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Fan L, Xue H, Wang Q, Yan Y, Du W. Development and Validation of a Nomogram for Predicting Risk of Emergency Department Revisits in Chinese Older Patients. Healthc Policy 2022; 15:2283-2295. [PMID: 36510569 PMCID: PMC9738955 DOI: 10.2147/rmhp.s391731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/26/2022] [Indexed: 12/12/2022] Open
Abstract
Objective The identification of older patients at risk of repeated emergency department (ED) visits is crucial for managing preventable adverse outcomes. This study aims to identify risk factors associated with ED revisits and to develop and validate a nomogram for predicting risk of geriatric ED revisits. Methods This was a cohort study comprising 553 older patients, who attended the two tertiary hospitals EDs in China from August 2018 to February 2019 and were prospectively followed for any unplanned revisit within 1 year after discharge. Patients were randomly assigned to a training or validation set at a ratio of 2:1. Stepwise selection procedure was applied to select factors associated with ED revisits for inclusion in a multivariable logistic model from which a nomogram was elaborated. Discrimination, calibration and clinical utility of the nomogram were assessed using C-statistic, calibration plot, Hosmer-Lemeshow test, and decision curve analysis (DCA). Results The final nomogram included four predictors for ED revisits: age, BMI, frailty and polypharmacy. Older patients having revisits were more likely to be frail (OR = 1.17, p = 0.031), have polypharmacy (OR = 1.69, p = 0.049) or BMI <18.5 kg/m2 (OR = 2.45, p = 0.025), and were less likely to be older than 90 years (OR = 0.21, p = 0.002). The nomogram demonstrated acceptable discrimination ability in the training (C-index = 0.661) and validation sets (C-index = 0.651), satisfactory calibration (p > 0.05), and good clinical applicability. Conclusion A nomogram incorporating four obtainable variables was constructed to individualize ED readmission risk in older patients. These patients may benefit from early triage and better-targeted care if considering the nomogram as a clinical decision aid.
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Affiliation(s)
- Lijun Fan
- School of Public Health, Southeast University, Nanjing, People’s Republic of China,School of Public Health, Sun Yat-sen University, Guangzhou, People’s Republic of China
| | - Hui Xue
- School of Public Health, Southeast University, Nanjing, People’s Republic of China
| | - Qian Wang
- Guangdong Provincial Geriatrics Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People’s Republic of China
| | - Yuhan Yan
- General Hospital of Eastern Theater Command, Nanjing, People’s Republic of China,Yuhan Yan, General Hospital of Eastern Theater Command, Nanjing, 210009, People’s Republic of China, Email
| | - Wei Du
- School of Public Health, Southeast University, Nanjing, People’s Republic of China,Correspondence: Wei Du, School of Public Health, Southeast University, Nanjing, 210009, People’s Republic of China, Email
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Kolk D, Kruiswijk AF, MacNeil-Vroomen JL, Ridderikhof ML, Buurman BM. Older patients' perspectives on factors contributing to frequent visits to the emergency department: a qualitative interview study. BMC Public Health 2021; 21:1709. [PMID: 34544405 PMCID: PMC8454044 DOI: 10.1186/s12889-021-11755-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 09/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Older patients are at high risk of unplanned revisits to the emergency department (ED) because of their medical complexity. To reduce the number of ED visits, we need more knowledge about the patient-level, environmental, and healthcare factors involved. The aim of this study was to describe older patients' perspectives and experiences before and after an ED visit, and to identify factors that possibly contribute to frequent ED revisits. METHODS This was a qualitative description study. We performed semi-structured individual interviews with older patients who frequently visited the ED and were discharged home after an acute visit. Patients were enrolled in the ED of a university medical centre using purposive sampling. Interviews were recorded, transcribed, and coded independently by two researchers. Theoretical analysis was used to identify recurring patterns and themes in the data. Interviews were conducted until thematic saturation was reached. RESULTS In-depth interviews were completed with 13 older patients. Three main themes emerged: 1) medical events leading to feelings of crisis, 2) patients' untreated health problems, and 3) persistent problems in health and daily functioning post discharge. Participants identified problems before and after their ED visit that possibly contributed to further ED visits. These problems included increasing symptoms leading to feelings of crisis, the relationship with the general practitioner, incomplete discharge information at the ED, and inadequate follow-up and lack of recovery after an ED visit. CONCLUSIONS This qualitative study identified multiple factors that may contribute to frequent ED visits among older patients. Older patients in need of acute care might benefit from hospital-at-home interventions, or acute care provided by geriatric emergency teams in the primary care setting. Identifying frailty in the ED is needed to improve discharge communication and adequate follow-up is needed to improve recovery after an acute ED visit.
