A Brief Risk Stratification Tool to Predict Functional Decline in Older Adults Discharged from Emergency Departments

Patient-reported outcome measure use among older adults after emergency department care: A systematic review

BACKGROUND

Patient-reported outcome measures (PROMs) are gaining favor in clinical and research settings given their ability to capture a patient's symptom burden, functional status, and quality of life. Our objective in this systematic review was to summarize studies including PROMs assessed among older adults (age ≥ 65 years) after seeking emergency care.

METHODS

With the assistance of a medical librarian, we searched Ovid MEDLINE, PubMed, Embase, CINAHL, Web of Science-Core Collection, and Cochrane CENTRAL from inception through June 2023 for studies in which older adult ED patients had PROMs assessed in the post-emergency care time period. Independent reviewers performed title/abstract review, full-text screening, data extraction, study characteristic summarization, and risk-of-bias (RoB) assessments.

RESULTS

Our search strategy yielded 5153 studies of which 56 met study inclusion criteria. Within included studies, 304 unique PROM assessments were performed at varying time points after the ED visit, including 61 unique PROMs. The most commonly measured domain was physical function, assessed within the majority of studies (47/56; 84%), with measures including PROMs such as Katz activities of daily living (ADLs), instrumental ADLs, and the Barthel Index. PROMs were most frequently assessed at 1-3 months after an ED visit (113/304; 37%), greater than 6 months (91/304; 30%), and 4-6 months (88/304; 29%), with very few PROMs assessed within 1 month of the ED visit (12/304; 4%). Of the 16 interventional studies, two were determined to have a low RoB, four had moderate RoB, nine had high RoB, and one had insufficient information. Of the 40 observational studies, 10 were determined to be of good quality, 20 of moderate quality, and 10 of poor quality.

CONCLUSIONS

PROM assessments among older adults following an ED visit frequently measured physical function, with very few assessments occurring within the first 1 month after an ED visit.

Using Design Thinking for Co-Creating an Integrated Care Pathway Including Hospital at Home for Older Adults with an Acute Moderate-Severe Respiratory Infection in the Netherlands

Introduction

Acute respiratory infections are common in frail, community-dwelling older people and are accompanied by considerable diagnostic and prognostic uncertainties. Inadequately coordinated care is associated with unnecessary hospital referral and admission with potential iatrogenic harm. Therefore, we aimed to co-create a regional integrated care pathway (ICP), including a hospital at home journey.

Developing the ICP

Tasked with using design thinking methodology, stakeholders from regional healthcare facilities, together with patient representatives, were assigned to different focus groups based on their expertise. The focus of each session was to co-create ideal patient journeys suitable for embedding in the ICP.

Results

Based on these sessions, a regional cross-domain ICP was developed that comprises three patient journeys. The first journey included a hospital at home track, the second a tailored visit, with priority assessment, to regional emergency departments, and the third concerned referral to readily available nursing home 'recovery-beds' under the supervision of an elderly care medicine specialist.

Conclusion

Using design thinking and involving end-users during the whole process, we created an ICP for community-dwelling frail older people with moderate-severe acute respiratory infections. This resulted in three realistic patient journeys, including a hospital at home track, which will be implemented and evaluated in the near future.

Frailty and Cancer: Current Perspectives on Assessment and Monitoring

Frailty, an age-related condition of increased vulnerability to acute endogenous or exogenous stressors, is a key barrier to successful treatment of cancer in older people. In this group of patients, assessment of frailty is required before starting a new treatment. According to guidelines, the gold standard to assess frailty in older adults with cancer is geriatric screening followed by geriatric assessment (GA) across essential GA-domains (social status, physical function, nutrition, cognition, emotion, co-morbidity, polypharmacy). GA enables tailoring of both oncological therapy and non-oncological interventions to the patient's vulnerabilities. Large clinical trials recently have demonstrated that the feasibility and tolerability of systemic cancer treatment in older patients are significantly improved by such GA-guided management. Indications and optimal tools for frailty monitoring during the course of cancer treatment have not yet been defined in greater detail. New technologies such as wearable sensors or apps offer promising new opportunities to further develop frailty monitoring. This review describes the current standards and perspectives for the assessment and monitoring of frailty in elderly patients with cancer.

Identifying vulnerable older adults at risk for functional decline in cardiac care wards: time to shift the paradigm

OBJECTIVE

To determine whether routine screening with the Flemish version of the Triage Risk Screening Tool (fTRST) is a valid approach to determine which patients on cardiac care wards are at risk for inhospital functional decline and would benefit from geriatric expertise consultation.

METHODS

A secondary data-analysis of the G-COACH before-cohort, describing patient profiles and routine care processes, in 189 older adults on two cardiac care wards in the University Hospitals Leuven between September 2016 and June 2017. Inhospital functional decline was defined as an increase of at least one point on the Katz Index of Activities of Daily Living or death between hospital admission and discharge.

RESULTS

Nine in 10 patients had at least one geriatric syndrome and one-third developed functional decline. Based on the fTRST proposed cut-off of ≥2, 156 (82.5%) patients were at risk for functional decline (sensitivity of 95.2%, specificity of 23.8%, negative predictive value of 90.9% and Area Under the Curve of 0.60). Of the 156 'at risk' patients, 43 (27.6%) received a consultation by the geriatric consultation team after a median of four hospitalization days. A positive fTRST was not significantly related to geriatric consultations (x² = 0.57; p = 0.45).

CONCLUSION

The fTRST has a low discriminative value in identifying older cardiology patients at risk for functional decline. Given the high prevalence of geriatric syndromes, we propose a new paradigm were all older adults on cardiac care wards undergo a needs assessment upon hospital admission.

Performance of two frailty screening tools among patients with cancer in Taiwan

Background

Comprehensive Geriatric Assessment (CGA) is the gold standard for detecting frailty in elderly patients with cancer. Since CGA is time- and resource-consuming, many alternative frailty screening tools have been developed; however, it remains unknown whether these tools are suitable for older and adult patients with cancer. Therefore, we used the data collected for a large longitudinal study to compare the diagnostic performances of two frailty screening tools (Geriatric 8 [G8] and Flemish version of the Triage Risk Screening Tool [fTRST]) to identify frailty risk profile among patients with cancer.

Methods

Patients aged ≥20 years with newly diagnosed cancer were enrolled. Frailty screening with G8, fTRST, and CGA were performed before anti-cancer treatment. Diagnostic characteristics obtained using G8 and fTRST were analyzed by C-index, and the validity of G8 and fTRST was also determined.

Results

40.9% of the 755 patients with cancer displayed frailty on CGA. Both G8 and fTRST showed high sensitivity (80.6–88.4%) and negative predictive value (81.0–81.2%). The C-index of G8 was higher than that of fTRST (0.77 vs 0.71, p = .01). Moreover, the best G8 and fTRST cut-off points were ≤13 and ≥ 2, respectively. The validities of G8 and fTRST were also confirmed; however, frailty age differences were not observed in our study.

Conclusion

Frailty is a common problem for patients with cancer, and routine frailty screening is essential for both older and adult patients. G8 and fTRST are simple and useful frailty screening tools, while G8 is more suitable than fTRST for Taiwanese patients with cancer.

Patients in need of comprehensive geriatric assessment: The utility of the InterRAI emergency department screener

INTRODUCTION

The interRAI Emergency Department-Screener (ED-screener) is a risk stratification instrument incorporating functional and social aspects to identify older adults in EDs. The aim was to assess the construct validity and utility of the ED-screener in comparison with more established instruments.

METHODS

The ED-screener, Triage Risk Screening Tool (TRST) and Identification of Seniors at Risk (ISAR) were administered to older ED-patients. Construct validity was assessed by correlation with TRST and ISAR. The ED-screener scores that corresponded to the established cut-offs for ISAR and TRST were assessed with linear regression. The sensitivity and specificity of the ED-screener for mortality at 4-months were calculated.

