The Prognostic Accuracy of Clinical Judgment Versus a Validated Frailty Screening Instrument in Older Patients at the Emergency Department: Findings of the AmsterGEM Study

STUDY OBJECTIVE

To compare the prognostic accuracy of clinical judgment for frailty in older patients at the emergency department with a validated screening instrument and patient-perceived frailty.

METHODS

A prospective cohort study in patients 70 years of age and older in 2 Dutch EDs with a follow-up of 3 months. A dichotomous question was asked to the physician and patient: "Do you consider the patient / yourself to be frail?" The Identification of Seniors At Risk-Hospitalized Patients (ISAR-HP) was used as a validated screening instrument. The primary composite outcome consisted of either functional decline, institutionalization, or mortality.

RESULTS

A total of 736 patients were included. The physician identified 59% as frail, compared with 49% by ISAR-HP and 43% by patients themselves. The level of agreement was fair (Fleiss Kappa, 0.31). After 3 months, 31% of the patients experienced at least 1 adverse health outcome. The sensitivity was 79% for the physician, 72% for ISAR-HP, 61% for the patient, and 48% for all 3 combined. The specificity was 50% for the physician, 63% for ISAR-HP, 66% for the patient, and 85% for all 3 positive. The highest positive likelihood ratio was 3.03 (physician, ISAR-HP, patient combined), and the lowest negative likelihood ratio was 0.42 (physician). The areas under the receiver operating curves were all poor: 0.68 at best for ISAR-HP.

CONCLUSION

Clinical judgment for frailty showed fair agreement with a validated screening instrument and patient-perceived frailty. All 3 instruments have poor prognostic accuracy, which does not improve when combined. These findings illustrate the limited prognostic value of clinical judgment as a frailty screener in older patients at the ED.

Agreement and reliability of a symptom modification test cluster for patients with subacromial pain syndrome

OBJECTIVES

To identify if a plausible theoretical construct exists for a test cluster in a group of patients with subacromial pain syndrome presenting with glenohumeral internal rotation deficit (GIRD); determine the intertester agreement and reliability of the proposed test cluster; determine if there are any meaningful relationships between the test cluster and the component tests for the entire sample; and determine if there are any differences in disability on the Dutch version of the shoulder pain and disability index between participants with a positive and negative test cluster.

METHODS

This study is a retrospective secondary analysis of data that were collected to determine the interrater agreement and reliability of clinical tests for assessment of patients with shoulder pain in primary care.

RESULTS

The test cluster total agreement and negative specific agreement was 87.8 and 90.4%, respectively. The prevalence-adjusted bias-adjusted kappa for the test cluster was substantial at 0.76. There were statistically significant meaningful relationships (≥0.50) between GIRD and the test cluster for Tester A (Phi = 0.71, p < .01) and Tester B (Phi = 0.82, p < .01). No differences in disability were identified between those with a positive and negative test cluster.

CONCLUSION

The test cluster described in this study may be a reliable means of identifying a subgroup of patients with subacromial pain syndrome related to GIRD. Future research should look to validate this test cluster prospectively.

What Outcomes do Dutch Healthcare Professionals Perceive as Important Before Participation in Moral Case Deliberation?

BACKGROUND

There has been little attention paid to research on the outcomes of clinical ethics support (CES) or critical reflection on what constitutes a good CES outcome. Understanding how CES users perceive the importance of CES outcomes can contribute to a better understanding, use of and normative reflection on CES outcomes.

OBJECTIVE

To describe the perceptions of Dutch healthcare professionals on important outcomes of moral case deliberation (MCD), prior to MCD participation, and to compare results between respondents.

METHODS

This mixed-methods study used both the Euro-MCD instrument and semi-structured interviews. Healthcare professionals who were about to implement MCD were recruited from nursing homes, hospitals, psychiatry and mentally disabled care institutions.