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Affiliation(s)
- Daisy Kolk
- Amsterdam UMC, University of Amsterdam, Emergency Medicine, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, Netherlands. .,Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC, University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health, Meibergdreef 9, Amsterdam, Netherlands.
| | - Anton F Kruiswijk
- Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC, University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health, Meibergdreef 9, Amsterdam, Netherlands.,OLVG Hospital, Department of Geriatric Medicine, Amsterdam, the Netherlands
| | - Janet L MacNeil-Vroomen
- Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC, University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health, Meibergdreef 9, Amsterdam, Netherlands
| | - Milan L Ridderikhof
- Amsterdam UMC, University of Amsterdam, Emergency Medicine, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, Netherlands
| | - Bianca M Buurman
- Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC, University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health, Meibergdreef 9, Amsterdam, Netherlands.,ACHIEVE - Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, Netherlands
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Geriatric assessment for older adults admitted to the emergency department: A systematic review and meta-analysis. Exp Gerontol 2020; 144:111184. [PMID: 33279664 DOI: 10.1016/j.exger.2020.111184] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 11/12/2020] [Accepted: 11/28/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Older adults are the most frequent users of emergency services. Comprehensive geriatric assessment (CGA) can help identify high-risk older adults at an early stage. We conducted a systematic review and meta-analysis to identify and evaluate CGA tools used in the emergency department (ED), analyze their predictive validity for adverse outcomes and recommend tools for this particular situation. METHODS We systematically searched Medline, Web of Science and CENTRAL for eligible articles published in peer-reviewed journals that observed patients ≥65 years admitted to the ED, used at least one assessment tool and reported adverse outcomes of interest. We performed a descriptive analysis and a bivariate meta-analysis of the diagnostic accuracy and predictive validity of the assessment tools for the chosen adverse outcomes. RESULTS 28 eligible studies were included. The pooled sensitivity (95% CI) of the assessment tools for predicting mortality within short (28-90 days) and long (180-365 days) periods after the first ED visit was 0.77 (0.61-0.89) and 0.79 (0.46-0.96), respectively, with specificity (95% CI) values of 0.45 (0.32-0.59) and 0.37 (0.14-0.65). These findings indicate that the tools used in the included studies had modest predictive accuracy for mortality and were more appropriate for identifying individuals at high risk of readmission in the short term than in the long term. CONCLUSIONS Early use of assessment tools in the ED might improve clinical decision making and reduce negative outcomes for older adults.
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Gips E, Spilsbury K, Boecker C, Ng R, Arendts G. Do frailty and comorbidity indices improve risk prediction of 28-day ED reattendance? Reanalysis of an ED discharge nomogram for older people. Aging Clin Exp Res 2019; 31:1401-1406. [PMID: 30560431 DOI: 10.1007/s40520-018-1089-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 12/04/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND In older people, quantification of risk of reattendance after emergency department (ED) discharge is important to provide adequate post ED discharge care in the community to appropriately targeted patients at risk. METHODS We reanalysed data from a prospective observational study, previously used for derivation of a nomogram for stratifying people aged 65 and older at risk for ED reattendance. We investigated the potential effect of comorbidity load and frailty by adding the Charlson or Elixhauser comorbidity index and a ten-item frailty measure from our data to develop four new nomograms. Model I and model F built on the original nomogram by including the frailty measure with and without the addition of the Charlson comorbidity score; model E adapted for efficiency in the time-constrained environment of ED was without the frailty measure; and model P manually constructed in a purposeful stepwise manner and including only statistically significant variables. Areas under the ROC curve of models were compared. The primary outcome was any ED reattendance within 28 days of discharge. RESULTS Data from 1357 patients were used. The point estimate of the respective areas under ROC were 0.63 (O), 0.63 (I), 0.68 (E), 0.71 (P) and 0.63 (F). CONCLUSION Addition of a comorbidity index to our previous model improves stratifying elderly at risk of ED reattendance. Our frailty measure did not demonstrate any additional predictive benefit.
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Affiliation(s)
- Evert Gips
- Department of Emergency Medicine, Fiona Stanley Hospital, South Metropolitan Health Service, Perth, WA, Australia
- Department of Emergency Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Katrina Spilsbury
- Centre for Population Health Research, Curtin University, Perth, WA, Australia
- Institute of Health Research, The University of Notre Dame Australia, Perth, WA, Australia
| | - Claus Boecker
- Department of Emergency Medicine, Fiona Stanley Hospital, South Metropolitan Health Service, Perth, WA, Australia
| | - Rebecca Ng
- Department of Emergency Medicine, Fiona Stanley Hospital, South Metropolitan Health Service, Perth, WA, Australia
| | - Glenn Arendts
- University of Western Australia, Perth, WA, Australia.