RESULTS

Two hundred patients were included (mean age 78.5 years, 44% male). Majority (85%) lived at home, 43% lived alone and 53% received home care. The scores of 3.02 and 3.01 on ED-screener corresponded to the cut-off score of 2 on the other instruments. The correlation of the ED-screener with ISAR and TRST was 0.56 and 0.41 respectively. A score of 3 on the ED-screener was 100% sensitive and 28% specific for 4-month mortality.

CONCLUSION

These findings provide support for the construct validity of the ED-screener and its ability to predict outcomes in its intended setting.

Risk Factors for Disability After Emergency Department Discharge in Older Adults

OBJECTIVES

We have previously shown that older adults discharged from the emergency department (ED) experience an increased disability burden within a 6-month time period after ED discharge. The objective of this study was to identify risk factors associated with increased disability burden among older adults discharged from the ED.

METHODS

This study is part of an ongoing longitudinal study of 754 community-living persons aged ≥70 years. The analytic sample included 813 ED visits without hospitalization from 430 participants who had at least one visit to an ED during a 14-year follow-up period (1998-2012). Information on ED visits and disability burden in 13 functional activities was collected during monthly interviews. Twenty-nine candidate risk factors were evaluated for their independent associations with increased disability burden using a longitudinal multivariable model.

RESULTS

In the multivariable analyses, age ≥85 (adjusted risk ratio [aRR] = 1.14, 95% confidence interval [CI] = 1.05 to 1.24), being unmarried (aRR = 1.15, 95% CI = 1.05 to 1.27), lower-extremity weakness (aRR = 1.20, 95% CI = 1.07 to 1.34), and physical frailty (aRR = 1.25, 95% CI = 1.13 to 1.37) were associated with increased disability burden. As the number of risk factors increased, the predicted mean disability burden (on a scale of 0 to 13) also increased, ranging from a value of 1.80 (95% CI = 1.43 to 2.27) for 0 risk factors to a value of 8.59 (95% CI = 7.93 to 9.29) for four risk factors.

CONCLUSIONS

Among older adults discharged from the ED, several risk factors were associated with increased disability burden over the following 6 months, including age ≥85, being unmarried, lower-extremity weakness, and physical frailty. Further research is needed to evaluate whether risk stratification based on nonmodifiable factors or interventions targeting modifiable risk factors improve functional outcomes for older adults discharged from the ED.

Management following endoscopic resection in elderly patients with early-stage upper gastrointestinal neoplasia

With the ongoing increase in the aging population in Japan, the number of elderly patients among the total population with upper gastrointestinal (GI) neoplasia has also been increasing. As elderly patients present unique age-related variations in their physical condition, the therapeutic approach for upper GI neoplasia should be differentiated between elderly and nonelderly patients. According to the existing guidelines, additional treatment is the standard therapy in patients who undergo endoscopic resection (ER) with a possible risk of lymph node metastasis (LNM) for upper GI neoplasia. However, due to the relatively low rate of LNM, applying additional treatment in all elderly patients may be excessive. Although additional treatment has the advantage of reducing cancer-specific mortality, its disadvantages include deteriorated quality of life, complications, and mortality in surgery. In patients with early gastric cancer, we propose treatment decisions be made using a risk-scoring system for LNM and upon considering the physical condition of the patient after ER with curability C-2. In those with superficial esophageal squamous cell carcinoma with a possible risk of LNM after ER, selective chemoradiotherapy may be a less-invasive treatment option, although the present standard treatment is esophagectomy. When considering the treatment decision, achieving a "cure" of the tumor has been regarded as critical. However, as the main cause of mortality in elderly patients with ER for upper GI neoplasia is noncancer-related death, both achieving a "cure" and also a good level of "care" is important in the management of elderly patients.

Ability of Emergency Department Physicians Using a Functional Autonomy-Assessing Version of the Triage Risk Screening Tool to Detect Frail Older Patients Who Require Mobile Geriatric Team Consultation

OBJECTIVES

Frailty in older people associates with poor outcomes. Screening by ED physicians would greatly facilitate detection of frail older patients but our previous attempt to introduce routine ED-physician screening with Short Emergency Geriatric Assessment (SEGA), a 13-item frailty tool that French geriatricians use to identify frail patients, failed due to its length and complexity. A national committee recently generated a new version of the fast and simple 5-item Triage Risk Screening Tool (TRST) in which a subjective item ('nurse concern') was replaced by an item assessing basic activities of daily living. The ability of ED physicians using this French-TRST to accurately detect frail patients who require comprehensive geriatric assessment was assessed.

DESIGN

Prospective cross-sectional study on diagnostic accuracy relative to the gold standard, namely, geriatrician-administered SEGA.

SETTING

Tertiary-care hospital, France.

SUBJECTS AND MEASUREMENTS

The participants were 498 ≥75-year-old patients who visited the ED in 2018-2019 and were administered French-TRSTs by first ED physicians and then geriatricians, followed by SEGA, all within 24 hours. Diagnostic accuracy variables were calculated. Geriatrician-TRST was used to identify TRST items that associated with ED physician misclassification of frail patients.

RESULTS

Emergency-TRST was significantly less sensitive than Geriatrician-TRST (88% vs. 93%; p=0.04) and tended to have lower negative predictive value (66% vs. 77%; p=0.09). Emergency-TRSTs rated four French-TRST items less well than Geriatrician-TRSTs.

CONCLUSIONS

As a substitute for SEGA in the ED, the French-TRST performed quite well overall but the ED physicians detected frail patients less well than the geriatricians. Modifications of the French-TRST that may improve the diagnostic performance of ED physicians are discussed.

Troponin Testing and Coronary Syndrome in Geriatric Patients With Nonspecific Complaints: Are We Overtesting?

BACKGROUND

Elderly patients presenting to the emergency department (ED) with nonspecific complaints (NSCs) often undergo troponin testing to assess for atypical acute coronary syndrome (ACS). However, the rate of ACS and utility of troponin testing in this population is unknown. We sought to determine the rate of ACS and diagnostic yield of troponin testing in elderly patients with NSCs.

METHODS

We retrospectively identified all patients aged ≥ 65 years triaged in the ED with NSCs from January 1, 2017, to June 30, 2017. NSCs were defined a priori and included complaints such as weakness, dizziness, or fatigue. NSCs were verified in ED provider notes by trained abstractors blind to testing results. Exclusions were focal chief complaint in provider notes, fever, and no troponin ordered. ACS was strictly defined and independently adjudicated by two trained physician researchers blind to the study hypothesis. We calculated the proportion of patients with ACS within 30 days and the test characteristics of troponin to diagnose ACS.

RESULTS

Screening identified 1,146 encounters, and 552 were excluded for fever or focal chief complaints in the provider notes. Of the remaining 594 patients, troponin was ordered in 412 (69%), comprising the study cohort. The mean (±SD) age was 78.7 (±8.3) years, with 58% female and 75% admitted. Troponin elevation occurred in 81 patients (20%). ACS occurred in 5 of 412 (1.2%). Troponin was 100% sensitive (95% confidence interval [CI] = 48% to 100%) and 81% specific (95% CI = 77% to 85%) for ACS. Of patients with elevated troponin, 93.8% were false positives (no ACS). All patients with troponin elevation were admitted, but only one underwent angiography and no patients received reperfusion therapy.

CONCLUSIONS

While consideration for ACS is prudent in selected elderly patients with NSCs, ACS was rare and no patients received reperfusion therapy. Given the false-positive rate in our study, our results may not support routine troponin testing for ACS in this population.

Factors Associated With Perceived Worsened Physical Health Among Older Adults Who Are Newly Enrolled Long-term Services and Supports Recipients

Limited information exists on the perceived health of older adults new to receiving long-term services and supports (LTSS) compared with the year prior, posing challenges to the anticipation of health care need and optimization of wellness efforts for this growing population. In response, we sought to identify differences in perceived worsened physical health across three LTSS types (nursing home, assisted living, and home and community-based services) along with health-related quality of life (HRQoL) characteristics associated with older adults' ratings of perceived worsened physical health at the start of receiving LTSS. Enrolled LTSS recipients completed a single interview assessing their HRQoL. Bivariate and multivariable logistic regression analyses were performed to determine associations in LTSS types and HRQoL characteristics with perceived worsened physical health among older adults (≥60 years old) since 1 year prior to study enrollment. Among the 467 LTSS recipients, perceived physical health was rated as worse than the previous year by 36%. Bivariate analyses revealed no differences in perceived worsened physical health across LTSS types. In adjusted analyses, religiousness/spirituality and better mental and general health perception had a decreased odds of being associated with perceived worsened physical health (P < .05). Participants with major changes in their health in the past 6 months were more likely to report perceived worsened physical health (P < .001). Findings provide information that may be used to target efforts to enhance perceived physical health and improve quality of life among LTSS enrollees.

