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Albrecht R, Espejo T, Riedel HB, Nissen SK, Banerjee J, Conroy SP, Dreher-Hummel T, Brabrand M, Bingisser R, Nickel CH. Clinical Frailty Scale at presentation to the emergency department: interrater reliability and use of algorithm-assisted assessment. Eur Geriatr Med 2024; 15:105-113. [PMID: 37971677 PMCID: PMC10876739 DOI: 10.1007/s41999-023-00890-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 10/19/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE The Clinical Frailty Scale (CFS) allows health care providers to quickly stratify older patients, to support clinical decision-making. However, few studies have evaluated the CFS interrater reliability (IRR) in Emergency Departments (EDs), and the freely available smartphone application for CFS assessment was never tested for reliability. This study aimed to evaluate the interrater reliability of the Clinical Frailty Scale (CFS) ratings between experienced and unexperienced staff (ED clinicians and a study team (ST) of medical students supported by a smartphone application to assess the CFS), and to determine the feasibility of CFS assignment in patients aged 65 or older at triage. METHODS Cross-sectional study using consecutive sampling of ED patients aged 65 or older. We compared assessments by ED clinicians (Triage Clinicians (TC) and geriatric ED trained nurses (geriED-TN)) and a study team (ST) of medical students using a smartphone application for CFS scoring. The study is registered on Clinicaltrials.gov (NCT05400707). RESULTS We included 1349 patients aged 65 and older. Quadratic-weighted kappa values for ordinal CFS levels showed a good IRR between TC and ST (ϰ = 0.73, 95% CI 0.69-0.76), similarly to that between TC and geriED-TN (ϰ = 0.75, 95% CI 0.66-0.82) and between the ST and geriED-TN (ϰ = 0.74, 95% CI 0.63-0.81). A CFS rating was assigned to 972 (70.2%) patients at triage. CONCLUSION We found good IRR in the assessment of frailty with the CFS in different ED providers and a team using a smartphone application to support rating. A CFS assessment occurred in more than two-thirds (70.2%) of patients at triage.
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Affiliation(s)
- Rainer Albrecht
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, 4031, Basel, Switzerland
| | - Tanguy Espejo
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, 4031, Basel, Switzerland
| | - Henk B Riedel
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, 4031, Basel, Switzerland
| | - Søren K Nissen
- Research Unit for Emergency Medicine, Odense University Hospital, Odense, Denmark
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
| | - Jay Banerjee
- University Hospitals of Leicester NHS Trust, Leicester, UK
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Simon P Conroy
- St Pancras Hospital, Central and North West London NHS Foundation Trust, London, UK
- MRC Unit for Lifelong Health and Ageing, University College London, University College London Hospitals, London, UK
| | - Thomas Dreher-Hummel
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, 4031, Basel, Switzerland
| | - Mikkel Brabrand
- Research Unit for Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Roland Bingisser
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, 4031, Basel, Switzerland
| | - Christian H Nickel
- Emergency Department, University Hospital Basel, University of Basel, Petersgraben 2, 4031, Basel, Switzerland.
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2
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Xu Q, Li F, Chen X. Factors Affecting Mortality in Elderly Hypertensive Hospitalized Patients with COVID-19: A Retrospective Study. Clin Interv Aging 2023; 18:1905-1921. [PMID: 38020447 PMCID: PMC10674107 DOI: 10.2147/cia.s431271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/07/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose Corona Virus Disease 2019 (COVID-19) endangers the health and survival of the elderly. We tried to explore factors especially kidney function which affected mortality in elderly hypertensive patients with COVID-19. Methods We conducted a retrospective research of 748 COVID-19 elderly patients (≥65 years old) at Zhejiang Hospital. This study compared demographic data, laboratory values, comorbidities, treatments, and clinical outcomes of hypertension and non-hypertension participants, and subgroup analysis of age and frailty was conducted in the hypertension population. Survival analysis was used to determine risk factors for death in elderly patients with COVID-19. Results Our study revealed that the elderly hypertensive patients with COVID-19 had higher blood urea nitrogen (BUN), serum uric acid (UA), serum creatinine (Scr), lower estimated glomerular filtration rate (eGFR), higher incidence of severity, admission to intensive care unit (ICU) and death, and longer in-hospital stay than non-hypertensive patients, which also occurred in the very elderly hypertensive patients compared with younger hypertensive patients and frail hypertensive patients compared with no-frail hypertensive patients. In addition, the prevalence of acute kidney injury (AKI) was higher in the oldest old hypertensive patients and frail hypertensive patients. Multivariate survival analysis indicated that the independent risk factors for death from COVID-19 were age ≥80 years, heart failure, antiviral therapy, calcium channel blocker (CCB) therapy, mechanical ventilation, AKI, and eGFR<60 mL/min per 1.73 m2. Conclusion The results of the present study suggested that the elderly hypertensive patients with COVID-19 would have more serious kidney injury, more serious disease progression and higher mortality, which also occurred in very elderly and frailty subgroup. Kidney dysfunction was closely related to mortality in elderly patients with COVID-19.