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Cesari M. There is much more than just diseases that underlies frailty in older persons. Aging Clin Exp Res 2019; 31:1349-1350. [PMID: 31115874 DOI: 10.1007/s40520-019-01221-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 05/10/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Matteo Cesari
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
- Geriatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Pace 9, 20122, Milan, MI, Italy.
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Schwab C, Hindlet P, Sabatier B, Fernandez C, Korb-Savoldelli V. Risk scores identifying elderly inpatients at risk of 30-day unplanned readmission and accident and emergency department visit: a systematic review. BMJ Open 2019; 9:e028302. [PMID: 31362964 PMCID: PMC6677948 DOI: 10.1136/bmjopen-2018-028302] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 06/19/2019] [Accepted: 06/20/2019] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES The aim of this systematic review was to describe and analyse the performance statistics of validated risk scores identifying elderly inpatients at risk of early unplanned readmission. DATA SOURCES We identified potentially eligible studies by searching MEDLINE, EMBASE, COCHRANE and Web of Science. Our search was restricted to original studies, between 1966 and 2018. ELIGIBILITY CRITERIA Original studies, which internally or externally validated the clinical scores of hospital readmissions in elderly inpatients. DATA EXTRACTION AND SYNTHESIS A data extraction grid based on Strengthening the Reporting of Observational Studies in Epidemiology and Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis statements was developed and completed by two reviewers to collect general data. The same process was used to extract metrological data of the selected scores. QUALITY ASSESSMENT OF THE INCLUDED STUDIES Assessment of the quality and risk of bias in individual studies was performed by two reviewers, using the validated Effective Public Health Practice Project quality assessment tool. PARTICIPANTS Elderly inpatients discharged to home from hospital or returning home after an accident and emergency department visit. RESULTS A total of 12 studies and five different scores were included in the review. The five scores present area under the receiving operating characteristic curve between 0.445 and 0.69. Identification of Senior At Risk (ISAR) and Triage Risk Screening Tool (TRST) scores were the more frequently validated scores with ISAR being more sensitive and TRST more specific. CONCLUSIONS The TRST and ISAR scores have been extensively studied and validated. The choice of the most suitable score relies on available patient data, patient characteristics and the foreseen clinical care intervention. In order to pair the intervention with the appropriate clinical score, further studies of external validation of clinical scores, identifying elderly patients at risk of early unplanned readmission, are needed. PROSPERO REGISTRATION NUMBER CRD42017054516.
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Affiliation(s)
- Camille Schwab
- UMR-S 1136- Institut Pierre Louis D’Epidémiologie et de Santé Publique, Sorbonne Université, UPMC Univ Paris 06, Paris, France
- Service Pharmacie, Hôpital Européen Georges Pompidou, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Patrick Hindlet
- UMR-S 1136- Institut Pierre Louis D’Epidémiologie et de Santé Publique, Sorbonne Université, UPMC Univ Paris 06, Paris, France
- Service Pharmacie, Hôpital Saint-Antoine, Assistance Publique – Hôpitaux de Paris, Paris, France
- Faculté de Pharmacie, Université Paris-Sud, Paris, France
| | - Brigitte Sabatier
- Service Pharmacie, Hôpital Européen Georges Pompidou, Assistance Publique – Hôpitaux de Paris, Paris, France
- INSERM UMR 1138 Team 22: Information Sciences to Support, Personalized Medicine, Cordelier Research Center, Paris, France
| | - Christine Fernandez
- UMR-S 1136- Institut Pierre Louis D’Epidémiologie et de Santé Publique, Sorbonne Université, UPMC Univ Paris 06, Paris, France
- Service Pharmacie, Hôpital Saint-Antoine, Assistance Publique – Hôpitaux de Paris, Paris, France
- Faculté de Pharmacie, Université Paris-Sud, Paris, France
| | - Virginie Korb-Savoldelli
- Service Pharmacie, Hôpital Européen Georges Pompidou, Assistance Publique – Hôpitaux de Paris, Paris, France
- Faculté de Pharmacie, Université Paris-Sud, Paris, France
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Southerland LT, Pearson S, Hullick C, Carpenter CR, Arendts G. Safe to send home? Discharge risk assessment in the emergency department. Emerg Med Australas 2019; 31:266-270. [DOI: 10.1111/1742-6723.13250] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 01/20/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Lauren T Southerland
- Department of Emergency MedicineThe Ohio State University Wexner Medical Center Columbus Ohio USA
| | - Scott Pearson
- Department of Emergency MedicineChristchurch Hospital Christchurch New Zealand