Validation of the Elderly Risk Assessment Index in the Emergency Department

OBJECTIVES

The Elderly Risk Assessment (ERA) score is a validated index for primary care patients that predict hospitalizations, mortality, and Emergency Department (ED) visits. The score incorporates age, prior hospital days, marital status, and comorbidities. Our aim was to validate the ERA score in ED patients.

METHODS

Observational cohort study of patients age ≥ 60 presenting to an academic ED over a 1-year period. Regression analyses were performed for associations with outcomes (hospitalization, return visits and death). Medians, interquartile range (IQR), odds ratios (OR) and 95% confidence intervals (CI) were calculated.

RESULTS

The cohort included 27,397 visits among 18,607 patients. Median age 74 years (66-82), 48% were female and 59% were married. Patients from 54% of visits were admitted to the hospital, 16% returned to the ED within 30 days, and 18% died within one year. Higher ERA scores were associated with: hospital admission (score 10 [4-16] vs 5 [1-11], p < 0.0001), return visits (11 [5-17] vs 7 [2-13], p < 0.0001); and death within one year (14 [7-20] vs 6 [2-13], p < 0.0001). Patients with ERA score ≥ 16 were more likely to be admitted to the hospital, OR 2.14 (2.02-2.28, p < 0.0001), return within 30 days OR 1.99 (1.85-2.14), and to die within a year, OR 2.69 (2.54-2.85).

CONCLUSION

The ERA score can be automatically calculated within the electronic health record and helps identify patients at increased risk of death, hospitalization and return ED visits. The ERA score can be applied to ED patients, and may help prognosticate the need for advanced care planning.

Validation of the Elderly Risk Assessment Index in the Emergency Department

OBJECTIVES

The Elderly Risk Assessment (ERA) score is a validated index for primary care patients that predict hospitalizations, mortality, and Emergency Department (ED) visits. The score incorporates age, prior hospital days, marital status, and comorbidities. Our aim was to validate the ERA score in ED patients.

METHODS

Observational cohort study of patients age ≥ 60 presenting to an academic ED over a 1-year period. Regression analyses were performed for associations with outcomes (hospitalization, return visits and death). Medians, interquartile range (IQR), odds ratios (OR) and 95% confidence intervals (CI) were calculated.

RESULTS

The cohort included 27,397 visits among 18,607 patients. Median age 74 years (66-82), 48% were female and 59% were married. Patients from 54% of visits were admitted to the hospital, 16% returned to the ED within 30 days, and 18% died within one year. Higher ERA scores were associated with: hospital admission (score 10 [4-16] vs 5 [1-11], p < 0.0001), return visits (11 [5-17] vs 7 [2-13], p < 0.0001); and death within one year (14 [7-20] vs 6 [2-13], p < 0.0001). Patients with ERA score ≥ 16 were more likely to be admitted to the hospital, OR 2.14 (2.02-2.28, p < 0.0001), return within 30 days OR 1.99 (1.85-2.14), and to die within a year, OR 2.69 (2.54-2.85).

CONCLUSION

The ERA score can be automatically calculated within the electronic health record and helps identify patients at increased risk of death, hospitalization and return ED visits. The ERA score can be applied to ED patients, and may help prognosticate the need for advanced care planning.

SPMSQ for risk stratification of older patients in the emergency department : An exploratory prospective cohort study

Background

Risk stratification of older patients in the emergency department (ED) is seen as a promising and efficient solution for handling the increase in demand for geriatric emergency medicine. Previously, the predictive validity of commonly used tools for risk stratification, such as the identification of seniors at risk (ISAR), have found only limited evidence in German geriatric patient samples. Given that the adverse outcomes in question, such as rehospitalization, nursing home admission and mortality, are substantially associated with cognitive impairment, the potential of the short portable mental status questionnaire (SPMSQ) as a tool for risk stratification of older ED patients was investigated.

Objective

To estimate the predictive validity of the SPMSQ for a composite endpoint of adverse events (e.g. rehospitalization, nursing home admission and mortality).

Method

This was a prospective cohort study with 260 patients aged 70 years and above, recruited in a cardiology ED. Patients with a likely life-expectancy below 24 h were excluded. Follow-up examinations were conducted at 1, 3, 6 and 12 month(s) after recruitment.

Results

The SPMSQ was found to be a significant predictor of adverse outcomes not at 1 month (area under the curve, AUC 0.55, 95% confidence interval, CI 0.46–0.63) but at 3 months (AUC 0.61, 95% CI 0.54–0.68), 6 months (AUC 0.63, 95% CI 0.56–0.70) and 12 months (AUC 0.63, 95% CI 0.56–0.70) after initial contact.

Conclusion

For longer periods of observation the SPMSQ can be a predictor of a composite endpoint of adverse outcomes even when controlled for a range of confounders. Its characteristics, specifically the low sensitivity, make it unsuitable as an accurate risk stratification tool on its own.

Electronic supplementary material

The online version of this article (10.1007/s00391-019-01626-z) contains supplementary material, which is available to authorized users.

Perceptions and expectations of health-related quality of life among geriatric patients seeking emergency care: a qualitative study

Background

Health-related quality of life (HRQoL), encompassing social, emotional, and physical wellbeing is an important clinical outcome of medical care, especially among geriatric patients. It is unclear which domains of HRQoL are most important to geriatric patients and which domains they hope to address when using the Emergency Department (ED). The objective of this study was to understand which aspects of HRQoL are most valued by geriatric patients in the ED and what expectations patients have for addressing or improving HRQoL during an ED visit.

Methods

This was a qualitative focus group study of geriatric ED patients from an urban, academic ED in the United States with > 16,500 annual geriatric visits. Patients were eligible if they were age > =65 years and discharged from the ED within 45 days of recruitment. Semi-structured pilot interviews and focus groups were conducted several weeks after the ED visit. Participants shared their ED experiences and to discuss their perceptions of the subsequent impact on their quality of life, focusing on the domains of physical, mental, and social health. Latent content and constant comparative methods were used to code focus group transcripts and analyze for emergent themes.

Results

Three individuals participated in pilot interviews and 31 participated in six focus groups. Twelve codes across five main themes relating to HRQoL were identified. Patients recalled: (1) A strong desire to regain physical function, and (2) anxiety elicited by the emotional experience of seeking care in the emergency department, due to uncertainty in diagnosis, treatment, and prognosis. In addition, patients noted both (3) interpersonal impacts of health on quality of life, primarily mediated primarily by social interaction, and (4) an individual experience of health and quality of life mediated primarily by mental health. Finally, (5) patients questioned if the ED was the right place to attempt to address HRQoL.

Conclusions

Patients expressed anxiety around the time of their ED visit related to uncertainty, they desired functional recovery, and identified both interpersonal effects of health on quality of life mediated by social health, and an individual experience of health and quality of life mediated by mental health.

Examining Age Inequalities in Operationalized Components of Advance Care Planning: Truncation of the ACP Process With Age

CONTEXT

Opportunities for patients to receive unnecessary, costly, and potentially harmful care near the end of life abound. Advance care planning (ACP) can help to make this vulnerable period better for patients, caregivers, and providers.

OBJECTIVE

The objective of this study was to determine whether older age predicted the presence of certain forms of retrievable ACP documentation in the electronic health record (EHR) in a large sample of hospice-referred patients.