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Affiliation(s)
- Qun Xu
- School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People’s Republic of China
| | - Fangzhou Li
- Department of Geriatrics, Zhejiang Provincial Hospital of Chinese Medicine, Hangzhou, Zhejiang Province, People’s Republic of China
| | - Xujiao Chen
- Department of Geriatrics, Zhejiang Provincial Hospital of Chinese Medicine, Hangzhou, Zhejiang Province, People’s Republic of China
- Zhejiang Hospital, Hangzhou, Zhejiang Province, People's Republic of China
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3
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Matsumoto C, Shibata S, Kishi T, Morimoto S, Mogi M, Yamamoto K, Kobayashi K, Tanaka M, Asayama K, Yamamoto E, Nakagami H, Hoshide S, Mukoyama M, Kario K, Node K, Rakugi H. Long COVID and hypertension-related disorders: a report from the Japanese Society of Hypertension Project Team on COVID-19. Hypertens Res 2023; 46:601-619. [PMID: 36575228 PMCID: PMC9793823 DOI: 10.1038/s41440-022-01145-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 12/09/2022] [Accepted: 12/12/2022] [Indexed: 12/28/2022]
Abstract
The coronavirus disease 2019 (COVID-19) affects infected patients even after the acute phase and impairs their health and quality of life by causing a wide variety of symptoms, referred to as long COVID. Although the evidence is still insufficient, hypertension is suspected to be a potential risk factor for long COVID, and the occurrence of cardiovascular diseases seems to be a key facet of multiple conditions observed in long COVID. Nonetheless, there are few reports that comprehensively review the impacts of long COVID on hypertension and related disorders. As a sequel to our previous report in 2020 which reviewed the association of COVID-19 and hypertension, we summarize the possible influences of long COVID on hypertension-related organs, including the cardiovascular system, kidney, and endocrine system, as well as the pathophysiological mechanisms associated with the disorders in this review. Given that the clinical course of COVID-19 is highly affected by age and sex, we also review the impacts of these factors on long COVID. Lastly, we discuss areas of uncertainty and future directions, which may lead to better understanding and improved prognosis of clinical problems associated with COVID-19.
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Affiliation(s)
- Chisa Matsumoto
- Department of Cardiology, Preventive medicine, Tokyo Medical University, Tokyo, Japan.
| | - Shigeru Shibata
- Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan.
