Prognostic Stratification of Elderly Patients in the Emergency Department: A Comparison Between the “Identification of Seniors at Risk” and the “Silver Code”

Bari, Mauro Di; Salvi, F.; Roberts, Anna Teresa; Balzi, Daniela; Lorenzetti, B; Morichi, Valeria; Rossi, Lorena; Lattanzio, Fabrizia; Marchionni, Niccolò

doi:10.1093/gerona/glr209

Cited by 48 publications

(49 citation statements)

References 16 publications

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“…Our finding, that the ISAR has a poor discriminating value to predict adverse outcomes in older patients discharged from UK acute medical units, shows that the ISAR did not perform as well as in the original Canadian study [6], where the tool was shown to be 'fair' discriminating value (AUC: 0.71). However, our findings are compatible with more recent European and Asian studies [7][8][9][10][11][12] which have reported areas under the curves for the ISAR between 'no value' (0.5) and 'fair' (0.7). As our study only evaluated the 'best' 40%, further studies are warranted taking 'all comers' before the utility of this tool can be judged.…”

Section: Discussionsupporting

confidence: 93%

“…The ISAR includes six simple dichotomous questions, making it simple and acceptable for patients and staff alike. The ISAR has been tested in North America [6], many European countries [7][8][9][10][11] and Hong Kong [12] where its predictive value varied between 'fair' and 'poor' [determined using receiveroperator curve (ROC) analysis which takes both specificity and sensitivity into account], the difference depending upon the case mix and the health services available in different countries. For the ISAR to be used in the UK, it is important to demonstrate adequate predictive ability in UK settings, but this has not yet been done, and this was the purpose of this study.…”

Section: Introductionmentioning

confidence: 99%

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The Identification Of Seniors At Risk (ISAR) Score to predict clinical outcomes and health service costs in older people discharged from UK acute medical units

Edmans

Bradshaw

Gladman

et al. 2013

European Geriatric Medicine

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Background: tools are required to identify high-risk older people in acute emergency settings so that appropriate services can be directed towards them. Objective: to evaluate whether the Identification of Seniors At Risk (ISAR) predicts the clinical outcomes and health and social services costs of older people discharged from acute medical units. Design: an observational cohort study using receiver-operator curve analysis to compare baseline ISAR to an adverse clinical outcome at 90 days (where an adverse outcome was any of death, institutionalisation, hospital readmission, increased dependency in activities of daily living (decrease of 2 or more points on the Barthel ADL Index), reduced mental well-being (increase of 2 or more points on the 12-point General Health Questionnaire) or reduced quality of life (reduction in the EuroQol-5D) and high health and social services costs over 90 days estimated from routine electronic service records. Setting: two acute medical units in the East Midlands, UK. Participants: a total of 667 patients aged ≥70 discharged from acute medical units. Results: an adverse outcome at 90 days was observed in 76% of participants. The ISAR was poor at predicting adverse outcomes (AUC: 0.60, 95% CI: 0.54-0.65) and fair for health and social care costs (AUC: 0.70, 95% CI: 0.59-0.81). Conclusions: adverse outcomes are common in older people discharged from acute medical units in the UK; the poor predictive ability of the ISAR in older people discharged from acute medical units makes it unsuitable as a sole tool in clinical decision-making.

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Section: Discussionsupporting

confidence: 93%

Section: Introductionmentioning

confidence: 99%

The Identification Of Seniors At Risk (ISAR) Score to predict clinical outcomes and health service costs in older people discharged from UK acute medical units

Edmans

Bradshaw

Gladman

et al. 2013

European Geriatric Medicine

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“…Seven different geriatric prognostic screening instruments were assessed in the included studies: Identification of Seniors at Risk (ISAR), 9 TRST, 10 the Silver 57,71 were each assessed by two studies involving 464 and 12,451 patients, respectively. The studies evaluated a wide range of outcomes at post-ED time frames ranging from 14 days to 1 year.…”