METHODS

This was a retrospective analysis of medical-record data on 3595 patients referred to hospice between January 1, 2013 and December 31, 2015. EHR documentation of an ACP note in the problem list, presence of a scanned advance directive, and the presence of a verified do-not-resuscitate order were the outcome measures. Logistic regression was used to assess the effect of age, education, race, gender, cancer diagnosis, dementia diagnosis, palliative encounter, and death on the outcome variables.

RESULTS

Our results suggest that when we control for prognosis, patients over age 70 years may experience gaps in ACP communication. We found that as patients age, the odds of having documentation of a conversation (odds ratio [OR] = 0.56; P < 0.001) or scanned advance directive decreased (OR = 0.63; P < 0.001), while the odds of having a verified do-not-resuscitate order increased (OR = 1.42; P < 0.001).

CONCLUSION

The results of this study may imply some degree of unilateral and physician-driven decision making for end-of-life care among older adults. Collaborative efforts between an interdisciplinary medical team should focus on developing policies to address this potential disparity between younger and older adults at the end of life.

[Functional decline risk in elderly patients not institutionalized]

OBJECTIVE

To assess the risk of functional decline (DF) by using several prediction scales.

MATERIAL AND METHODS

A multicentre, observational, cross-sectional study was conducted on a population of 70 years or more in the health area of ??Toledo. Institutionalised, terminal ill, and patients dependent for three or more basic activities of daily life, were excluded. The sample (480 patients) was calculated for an estimated DF prevalence of 15%, accuracy 2%, confidence level 95%, and 10% of estimated losses. Stratified sampling; first by conglomerates (Health Centres) and then systematic sampling (1/15) by list of patients ordered by age. Response rate: 98%.

VARIABLES

Sociodemographic, morbidity, questionnaires to assess the functional capacity for basic activities (Katz index), and tools (Lawton-Brody index) of daily life and risk prediction rules of DF (SHERPA, TRST, ISAR-PC and Inouye). Approved by the Clinical Research Ethics Committee of Toledo.

RESULTS

The mean age was 77.94 (SD: 6.27), with 54.4% women. Mean number of illnesses: 4.38 (SD: 2.17) and drugs: 5.57 (SD: 3.35). Risk of DF according to the prediction rules: SHERPA: 32.7% (95% CI: 28.52-36.88) (slight risk: 17.2% [95% CI: 13.83-20.57]; moderate: 9.7% [95% CI: 7.06-12.34] and high: 5.8% [95% CI: 3.72-7.88]); TRST: 42% (95% CI: 37.6-46.4); ISAR-PC: 75.4% (95% CI: 71.14-78.86); Inouye: 49.3% (95% CI: 44.84-53.76) (mean risk: 44.5% [95% CI: 40.07-48.93], and high: risk 4.8% [95% CI: 2.89-6.71]).

CONCLUSIONS

A significant percentage of patients are at risk of DF, but there is a wide variation between the different rules. In general, the risk is lower than that found in other studies, and it is necessary to validate new rules adapted to our environment.

Preoperative geriatric assessment and follow-up of patients older than 75 years undergoing elective surgery for suspected colorectal cancer

OBJECTIVES

We investigated the predictive value of specific tools used in a Comprehensive Geriatric Assessment (CGA) with regard to postoperative outcome in patients 75 years and older undergoing elective colorectal cancer (CRC) surgery. Furthermore, recovery was followed over the first postoperative year using the same assessment tools.

MATERIAL AND METHODS

Baseline clinical and CGA variables including functional and nutritional status, pressure sore risk, fall risk, cognition, depression, polypharmacy, comorbidity, and health-related quality-of-life (HRQoL) were prospectively recorded. Outcome variables were postoperative complications and length of stay (LOS). Patients were likewise followed up at one, three and twelve months postoperatively.

RESULTS

Forty-nine patients underwent surgery (median age 81 years). Forty-three per cent had ASA (American Society of Anesthesiologists) class 2 47% had ASA class 3. Postoperative complications occurred in 32.7%. Median LOS was eight days. In univariate analyses, none of the parameters tested predicted postoperative complication or LOS. During follow-up, all patients recovered to baseline values apart from HRQoL which was still reduced at three and twelve months (p = .017). Nutritional status had improved twelve months after surgery (p = .011).

CONCLUSIONS

No association could be found in this study between the results of a comprehensive geriatric assessment and prolonged length of stay or postoperative complication rate after elective surgery for colorectal cancer. Patients recovered well during the first year after surgery. Quality of life, however, was still lower than prior to surgery.

Frailty Could Predict Death in Older Adults after Admissionat Emergency Department? A 6-month Prospective Study from a Middle-Income Country

BACKGROUND

The number of older adults attending emergency department (ED) is increasing all over the world. Usually, those patients are potentially more complex due to their greater number of comorbidities, cognitive disorders, and functional or physical disabilities. Frailty is a vulnerable state that could predict adverse outcomes of those patients. There are very few studies that addressed this topic in the ED, and none of them used a simple instrument for frailty assessment.

OBJECTIVES

The primary outcome was to evaluate the association between frailty identified through the FRAIL questionnaire at baseline and death after a 6-month follow-up period after hospital discharge from the ED. Secondary outcomes were readmission to the ED and disability after 6 months.

METHODS

A 6-month follow-up prospective study (FASES study) was conducted at a university-based trauma-center ED in Jundiaí, southwestern of Brazil. A total of 316 older adults aged 60 or older were randomly included based on a lottery of their medical record admission number. Frailty was evaluated through the FRAIL questionnaire. The association between frailty and death was estimated through a binary logistic regression adjusted for age, sex, and cognitive performance.

RESULTS

From the total sample, the mean age was 72.11±8.0 years, and 51.6% were women. Participants presented 2.28±1.4 comorbidities and 25.6% were frail. Mean hospital stay was 5.43±5.6 days. Death occurred in 52 participants, readmission to the emergency in 55, and new disability in 16 after 6 months. Frailty was associated with an odds ratio of 2.18 for death after 6 months (95% CI = 1.10-4.31; p = 0.024). This association lost significance after multivariate analysis taking into account cognitive performance. There was no association between frailty status at baseline and readmission to the ED or disability.

CONCLUSION

The identification of frailty using the FRAIL at admission was not predictive of death after a 6-month period after discharge from the ED. Simple frailty assessment could identify patients at higher risk for death in the follow-up.

What evidence is there for the identification and management of frail older people in the emergency department? A systematic mapping review

Background

Emergency departments (EDs) are facing unprecedented levels of demand. One of the causes of this increased demand is the ageing population. Older people represent a particular challenge to the ED as those older people who are frail will require management that considers their frailty alongside their presenting complaint. How to identify these older people as frail and how best to manage them in the ED is a major challenge for the health service to address.

Objectives

To systematically map interventions to identify frail and high-risk older people in the ED and interventions to manage older people in the ED and to map the outcomes of these interventions and examine whether or not there is any evidence of the impact of these interventions on patient and health service outcomes.

Design

A systematic mapping review.

Setting

Evidence from developed countries on interventions delivered in the ED.

Participants

Frail and high-risk older people and general populations of older people (aged > 65 years).

Interventions

Interventions to identify older people who are frail or who are at high risk of adverse outcomes and to manage (frail) older people within the ED.

Main outcome measures

Patient outcomes (direct and indirect) and health service outcomes.

Data sources

Evidence from 103 peer-reviewed articles and conference abstracts and 17 systematic reviews published from 2005 to 2016.

Review methods

A review protocol was drawn up and a systematic database search was undertaken for the years 2005–2016 (using MEDLINE, EMBASE, The Cochrane Library, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Health Management Information Consortium and PROSPERO). Studies were included according to predefined criteria. Following data extraction, evidence was classified into interventions relating to the identification of frail/high-risk older people in the ED and interventions relating to their management. A narrative synthesis of interventions/outcomes relating to these categories was undertaken. A quality assessment of individual studies was not undertaken; instead, an assessment of the overall evidence base in this area was made.