| | - Takuya Kishi
- Department of Graduate School of Medicine (Cardiology), International University of Health and Welfare, Okawa, Japan
| | - Satoshi Morimoto
- Department of Endocrinology and Hypertension, Tokyo Women's Medical University, Tokyo, Japan
| | - Masaki Mogi
- Department of Pharmacology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Koichi Yamamoto
- Department of Geriatric and General Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Kazuo Kobayashi
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan.,Kobayashi Internal Medicine Clinic, Sagamihara, Japan
| | - Masami Tanaka
- Department of Internal Medicine, Adachi Medical Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Kei Asayama
- Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan
| | - Eiichiro Yamamoto
- Department of Cardiovascular Medicine, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Hironori Nakagami
- Department of Health Development and Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan.,Center for Infectious Disease Education and Research, Osaka University, Osaka, Japan
| | - Satoshi Hoshide
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Masashi Mukoyama
- Department of Nephrology, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, Saga, Japan
| | - Hiromi Rakugi
- Department of Geriatric and General Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
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4
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Kabell Nissen S, Rueegg M, Carpenter CR, Kaeppeli T, Busch J, Fournaise A, Dreher‐Hummel T, Bingisser R, Brabrand M, Nickel CH. Prognosis for older people at presentation to emergency department based on frailty and aggregated vital signs. J Am Geriatr Soc 2022; 71:1250-1258. [PMID: 36511431 DOI: 10.1111/jgs.18170] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 11/07/2022] [Accepted: 11/19/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Risk stratification for older people based on aggregated vital signs lack the accuracy to predict mortality at presentation to the Emergency Department (ED). We aimed to develop and internally validate the Frailty adjusted Prognosis in ED tool (FaP-ED) for 30-day mortality combining frailty and aggregated vital signs. METHODS Single-center prospective cohort of undifferentiated ED patients aged 65 or older, consecutively sampled upon ED presentation from a tertiary Emergency Center. Vital signs were aggregated using the National Early Warning Score (NEWS) as a measure of illness or injury severity and frailty was assessed with the Clinical Frailty Scale (CFS). The FaP-ED was constructed by combining NEWS and CFS in multivariable logistic regression. The primary outcome was 30-day mortality. Measures of discrimination and calibration were assessed to evaluate predictive performance and internally validated using bootstrapping. RESULTS 2250 patients were included, 67 (1.8%) were omitted from analyses due to missing CFS, loss to follow-up, or terminal illness. Thirty-day mortality rate was 5.4% (N = 122, 95% CI = 4.5%-6.4%). Median NEWS was 1 (Inter-Quartile Range (IQR): 0-3) and median CFS was 4 (IQR: 3-5). The Area Under Receiver Operating Characteristic (AUROC) for FaP-ED was 0.86 (95% CI = 0.83-0.90). This was significantly higher than NEWS (0.81, 95% CI = 0.77-0.85, DeLong: Z = 3.5, p < 0.001) or CFS alone (0.82, 95% CI = 0.78-0.86, DeLong: Z = 4.4, p < 0.001). Bootstrapped estimates of FaP-ED AUROC, calibration slope, and intercept were 0.86, 0.95, and -0.09, respectively, suggesting internal validity. A decision-threshold of CFS 5 and NEWS 3 was proposed based on qualitative comparison of positive Likelihood Ratio at all relevant FaP-ED cutoffs. CONCLUSION Combining aggregated vital signs and frailty accurately predicted 30-day mortality at ED presentation and illustrated an important clinical interaction between frailty and illness severity. Pending external validation, the Fap-ED operationalizes the concept of such "geriatric urgency" for the ED setting.
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Affiliation(s)
- Søren Kabell Nissen
- Institute of Regional Health Research University of Southern Denmark Esbjerg Denmark
- Department of Emergency Medicine Hospital South West Jutland, University hospital of Southern Denmark Esbjerg Denmark
| | - Marco Rueegg
- Department of Emergency Medicine University Hospital Basel, University of Basel Basel Switzerland
| | - Christopher R. Carpenter
- Department of Emergency Medicine Washington University in St. Louis School of Medicine, Emergency Care Research Core St. Louis Michigan USA
| | - Tobias Kaeppeli
- Department of Emergency Medicine University Hospital Basel, University of Basel Basel Switzerland
| | - Jeanette‐Marie Busch
- Department of Emergency Medicine University Hospital Basel, University of Basel Basel Switzerland
| | - Anders Fournaise
- Department of Cross‐sectoral Collaboration Region of Southern Denmark Vejle Denmark
- Epidemiology, Biostatistics and Biodemography, Department of Public Health University of Southern Denmark Odense Denmark
- Geriatric Research Unit, Department of Geriatric Medicine Odense University Hospital Odense Denmark
| | - Thomas Dreher‐Hummel
- Department of Emergency Medicine University Hospital Basel, University of Basel Basel Switzerland
| | - Roland Bingisser
