinomial regression and XGBoost were developed in 2011\u20132015 and evaluated without updating in 2015\u20132018. Penalized regression was primary because it matched XGBoost while remaining transparent. The locked model was applied to 2018 origins for exploratory 2020 validation of observable death and ADL components.\nResults\n The analysis comprised 12,866 transitions from 7,353 participants; 5,175 formed the 2015\u20132018 evaluation set, including 361 dual-vulnerability outcomes and 389 deaths. Penalized regression achieved a macro-AUROC of 0.722 (95% CI 0.712\u20130.734) and Brier score of 0.570 (0.557\u20130.583). AUROCs were 0.728 for dual vulnerability, 0.755 for death, and 0.629 for CHE alone. XGBoost did not improve macro-AUROC (0.720). Of 8,532 eligible 2018 origins, 8,004 had death or ADL status observed in 2020. Exploratory component AUROCs were 0.813 for death and 0.801 for ADL difficulty or death. The highest-risk 20% contained 53.5% of deaths and 46.1% of dual-vulnerability-or-death outcomes.\nConclusions\n Joint functional-financial states were dynamic and prognostically distinct. A transparent penalized model provided moderate discrimination for dual vulnerability and death in the complete five-state evaluation and identified a manageable high-risk stratum for coordinated functional and financial review. The 2020 analysis supported only the observable clinical components. Isolated CHE remained difficult to forecast without detailed reimbursement, local-cost, and long-term-care information.<\/p>","DOI":"10.21203\/rs.3.rs-10694017\/v1","type":"posted-content","created":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T00:49:23Z","timestamp":1790642963000},"source":"Crossref","is-referenced-by-count":0,"title":["Predicting transitions between functional and financial vulnerability states and death in older Chinese adults: a longitudinal CHARLS study with temporal evaluation"],"prefix":"10.21203","author":[{"given":"Tianrun","family":"Piao","sequence":"first","affiliation":[{"name":"Guangdong Work Injury Rehabilitation Hospital"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aiqun","family":"He","sequence":"additional","affiliation":[{"name":"Guangdong Work Injury Rehabilitation Hospital"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jingbo","family":"Li","sequence":"additional","affiliation":[{"name":"Guangdong Work Injury Rehabilitation Hospital"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"61","DOI":"10.1093\/ije\/dys203","article-title":"Cohort profile: the China Health and Retirement Longitudinal Study (CHARLS)","volume":"43","author":"Zhao Y","year":"2014","unstructured":"Zhao Y, Hu Y, Smith JP, Strauss J, Yang G. Cohort profile: the China Health and Retirement Longitudinal Study (CHARLS). Int J Epidemiol. 2014;43:61\u20138. 10.1093\/ije\/dys203.","journal-title":"Int J Epidemiol"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"914","DOI":"10.1001\/jama.1963.03060120024016","article-title":"Studies of illness in the aged: the Index of ADL: a standardized measure of biological and psychosocial function","volume":"185","author":"Katz S","year":"1963","unstructured":"Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged: the Index of ADL: a standardized measure of biological and psychosocial function. 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