Results

Of the 90 included studies, 32 focused on a frail/high-risk population and 60 focused on an older population. These studies reported on interventions to identify (n = 57) and manage (n = 53) older people. The interventions to identify frail and at-risk older people, on admission and at discharge, utilised a number of different tools. There was extensive evidence on these question-based tools, but the evidence was inconclusive and contradictory. Service delivery innovations comprised changes to staffing, infrastructure and care delivery. There was a general trend towards improved outcomes in admissions avoidance, reduced ED reattendance and improved discharge outcomes.

Limitations

This review was a systematic mapping review. Some of the methods adopted differed from those used in a standard systematic review. Mapping the evidence base has led to the inclusion of a wide variety of evidence (in terms of study type and reporting quality). No recommendations on the effectiveness of specific interventions have been made as this was outside the scope of the review.

Conclusions

A substantial body of evidence on interventions for frail and high-risk older people was identified and mapped.

Future work

Future work in this area needs to determine why interventions work and whether or not they are feasible for the NHS and acceptable to patients.

Study registration

This study is registered as PROSPERO CRD42016043260.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Predicting hospital length of stay and short-term function after hip or knee arthroplasty: are both performance and comorbidity measures useful?

PURPOSE

Variations in hospital length of stay (LOS) and function are present after hip or knee arthroplasty. Comorbidity and performance measures have been associated with post-operative outcomes. It is however not known if both independently contribute to outcome prediction. The objective of this study was to evaluate the combined predictive ability of comorbidity scores (American Society of Anesthesiologists classification system (ASA), Charlson comorbidity index (CCI), 2008 version of the CCI (CCI08)) and a performance measure (Timed-Up-and-Go (TUG)) on LOS and short-term function in patients undergoing knee or hip arthroplasty.

METHODS

One hundred eight patients undergoing hip or knee arthroplasty were assessed preoperatively with the ASA, CCI, CCI08, and TUG. LOS was determined through administrative data. The Older Americans Resources and Services ADL questionnaire (OARS) was used to assess function two and six weeks after surgery. Logistic regression was used to assess the relationship between pre-operative assessments and LOS and OARS scores.

RESULTS

Both the ASA and TUG significantly contributed to LOS prediction. Odds ratio (OR) was 3.57 (95% confidence interval (CI) 1.26-10.07) for the ASA, and 2.18 (95% CI 1.67-4.15) for a one-standard deviation (SD) increase of 4.45 s of the TUG. Only the TUG was predictive of two weeks function and trending towards significance for six weeks function. One SD TUG increase yielded an OR of 2.14 (95% CI 1.53-3.79) for two week function.

CONCLUSIONS

The TUG and ASA can be used pre-operatively in combination to predict LOS, and TUG can also be used to predict short-term post-operative function.

Emergency Department Visits Without Hospitalization Are Associated With Functional Decline in Older Persons

STUDY OBJECTIVE

Among older persons, disability and functional decline are associated with increased mortality, institutionalization, and costs. The aim of the study was to determine whether illnesses and injuries leading to an emergency department (ED) visit but not hospitalization are associated with functional decline among community-living older persons.

METHODS

From a cohort of 754 community-living older persons who have been followed with monthly interviews for up to 14 years, we matched 813 ED visits without hospitalization (ED only) to 813 observations without an ED visit or hospitalization (control). We compared the course of disability during the following 6 months between the 2 matched groups. To establish a frame of reference, we also compared the ED-only group with an unmatched group who were hospitalized after an ED visit (ED-hospitalized). Disability scores (range 0 [lowest] to 13 [highest]) were compared using generalized linear models adjusted for relevant covariates. Admission to a nursing home and mortality were evaluated as secondary outcomes.

RESULTS

The ED-only and control groups were well matched. For both groups, the mean age was 84 years, and 69% were women. The baseline disability scores were 3.4 and 3.6 in the ED-only and control groups, respectively. During the 6-month follow-up period, the ED-only group had significantly higher disability scores than the control group, with an adjusted risk ratio of 1.14 (95% confidence interval [CI] 1.09 to 1.19). Compared with participants in the ED-only group, those who were hospitalized after an ED visit had disability scores that were significantly higher (risk ratio 1.17; 95% CI 1.12 to 1.22). Both nursing home admissions (hazard ratio 3.11; 95% CI 2.05 to 4.72) and mortality (hazard ratio 1.93; 95% CI 1.07 to 3.49) were higher in the ED-only group versus control group during the 6-month follow-up period.

CONCLUSION

Although not as debilitating as an acute hospitalization, illnesses and injuries leading to an ED visit without hospitalization were associated with a clinically meaningful decline in functional status during the following 6 months, suggesting that the period after an ED visit represents a vulnerable time for community-living older persons.

Impact of Emergency Department Visits and Hospitalization on Mobility Among Community-Dwelling Older Adults

PURPOSE

The study purpose was to assess the effects of emergency department visits on mobility as measured by Life-Space Assessment (LSA) scores and to compare life-space trajectories associated with emergency department visit only, hospitalization, and no event.

METHODS

A total of 410 community-dwelling adults aged ≥75 years who were living in the community, were able to communicate by telephone, could schedule an in-home interview, and could answer questions independently were followed from June 2010 to August 2014. In-home baseline and monthly telephone follow-up interviews collected data on LSA scores, emergency department use, and hospitalizations. Life-space is measured using a validated patient-reported tool reflecting community mobility and quality of life. Trajectories of LSA before and after an emergency department visit or hospitalization were compared with no event occurrence.

RESULTS

Mean age of participants was 81.7 years (standard deviation, 4.8); 57% were female, and 35% were African American. During 3 years of follow-up, 83 persons (20%) had an emergency department visit without subsequent hospitalization and 164 persons (40%) were hospitalized. Although baseline LSA scores were similar, in the month after an emergency department visit, adjusted LSA scores decreased by 6.1 points (P = .01) in comparison with hospitalized participants who experienced an average decrease of 18.0 points (P < .0001). Neither those with an emergency department visit only nor those with hospitalization recovered to their prior level of community mobility. Moreover, those with an emergency department visit showed no significant improvement in LSA scores up to 1 year later.

CONCLUSIONS

Older adults who experienced an emergency department visit or hospitalization had an associated decrease in community mobility without significant recovery.

Prediction of 90-day mortality in older patients after discharge from an emergency department: a retrospective follow-up study

Background

Older people frequently attend the emergency department (ED) and have a high risk of poor outcome as compared to their younger counterparts. Our aim was to study routinely collected clinical parameters as predictors of 90-day mortality in older patients attending our ED.

Methods

We conducted a retrospective follow-up study at the Leiden University Medical Center (The Netherlands) among patients aged 70 years or older attending the ED in 2012. Predictors were age, gender, time and way of arrival, presenting complaint, consulting medical specialty, vital signs, pain score and laboratory testing. Cox regression analyses were performed to analyse the association between these predictors and 90-day mortality.

Results

Three thousand two hundred one unique patients were eligible for inclusion. Ninety-day mortality was 10.5 % for the total group. Independent predictors of mortality were age (hazard ratio [HR] 1.06, 95 % confidence interval [95 % CI] 1.04-1.08), referral from another hospital (HR 2.74, 95 % CI 1.22-6.11), allocation to a non-surgical specialty (HR: 1.55, 95 % CI 1.13-2.14), increased respiration rate (HR up to 2.21, 95 % CI 1.25-3.92), low oxygen saturation (HR up to 1.96, 95 % CI 1.19-3.23), hypothermia (HR 2.27, 95 % CI 1.28-4.01), fever (HR 0.43, 95 % CI 0.24-0.75), high pain score (HR 1.55, 95 % CI 1.03-2.32) and the indication to perform laboratory testing (HR 3.44, 95 % CI 2.13-5.56).

Conclusions

Routinely collected parameters at the ED can predict 90-day mortality in older patients presenting to the ED. This study forms the first step towards creating a new and simple screening tool to predict and improve health outcome in acutely presenting older patients.

[Comprehensive geriatric assessment (CGA) in elderly with cancer: For whom?]