- Department of Emergency Medicine University Hospital Basel, University of Basel Basel Switzerland
| | - Mikkel Brabrand
- Institute of Regional Health Research University of Southern Denmark Esbjerg Denmark
- Department of Emergency Medicine Odense University Hospital Odense Denmark
| | - Christian H. Nickel
- Department of Emergency Medicine University Hospital Basel, University of Basel Basel Switzerland
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5
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Fehlmann CA, Nickel CH, Cino E, Al-Najjar Z, Langlois N, Eagles D. Frailty assessment in emergency medicine using the Clinical Frailty Scale: a scoping review. Intern Emerg Med 2022; 17:2407-2418. [PMID: 35864373 PMCID: PMC9302874 DOI: 10.1007/s11739-022-03042-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 06/20/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Frailty is a common condition present in older Emergency Department (ED) patients that is associated with poor health outcomes. The Clinical Frailty Scale (CFS) is a tool that measures frailty on a scale from 1 (very fit) to 9 (terminally ill). The goal of this scoping review was to describe current use of the CFS in emergency medicine and to identify gaps in research. METHODS We performed a systemic literature search to identify original research that used the CFS in emergency medicine. Several databases were searched from January 2005 to July 2021. Two independent reviewers completed screening, full text review and data abstraction, with a focus on study characteristics, CFS assessment (evaluators, timing and purpose), study outcomes and statistical methods. RESULTS A total of 4818 unique citations were identified; 34 studies were included in the final analysis. Among them, 76% were published after 2018, mainly in Europe or North America (79%). Only two assessed CFS in the pre-hospital setting. The nine-point scale was used in 74% of the studies, and patient consent was required in 69% of them. The main reason to use CFS was as a main exposure (44%), a potential predictor (15%) or an outcome (15%). The most frequently studied outcomes were mortality and hospital admission. CONCLUSION The use of CFS in emergency medicine research is drastically increasing. However, the reporting is not optimal and should be more standardized. Studies evaluating the impact of frailty assessment in the ED are needed. REGISTRATION https://doi.org/10.17605/OSF.IO/W2F8N.
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Affiliation(s)
- Christophe Alain Fehlmann
- Division of Emergency Medicine, Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON Canada
- Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Christian Hans Nickel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Emily Cino
- Faculty of Medicine, University of Ottawa, Ottawa, ON Canada
| | | | - Nigèle Langlois
- Health Sciences Library, University of Ottawa, Ottawa, Canada
| | - Debra Eagles
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON Canada
- Ottawa Hospital Research Institute, Ottawa, ON Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON Canada
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6
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Bouwmans P, Brandts L, Hilbrands LB, Duivenvoorden R, Vart P, Franssen CFM, Covic A, Islam M, Rabaté C, Jager KJ, Noordzij M, Gansevoort RT, Hemmelder MH. The clinical frailty scale as a triage tool for ICU admission of dialysis patients with COVID-19 - An ERACODA analysis. Nephrol Dial Transplant 2022; 37:2264-2274. [PMID: 36002034 PMCID: PMC9452166 DOI: 10.1093/ndt/gfac246] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Indexed: 11/15/2022] Open
Abstract
Background Several guidelines recommend using the Clinical Frailty Scale (CFS) for triage of critically ill coronavirus disease 2019 (COVID-19) patients. This study evaluates the impact of CFS on intensive care unit (ICU) admission rate and hospital and ICU mortality rates in hospitalized dialysis patients with COVID-19. Methods We analysed data of dialysis patients diagnosed with COVID-19 from the European Renal Association COVID-19 Database. The primary outcome was ICU admission rate and secondary outcomes were hospital and ICU mortality until 3 months after COVID-19 diagnosis. Cox regression analyses were performed to assess associations between CFS and outcomes. Results A total of 1501 dialysis patients were hospitalized due to COVID-19, of whom 219 (15%) were admitted to an ICU. The ICU admission rate was lowest (5%) in patients >75 years of age with a CFS of 7–9 and highest (27%) in patients 65–75 years of age with a CFS of 5. A CFS of 7–9 was associated with a lower ICU admission rate than a CFS of 1–3 [relative risk 0.49 (95% confidence interval 0.27–0.87)]. Overall, mortality at 3 months was 34% in hospitalized patients, 65% in ICU-admitted patients and highest in patients >75 years of age with a CFS of 7–9 (69%). Only 9% of patients with a CFS ≥6 survived after ICU admission. After adjustment for age and sex, each CFS category ≥4 was associated with higher hospital and ICU mortality compared with a CFS of 1–3. Conclusions Frail dialysis patients with COVID-19 were less frequently admitted to the ICU. Large differences in mortality rates between fit and frail patients suggest that the CFS may be a useful complementary triage tool for ICU admission in dialysis patients with COVID-19.