| | - Carolyn Hullick
- Faculty of HealthThe University of Newcastle Newcastle New South Wales Australia
- Hunter Medical Research Institute Newcastle New South Wales Australia
| | | | - Glenn Arendts
- School of MedicineThe University of Western Australia Perth Western Australia Australia
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A randomized-controlled trial of a patient-centred intervention in high-risk discharged older patients. Eur J Emerg Med 2018; 25:237-241. [PMID: 28027074 DOI: 10.1097/mej.0000000000000444] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The risk of early reattendance after discharge has been proposed as a performance indicator for emergency departments (EDs), but is not uniform in all patients. Those individuals at the highest risk of reattendance may benefit from an intense intervention to reduce this risk, and our objective was to test this hypothesis in a clinical trial. METHODS A randomized-controlled trial was conducted in the EDs of two hospitals. Very high-risk adults aged 65 years and older, identified using a validated risk-prediction nomogram and being discharged from ED, were randomized to receive a postdischarge patient-centred intervention or standard care. The intervention focused on identifying and supporting patients to address risk factors for future hospital presentation. The primary outcome measure was any unplanned ED reattendance within 28 days. Secondary outcomes included 28-day and 1-year hospital usage, institutionalization and death. RESULTS We enrolled 164 patients, 82 in each study arm. There was an 8% absolute (95% confidence interval: -7%-20%) and a 20% relative risk reduction for an intervention patient making an unplanned ED reattendance within 28 days. This difference was not statistically significant (P=0.26). CONCLUSION This postdischarge intervention was associated with only small and nonsignificant reductions in ED reattendance.
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Ziv-Baran T, Wasserman A, Shteinvil R, Zeltser D, Shapira I, Shenhar-Tsarfaty S, Meilik A, Goldiner I, Rogowski O, Berliner S, Halpern P. C-reactive protein and emergency department seven days revisit. Clin Chim Acta 2018; 481:207-211. [DOI: 10.1016/j.cca.2018.03.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 03/19/2018] [Indexed: 01/21/2023]
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10
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de Gelder J, Lucke JA, de Groot B, Fogteloo AJ, Anten S, Heringhaus C, Dekkers OM, Blauw GJ, Mooijaart SP. Predictors and Outcomes of Revisits in Older Adults Discharged from the Emergency Department. J Am Geriatr Soc 2018; 66:735-741. [DOI: 10.1111/jgs.15301] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Jelle de Gelder
- Department of Gerontology and Geriatrics; Leiden University Medical Center; Leiden the Netherlands
| | - Jacinta A. Lucke
- Department of Emergency Medicine; Leiden University Medical Center; Leiden the Netherlands
| | - Bas de Groot
- Department of Emergency Medicine; Leiden University Medical Center; Leiden the Netherlands
| | - Anne J. Fogteloo
- Department of Section on Acute Care, Department of Internal Medicine; Leiden University Medical Center; Leiden the Netherlands
| | - Sander Anten
- Section on Acute Care, Department of Internal Medicine; Alrijne Hospital; Leiden the Netherlands
| | - Christian Heringhaus
- Department of Emergency Medicine; Leiden University Medical Center; Leiden the Netherlands
| | - Olaf M. Dekkers
- Department of Clinical Epidemiology; Leiden University Medical Center; Leiden the Netherlands
| | - Gerard J. Blauw
- Department of Gerontology and Geriatrics; Leiden University Medical Center; Leiden the Netherlands
- Department of Internal Medicine; Haaglanden Medical Center; Bronovo the Netherlands
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Arendts G, Burkett E, Hullick C, Carpenter CR, Nagaraj G, Visvanathan R. Frailty, thy name is…. Emerg Med Australas 2017; 29:712-716. [PMID: 28971594 DOI: 10.1111/1742-6723.12869] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 08/31/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Glenn Arendts
- Department of Emergency Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Ellen Burkett
- Emergency Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Carolyn Hullick
- Emergency Department, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Christopher R Carpenter
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Guruprasad Nagaraj
- Emergency Department, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Renuka Visvanathan
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
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Hwang U, Carpenter C. Assessing geriatric vulnerability for post emergency department adverse outcomes: challenges abound while progress is slow. Emerg Med J 2015; 33:2-3. [DOI: 10.1136/emermed-2015-204983] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2015] [Indexed: 11/04/2022]
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