Scientific societies recommend the implementation of a comprehensive geriatric assessment (CGA) in cancer patients aged 70 and older. The EGA is an interdisciplinary multidimensional diagnostic process seeking to assess the frail older person in order to develop a coordinated plan of treatment and long-term follow-up. Identification of comorbidities and age-induced physiological changes that may increase the risk of anticancer treatment toxicities is essential to better assess the risk-benefit ratio in elderly cancer patients. The systematic implementation of a CGA for each patient is difficult to perform in daily practice. Therefore, it is recommended to screen vulnerable patients who will benefit from a complete CGA. Our work presents the vulnerability screening tools validated by at least two independent studies in a cancer elderly population setting. Among seven screening tools, the G8 and the VES13 are the most effective, and have been validated specifically in older population with cancer. The G8 is recommended by scientific societies and the French National Cancer Institute (INCa) because of its easy implementation in daily clinical practice, its high sensitivity and fair specificity. Although studies are underway to improve its performance, the G8 is currently the simplest tool to routinely identify older cancer patients who should have a complete assessment in geriatric oncology.

Prospective stratification of patients at risk for emergency department revisit: resource utilization and population management strategy implications

Background

Estimating patient risk of future emergency department (ED) revisits can guide the allocation of resources, e.g. local primary care and/or specialty, to better manage ED high utilization patient populations and thereby improve patient life qualities.

Methods

We set to develop and validate a method to estimate patient ED revisit risk in the subsequent 6 months from an ED discharge date. An ensemble decision-tree-based model with Electronic Medical Record (EMR) encounter data from HealthInfoNet (HIN), Maine’s Health Information Exchange (HIE), was developed and validated, assessing patient risk for a subsequent 6 month return ED visit based on the ED encounter-associated demographic and EMR clinical history data. A retrospective cohort of 293,461 ED encounters that occurred between January 1, 2012 and December 31, 2012, was assembled with the associated patients’ 1-year clinical histories before the ED discharge date, for model training and calibration purposes. To validate, a prospective cohort of 193,886 ED encounters that occurred between January 1, 2013 and June 30, 2013 was constructed.

Results

Statistical learning that was utilized to construct the prediction model identified 152 variables that included the following data domains: demographics groups (12), different encounter history (104), care facilities (12), primary and secondary diagnoses (10), primary and secondary procedures (2), chronic disease condition (1), laboratory test results (2), and outpatient prescription medications (9). The c-statistics for the retrospective and prospective cohorts were 0.742 and 0.730 respectively. Total medical expense and ED utilization by risk score 6 months after the discharge were analyzed. Cluster analysis identified discrete subpopulations of high-risk patients with distinctive resource utilization patterns, suggesting the need for diversified care management strategies.

Conclusions

Integration of our method into the HIN secure statewide data system in real time prospectively validated its performance. It promises to provide increased opportunity for high ED utilization identification, and optimized resource and population management.

Electronic supplementary material

The online version of this article (doi:10.1186/s12873-016-0074-5) contains supplementary material, which is available to authorized users.

Validity, Reliability and Feasibility of Tools to Identify Frail Older Patients in Inpatient Hospital Care: A Systematic Review

BACKGROUND

The objective of this study is to identify and review screening tools for frailty in older adults admitted to inpatient hospital care with respect to their validity, reliability and feasibility.

METHODS

Studies were identified through systematically searching PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase and PsycINFO and screening reference lists till June 2014. Papers dealing with screening tools aimed at identifying frail older patients in in-hospital care, and including information about validity, reliability or feasibility, were included in the review. The quality of the included studies was critically appraised via the Quality Assessment of Diagnostic Accuracy Studies (QUADAS).

RESULTS

From the originally identified 2001 studies 32 studies met the inclusion criteria, in which 16 screening tools were presented. The screening tools showed different characteristics with respect to the number of items, the method of administration and the domains included. The most frequently studied tools with respect to predictive validity were the Identification Seniors At Risk (ISAR) and Triage Risk Stratification Tool (TRST). Studies retrieved poorer information about reliability and feasibility. Overall sensitivity was fairly good. The ISAR, ISAR-HP (Identification Seniors At Risk Hospitalized Patients) and Multidimensional Prognostic Index (MPI) generally had the best sensitivity.

CONCLUSIONS

Many screening tools are available for daily practice. These tools to identify frail older patients in inpatient hospital care could be useful. For no tool, however, is clear evidence available yet regarding validity, reliability and feasibility. The overall sensitivity of the included screening tools was fairly good, whereas information on reliability and feasibility was lacking for most tools. In future research more attention should be given to the latter items.

Geriatric Disaster Preparedness

Introduction

The elderly population has proven to be vulnerable in times of a disaster. Many have chronic medical problems for which they depend on medications or medical equipment. Some older adults are dependent on caregivers for managing their activities of daily living (ADLs), such as dressing, and their instrumental activities of daily living (IADLs), such as transportation.

Problem

A coordinated effort for disaster preparation in the elderly population is paramount. This study assessed the potential needs and plans of older adults in the face of a local disaster.

Methods

The setting was a community-based, university-affiliated, urban emergency department (ED) that sees more than 77,000 adult patients per year. A survey on disaster plans and resources needed if evacuated was distributed to 100 community-residing ED patients and visitors aged 65 years and older from January through July 2013. Means and proportions are reported with 95% confidence intervals (CIs).

Results

Data were collected from 13 visitors and 87 patients. The mean age was 76 years, and 54% were female. Thirty-one responded that they had a disaster plan in place (31/100; CI, 22.4-41.4%). Of those 31, 94% (29/31; CI, 78.6-99.2%) had food and water as part of their plan, 62% (19/29; CI, 42.2-78.2%) had a supply of medication, and 35% (12/31; CI, 21.8-57.8%) had an evacuation plan. When asked what supplies the 100 subjects might need if evacuated, 33% (CI, 23.9-43.1%) needed a walker, 15% (CI, 8.6-23.5%) needed a wheelchair, 78% (CI, 68.6-85.7%) needed glasses, 17% (CI, 10.2-25.8%) needed a hearing aid, 16% (CI, 9.4-24.7%) needed a glucometer, 93% (CI, 86.1-97.1%) needed medication, 14% (CI, 7.8-22.4%) needed oxygen, 23% (CI, 15.2-32.5%) needed adult diapers, and 21% (CI, 13.2-30.3%) had medical equipment that required electricity. Many of the subjects also required help with one or more of their ADLS, the most common being dressing (17%; CI, 10.3-26.1%), or their IADLS, the most common being transportation (39%; CI, 29.7-49.7%). Only 42% (CI, 32.3-52.7%) were interested in learning more about disaster preparation.

Conclusion

Only a minority of the older adults in the study population had a disaster plan in place. Most of the respondents would require medications, and many would require medical supplies if evacuated.

BhallaMC, BurgessA, FreyJ, HardyW. Geriatric disaster preparedness. Prehosp Disaster Med. 2015;30(5):443–446.

Predicting early clinical function after hip or knee arthroplasty

Objectives

Patient function after arthroplasty should ideally quickly improve. It is not known which peri-operative function assessments predict length of stay (LOS) and short-term functional recovery. The objective of this study was to identify peri-operative functions assessments predictive of hospital LOS and short-term function after hospital discharge in hip or knee arthroplasty patients.

Methods

In total, 108 patients were assessed peri-operatively with the timed-up-and-go (TUG), Iowa level of assistance scale, post-operative quality of recovery scale, readiness for hospital discharge scale, and the Western Ontario and McMaster Osteoarthritis Index (WOMAC). The older Americans resources and services activities of daily living (ADL) questionnaire (OARS) was used to assess function two weeks after discharge.

Results

Following multiple regressions, the pre- and post-operative day two TUG was significantly associated with LOS and OARS score, while the pre-operative WOMAC function subscale was associated with the OARS score. Pre-operatively, a cut-off TUG time of 11.7 seconds for LOS and 10.3 seconds for short-term recovery yielded the highest sensitivity and specificity, while a cut-off WOMAC function score of 48.5/100 yielded the highest sensitivity and specificity. Post-operatively, a cut-off day two TUG time of 31.5 seconds for LOS and 30.9 seconds for short-term function yielded the highest sensitivity and specificity.