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Affiliation(s)
- Pim Bouwmans
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands. CARIM School for Cardiovascular Disease, University of Maastricht, Maastricht, The Netherlands
| | - Lloyd Brandts
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Luuk B Hilbrands
- Department of Nephrology, Radboud University Medical Center. Nijmegen, The Netherlands
| | - Raphaël Duivenvoorden
- Department of Nephrology, Radboud University Medical Center. Nijmegen, The Netherlands
| | - Priya Vart
- Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands.,Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
| | - Casper F M Franssen
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
| | - Adrian Covic
- Grigore T Popa University of Medicine and Pharmacy, Iasi, Romania / Dr Ci Parhon Hospital, Iasi, Romania
| | - Mahmud Islam
- Zonguldak Ataturk state hospital, Zonguldak, Turkey
| | | | - Kitty J Jager
- ERA Registry, Amsterdam UMC location University of Amsterdam, Medical Informatics, Amsterdam, The Netherlands.,Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, The Netherlands
| | - Marlies Noordzij
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
| | - Ron T Gansevoort
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
| | - Marc H Hemmelder
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, Maastricht, The Netherlands. CARIM School for Cardiovascular Disease, University of Maastricht, Maastricht, The Netherlands
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7
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Rueegg M, Nissen SK, Brabrand M, Kaeppeli T, Dreher T, Carpenter CR, Bingisser R, Nickel CH. The clinical frailty scale predicts 1-year mortality in emergency department patients aged 65 years and older. Acad Emerg Med 2022; 29:572-580. [PMID: 35138670 PMCID: PMC9320818 DOI: 10.1111/acem.14460] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/13/2021] [Accepted: 12/28/2021] [Indexed: 12/22/2022]
Abstract
Objective To validate the Clinical Frailty Scale (CFS) for prediction of 1‐year all‐cause mortality in the emergency department (ED) and compare its performance to the Emergency Severity Index (ESI). Methods Prospective cohort study at the ED of a tertiary care center in Northwestern Switzerland. All patients aged ≥65 years were included from March 18 to May 20, 2019, after informed consent. Frailty status was assessed using CFS, excluding level 9 (palliative). Acuity level was assessed using ESI. Both CFS and ESI were adjusted for age, sex and presenting condition in multivariable logistic regression. Prognostic performance was assessed for discrimination and calibration separately. Estimates were internally validated by Bootstrapping. Restricted mean survival time (RMST) was determined for all levels of CFS. Results In the final study population of 2191 patients, 1‐year all‐cause mortality was 17% (n = 372). RMST values ranged from 219 days for CFS 8 to 365 days for CFS 1. The adjusted CFS model had an area under receiver operating characteristic of 0.767 (95% confidence interval [CI]: 0.741–0.793), compared to 0.703 (95% CI: 0.673–0.732) for the adjusted ESI model. Conclusion The CFS predicts 1‐year all‐cause mortality for older ED patients and predicts survival time in a graded manner. The CFS is superior to the ESI when adjusted for age, sex, and presenting condition.
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Affiliation(s)
- Marco Rueegg
- Emergency Department University Hospital Basel, University of Basel Basel Switzerland
| | - Søren Kabell Nissen
- Institute of Regional Health Research, Centre South‐West Jutland University of Southern Denmark Odense Denmark
| | - Mikkel Brabrand
- Institute of Regional Health Research, Centre South‐West Jutland University of Southern Denmark Odense Denmark
- Department of Emergency Medicine Odense University Hospital, University of Southern Denmark Odense Denmark
| | - Tobias Kaeppeli
- Emergency Department University Hospital Basel, University of Basel Basel Switzerland
| | - Thomas Dreher
- Emergency Department University Hospital Basel, University of Basel Basel Switzerland
| | - Christopher R. Carpenter
- Department of Emergency MedicineWashington University in St. Louis School of Medicine, Emergency Care Research CoreSt. LouisMichiganUSA
| | - Roland Bingisser
- Emergency Department University Hospital Basel, University of Basel Basel Switzerland
| | - Christian H. Nickel
- Emergency Department University Hospital Basel, University of Basel Basel Switzerland
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