RESULTS

331 healthcare professionals completed the Euro-MCD instrument, 13 healthcare professionals were interviewed. The outcomes perceived as most important were 'more open communication', 'better mutual understanding', 'concrete actions', 'see the situation from different perspectives', 'consensus on how to manage the situation' and 'find more courses of action'. Interviewees also perceived improving quality of care, professionalism and the organization as important. Women, nurses, managers and professionals in mentally disabled care rated outcomes more highly than other respondents.

CONCLUSIONS

Dutch healthcare professionals perceived the MCD outcomes related to collaboration as most important. The empirical findings can contribute to shared ownership of MCD and a more specific use of MCD in different contexts. They can inform international comparative research on different CES types and contribute to normative discussions concerning CES outcomes. Future studies should reflect upon important MCD outcomes after having experienced MCD.

Evaluation of the usefulness of 2 prediction models of clinical prediction models in physical therapy: a qualitative process evaluation

OBJECTIVE

The purposes of this study were to (1) evaluate the usefulness of 2 prediction models by assessing the actual use and advantages/disadvantages of application in daily clinical practice and (2) propose recommendations to enhance their implementation.

METHODS

Physical therapists working in 283 practices in the area of Breda (the Netherlands) were invited to participate in this study. Two prediction models were presented: (1) to predict persistent shoulder pain and (2) to predict the preferable treatment in nonspecific neck pain. Participants were asked to apply both models in practice. After 2 months, their opinions about the usefulness of both models were gathered during a focus group meeting or by using an online questionnaire in order to identify the most important advantages/disadvantages of each prediction model.

RESULTS

In total, 46 physical therapists (13.8%) of 39 practices participated. Evaluative data were available from 32 participants who used the shoulder model 102 times and the neck model 126 times. For the shoulder model, the most frequent advantage (mentioned 14 times) was that it enabled physical therapists to estimate a motivated prognosis, that is, a prognosis based on the score of the model. The most frequent mentioned disadvantage was that participants expressed their doubts about the validity of the model because the model initially was developed for usage in a general practice setting. For the neck model, the most frequently mentioned advantage (29 times) was that the model was easy to interpret. The most important disadvantage (mentioned 14 times) was that the model only takes a few treatment options into account.

CONCLUSIONS

The physical therapists participating in this study reported that both models evaluated in this study were not easy to use in daily practice. Based on the findings of this study, we recommend that these models are modified to meet the practical needs of the therapist, before assessing their impact on daily clinical care and patient outcomes.

Analysis of unintended events in hospitals: inter-rater reliability of constructing causal trees and classifying root causes

BACKGROUND

Root cause analysis is a method to examine causes of unintended events. PRISMA (Prevention and Recovery Information System for Monitoring and Analysis: is a root cause analysis tool. With PRISMA, events are described in causal trees and root causes are subsequently classified with the Eindhoven Classification Model (ECM). It is important that root cause analysis tools are reliable, because they form the basis for patient safety interventions.

OBJECTIVES

Determining the inter-rater reliability of descriptions, number and classifications of root causes.

DESIGN

Totally, 300 unintended event reports were sampled from a database of 2028 events in 30 hospital units. The reports were previously analysed using PRISMA by experienced analysts and were re-analysed to compare descriptions and number of root causes (n = 150) and to determine the inter-rater reliability of classifications (n = 150).

MAIN OUTCOME MEASURES

Percentage agreement and Cohen's kappa (kappa).

RESULTS

Agreement between descriptions of root causes was satisfactory: 54% agreement, 17% partial agreement and 29% no agreement. Inter-rater reliability of number of root causes was moderate (kappa = 0.46). Inter-rater reliability of classifying root causes with the ECM was substantial from highest category level (kappa = 0.71) to lowest subcategory level (kappa = 0.63). Most discrepancies occurred in classifying external causes.

CONCLUSIONS

Results indicate that causal tree analysis with PRISMA is reliable. Analysts formulated similar root causes and agreed considerably on classifications, but showed variation in number of root causes. More training on disclosure of all relevant root causes is recommended as well as adjustment of the model by combining all external causes into one category.