Conclusions

The pre- and post-operative day two TUG can indicate hospital LOS and short-term functional capacities, while the pre-operative WOMAC function subscale can indicate short-term functional capacities.

Cite this article: Bone Joint Res 2015;4:145–151.

Instruments to identify elderly patients in the emergency department in need of geriatric care

The number of people with functional limitations, cognitive impairment and disability with unscheduled, unintended contact to emergency departments seeking acute medical care is increasing. With this, the problem of how to identify elderly people in need for acute geriatric care has evolved. The best solution to the problem would be to perform comprehensive geriatric assessment during the initial contact; however, comprehensive geriatric assessment is considered too complex and therefore not feasible for emergency departments. Instead, screening instruments have been developed and proposed. In this narrative review, selected screening instruments are discussed. The instrument best studied in various settings and countries is the Identification of Seniors At Risk (ISAR) screening tool which contains six simple questions that are easy to administer and can be assessed even in urgent situations. In recent years, several studies have examined the validity of ISAR in different European countries. Most of these studies, including one German study and a recent systematic review, confirmed the validity of ISAR. Unfortunately, evidence is conflicting, as some studies found only weak or even no association between ISAR and negative health outcomes. Other instruments have been investigated to a lesser extent and do not indicate obvious advantages over ISAR. Despite growing evidence in the field, there are still many uncertainties. Further research is needed to solve existing inconsistencies and to assess how elderly patients screened positive for acute geriatric care needs can best be managed further.

Real-time web-based assessment of total population risk of future emergency department utilization: statewide prospective active case finding study

Background

An easily accessible real-time Web-based utility to assess patient risks of future emergency department (ED) visits can help the health care provider guide the allocation of resources to better manage higher-risk patient populations and thereby reduce unnecessary use of EDs.

Objective

Our main objective was to develop a Health Information Exchange-based, next 6-month ED risk surveillance system in the state of Maine.

Methods

Data on electronic medical record (EMR) encounters integrated by HealthInfoNet (HIN), Maine’s Health Information Exchange, were used to develop the Web-based surveillance system for a population ED future 6-month risk prediction. To model, a retrospective cohort of 829,641 patients with comprehensive clinical histories from January 1 to December 31, 2012 was used for training and then tested with a prospective cohort of 875,979 patients from July 1, 2012, to June 30, 2013.

Results

The multivariate statistical analysis identified 101 variables predictive of future defined 6-month risk of ED visit: 4 age groups, history of 8 different encounter types, history of 17 primary and 8 secondary diagnoses, 8 specific chronic diseases, 28 laboratory test results, history of 3 radiographic tests, and history of 25 outpatient prescription medications. The c-statistics for the retrospective and prospective cohorts were 0.739 and 0.732 respectively. Integration of our method into the HIN secure statewide data system in real time prospectively validated its performance. Cluster analysis in both the retrospective and prospective analyses revealed discrete subpopulations of high-risk patients, grouped around multiple “anchoring” demographics and chronic conditions. With the Web-based population risk-monitoring enterprise dashboards, the effectiveness of the active case finding algorithm has been validated by clinicians and caregivers in Maine.

Conclusions

The active case finding model and associated real-time Web-based app were designed to track the evolving nature of total population risk, in a longitudinal manner, for ED visits across all payers, all diseases, and all age groups. Therefore, providers can implement targeted care management strategies to the patient subgroups with similar patterns of clinical histories, driving the delivery of more efficient and effective health care interventions. To the best of our knowledge, this prospectively validated EMR-based, Web-based tool is the first one to allow real-time total population risk assessment for statewide ED visits.

Risk factors and screening instruments to predict adverse outcomes for undifferentiated older emergency department patients: a systematic review and meta-analysis

OBJECTIVES

A significant proportion of geriatric patients experience suboptimal outcomes following episodes of emergency department (ED) care. Risk stratification screening instruments exist to distinguish vulnerable subsets, but their prognostic accuracy varies. This systematic review quantifies the prognostic accuracy of individual risk factors and ED-validated screening instruments to distinguish patients more or less likely to experience short-term adverse outcomes like unanticipated ED returns, hospital readmissions, functional decline, or death.

METHODS

A medical librarian and two emergency physicians conducted a medical literature search of PubMed, EMBASE, SCOPUS, CENTRAL, and ClinicalTrials.gov using numerous combinations of search terms, including emergency medical services, risk stratification, geriatric, and multiple related MeSH terms in hundreds of combinations. Two authors hand-searched relevant specialty society research abstracts. Two physicians independently reviewed all abstracts and used the revised Quality Assessment of Diagnostic Accuracy Studies instrument to assess individual study quality. When two or more qualitatively similar studies were identified, meta-analysis was conducted using Meta-DiSc software. Primary outcomes were sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) for predictors of adverse outcomes at 1 to 12 months after the ED encounters. A hypothetical test-treatment threshold analysis was constructed based on the meta-analytic summary estimate of prognostic accuracy for one outcome.

RESULTS

A total of 7,940 unique citations were identified yielding 34 studies for inclusion in this systematic review. Studies were significantly heterogeneous in terms of country, outcomes assessed, and the timing of post-ED outcome assessments. All studies occurred in ED settings and none used published clinical decision rule derivation methodology. Individual risk factors assessed included dementia, delirium, age, dependency, malnutrition, pressure sore risk, and self-rated health. None of these risk factors significantly increased the risk of adverse outcome (LR+ range = 0.78 to 2.84). The absence of dependency reduces the risk of 1-year mortality (LR- = 0.27) and nursing home placement (LR- = 0.27). Five constructs of frailty were evaluated, but none increased or decreased the risk of adverse outcome. Three instruments were evaluated in the meta-analysis: Identification of Seniors at Risk, Triage Risk Screening Tool, and Variables Indicative of Placement Risk. None of these instruments significantly increased (LR+ range for various outcomes = 0.98 to 1.40) or decreased (LR- range = 0.53 to 1.11) the risk of adverse outcomes. The test threshold for 3-month functional decline based on the most accurate instrument was 42%, and the treatment threshold was 61%.

CONCLUSIONS

Risk stratification of geriatric adults following ED care is limited by the lack of pragmatic, accurate, and reliable instruments. Although absence of dependency reduces the risk of 1-year mortality, no individual risk factor, frailty construct, or risk assessment instrument accurately predicts risk of adverse outcomes in older ED patients. Existing instruments designed to risk stratify older ED patients do not accurately distinguish high- or low-risk subsets. Clinicians, educators, and policy-makers should not use these instruments as valid predictors of post-ED adverse outcomes. Future research to derive and validate feasible ED instruments to distinguish vulnerable elders should employ published decision instrument methods and examine the contributions of alternative variables, such as health literacy and dementia, which often remain clinically occult.

Risk prediction of emergency department revisit 30 days post discharge: a prospective study

BACKGROUND

Among patients who are discharged from the Emergency Department (ED), about 3% return within 30 days. Revisits can be related to the nature of the disease, medical errors, and/or inadequate diagnoses and treatment during their initial ED visit. Identification of high-risk patient population can help device new strategies for improved ED care with reduced ED utilization.

METHODS AND FINDINGS

A decision tree based model with discriminant Electronic Medical Record (EMR) features was developed and validated, estimating patient ED 30 day revisit risk. A retrospective cohort of 293,461 ED encounters from HealthInfoNet (HIN), Maine's Health Information Exchange (HIE), between January 1, 2012 and December 31, 2012, was assembled with the associated patients' demographic information and one-year clinical histories before the discharge date as the inputs. To validate, a prospective cohort of 193,886 encounters between January 1, 2013 and June 30, 2013 was constructed. The c-statistics for the retrospective and prospective predictions were 0.710 and 0.704 respectively. Clinical resource utilization, including ED use, was analyzed as a function of the ED risk score. Cluster analysis of high-risk patients identified discrete sub-populations with distinctive demographic, clinical and resource utilization patterns.

CONCLUSIONS

Our ED 30-day revisit model was prospectively validated on the Maine State HIN secure statewide data system. Future integration of our ED predictive analytics into the ED care work flow may lead to increased opportunities for targeted care intervention to reduce ED resource burden and overall healthcare expense, and improve outcomes.

Screening tools for multidimensional health problems warranting a geriatric assessment in older cancer patients: an update on SIOG recommendations†

BACKGROUND

Screening tools are proposed to identify those older cancer patients in need of geriatric assessment (GA) and multidisciplinary approach. We aimed to update the International Society of Geriatric Oncology (SIOG) 2005 recommendations on the use of screening tools.

MATERIALS AND METHODS

SIOG composed a task group to review, interpret and discuss evidence on the use of screening tools in older cancer patients. A systematic review was carried out and discussed by an expert panel, leading to a consensus statement on their use.

RESULTS

Forty-four studies reporting on the use of 17 different screening tools in older cancer patients were identified. The tools most studied in older cancer patients are G8, Flemish version of the Triage Risk Screening Tool (fTRST) and Vulnerable Elders Survey-13 (VES-13). Across all studies, the highest sensitivity was observed for: G8, fTRST, Oncogeriatric screen, Study of Osteoporotic Fractures, Eastern Cooperative Oncology Group-Performance Status, Senior Adult Oncology Program (SAOP) 2 screening and Gerhematolim. In 11 direct comparisons for detecting problems on a full GA, the G8 was more or equally sensitive than other instruments in all six comparisons, whereas results were mixed for the VES-13 in seven comparisons. In addition, different tools have demonstrated associations with outcome measures, including G8 and VES-13.

CONCLUSIONS

Screening tools do not replace GA but are recommended in a busy practice in order to identify those patients in need of full GA. If abnormal, screening should be followed by GA and guided multidisciplinary interventions. Several tools are available with different performance for various parameters (including sensitivity for addressing the need for further GA). Further research should focus on the ability of screening tools to build clinical pathways and to predict different outcome parameters.

Impact of observation on disposition of elderly patients presenting to emergency departments with non-specific complaints

Background

Emergency Departments (EDs) have to cope with an increasing number of elderly patients, often presenting with non-specific complaints (NSC), such as generalized weakness. Acute morbidity requiring early intervention is present in the majority of patients with NSC. Therefore, an early and optimal disposition plan is crucial. The objective of this study was to prospectively study the disposition process of patients presenting to the ED with NSC.

Methods

For two years, all patients presenting with NSC presenting to an urban ED were screened and consecutively included. The initial disposition plan was compared to the effective transfer after observation. Optimal disposition was defined as a high accuracy regarding disposition of patients with acute morbidity to an internal medicine ward.

Results

The final study population consisted of 669 patients with NSC. Admission to internal medicine increased from 297 (44%) planned admissions to 388 (58%) effective admissions after observation. Conversely, transfers to geriatric community hospitals and discharges decreased from the initially planned 372 (56%) patients to 281 (42%) effectively transferred and discharged patients. The accuracy regarding disposition of patients with acute morbidity increased from 53% to 68% after observation.

Conclusion

Disposition planning in patients with NSC improves after observation, if defined by the accuracy regarding hospitalization of patients with acute morbidity. Further research should focus on risk stratification tools for timely disposition planning in order to reduce high admission rates for patients without acute morbidity and high readmission rates for discharged patients with non-specific complaints.

Assessing functional ability in older patients

Aim:

This study aimed to develop an understanding of how primary and secondary care health professionals perceive current practice and challenges in assessing older patients' functional abilities. A secondary aim was to gain insight into how these professionals perceive the need for generic tools for assessing functional ability among older patients.

Method:

A qualitative design was used to explore health professionals' perspectives on the assessment of older patients' functional ability. Two groups of health professionals participated in focus group interviews, with one group for each of the two different settings: the local hospital and the municipality.

Results:

Focus group interviews showed that health professionals in the hospital and the municipality expressed the need for an observation-based tool to predict and guide decisions about the rehabilitation needs of older patients. Participants from the hospital expressed a need for a fast and simple screening tool to identify those in need of further rehabilitation and care after discharge. Participants from the municipality expressed a need for a more detailed assessment tool to capture information about patients' ability to perform daily activities, any need for food delivery, and information about social relationships and home environment.

Conclusion:

The health professionals at the hospital and in the municipality had different expectations when it comes to assessment tools. All participants would like a simple tool that is quick to administer, to assess the quality of functional ability and predict the need for rehabilitation. The different context (hospital or primary care) seems to influence the way health professionals perceive the need for assessment of functional ability in older patients.

[Review of functional impairment associated with acute illness in the elderly]

Hospitalization is a risk for elderly population, with a high probability of having adverse events. The most important one is functional impairment, due to its high prevalence and the serious impact it has on the quality of life. The main risk factors for functional decline associated with hospitalization are, age, immobility, cognitive impairment, and functional status prior to admission. It is necessary to detect patients at risk in order to implement the necessary actions to prevent this deterioration, with physical exercise and multidisciplinary geriatric care being the most important.

Methodology for developing quality indicators for the care of older people in the Emergency Department

Background

Compared with younger people, older people have a higher risk of adverse health outcomes when presenting to emergency departments. As the population ages, older people will make up an increasing proportion of the emergency department population. Therefore it is timely that consideration be given to the quality of care received by older persons in emergency departments, and to consideration of those older people with special needs. Particular attention will be focused on important groups of older people, such as patients with cognitive impairment, residents of long term care and patients with palliative care needs. This project will develop a suite of quality indicators focused on the care of older persons in the emergency department.

Methods/design

Following input from an expert panel, an initial set of structural, process, and outcome indicators will be developed based on thorough systematic search in the scientific literature. All initial indicators will be tested in eight emergency departments for their validity and feasibility. Results of the data from the field studies will be presented to the expert panel at a second meeting. A suite of Quality Indicators for the older emergency department population will be finalised following a formal voting process.

Discussion

The predicted burgeoning in the number of older persons presenting to emergency departments combined with the recognised quality deficiencies in emergency department care delivery to this population, highlight the need for a quality framework for the care of older persons in emergency departments. Additionally, high quality of care is associated with improved survival & health outcomes of elderly patients. The development of well-selected, validated and economical quality indicators will allow appropriate targeting of resources (financial, education or quality management) to improve quality in areas with maximum potential for improvement.

Identifying functional decline: a methodological challenge

Background

Functional decline (FD) in older people has commonly been measured in the hospital setting with instruments which have been validated on decrease over time in capacity to undertake basic activities of daily living (ADL). In a nonhospitalized sample of older people (independently community dwelling, but potentially on the cusp of FD), it is possible that other measures could be used to predict decline. Early, accurate, and efficient identification of older community-dwelling people who are on the cusp of FD can assist in identifying appropriate interventions to slow the rate of decline.

Methods

This paper reports on associations between four outcome measures which have been associated with FD (instrumental ADLs [IADLs], quality of life, hospitalizations and falls). The sample was older individuals who were discharged from one large metropolitan emergency department (ED) during 2011–2012, without an inpatient admission.

Results

Of 597 individuals aged 65+ who provided baseline information, 148 subjects provided four outcome measures at both 1 and 3 months follow up. Overall, approximately 24% demonstrated decreased IADL scores over the 3 months, with domains of home activities, laundry, shopping, and getting places declining the most. Over this time, 18% fell often, and 11% were consistently hospitalized. Between 1 and 3 months follow up, 41% declined in mental component scores, and 50% declined in physical component scores. Low mental and physical component quality of life scores were associated with downstream increased falls and hospitalizations, and decreased quality of life and IADLs. However, change in the four outcome measures was largely independent in factor analysis.

Conclusion

Measuring the four outcome measures over 3 months post-discharge from an ED presentation, showed that changes in one were not generally correlated with changes in another. This result suggests that a wider measurement net could be cast to identify individuals who may not be coping safely or independently in the community after a minor health crisis. Individuals who declined in at least one outcome measure at 1 month, generally continued to decline over the next 2 months, thus suggesting early opportunities to screen and intervene to slow FD.