Section: Screening Instrumentsmentioning

confidence: 99%

“…57 The derivation and validation sets were consistent, but neither threshold was sufficiently prognostic for 1-year mortality. Di Bari et al 71 subsequently evaluated the Silver Code for 6-month outcomes of ED revisits, readmission, mortality, or any combination of these outcomes at the same two thresholds. Again, the Silver Code lacked sufficient prognostic accuracy to increase (LR+ ranges = 1.59 to 2.47) or decrease (LR-ranges = 0.70 to 0.88) the risk of these outcomes.…”

Section: Screening Instrumentsmentioning

confidence: 99%

Risk Factors and Screening Instruments to Predict Adverse Outcomes for Undifferentiated Older Emergency Department Patients: A Systematic Review and Meta‐analysis

Carpenter

Shelton

Fowler

et al. 2015

Academic Emergency Medicine

264

213

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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 testtreatment 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 r...

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“…22 Penelitian Salvi, dkk. 23 di Italia mendapatkan mortalitas 30 hari sebesar 6,5% dan mortalitas 6 bulan sebesar 19,5%. Sementara itu, Bari, dkk.…”

Section: Insiden Mortalitas 30 Hari Pasien Usia Lanjut Yang Datang Keunclassified

Performa Rapid Emergency Medicine Score (REMS) dalam Memprediksi Mortalitas 30 Hari Pasien Usia Lanjut di Instalasi Gawat Darurat

Rizka¹,

Harimurti²,

Pitoyo³

et al. 2017

JPDI

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ABSTRAKPendahuluan. Rapid Emergency Medicine Score (REMS) merupakan suatu instrumen yang banyak digunakan untuk melakukan stratifikasi risiko pasien non-bedah di Instalasi Gawat Darurat (IGD). Namun, pasien usia lanjut yang datang ke IGD seringkali datang dengan manifestasi klinis yang atipikal, sehingga performa REMS untuk populasi khusus ini perlu diuji. Penelitian ini dilakukan untuk menilai performa REMS pada populasi pasien usia lanjut yang datang ke IGD.Metode. Dilakukan penelitian kohort prospektif berbasis penelitian prognostik pada pasien usia >60 tahun yang datang ke IGD RS dr. Cipto Mangunkusumo (RSCM), Jakarta selama September hingga Oktober 2016. Subjek diikuti selama 30 hari sejak kedatangan ke IGD. Selanjutnya dilakukan perhitungan kalibrasi (uji Hosmer Lemeshow) dan diskriminasi (perhitungan Area under ROC Curve) REMS dalam memprediksi mortalitas 30 hari pasien usia lanjut.Hasil. Terdapat 321 pasien usia lanjut masuk IGD selama periode penelitian dan 306 di antaranya memenuhi kriteria pemilihan. Dari seluruh subjek, 163 (53,2% pasien adalah laki-laki. Insiden kematian 30 hari sebanyak 22,8% (IK95% 22,3-23,3). Rerata usia 68,3 (SB 6,7) tahun. Sebanyak 83 (27%) pasien dikategorikan triage merah. Terdapat 154 (50%) pasien dengan REMS 0-7, 140 (46%) dengan REMS 8-17 dan 12(4%) with REMS lebih dari 17. Plot kalibrasi menunjukkan r=0,23 dengan hasil uji Hosmer Lemeshow buruk (p=0,00). AUC REMS untuk memprediksi mortalitas 30 hari pasien usia lanjut adalah 0,45 (95% CI 0,23-0,66).Simpulan. REMS menunjukkan performa yang buruk dalam memprediksi mortalitas 30 hari pasien usia lanjut di IGD.

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Prognostic Stratification of Elderly Patients in the Emergency Department: A Comparison Between the “Identification of Seniors at Risk” and the “Silver Code”

Abstract: Prognostic stratification of elderly ED patients with the SC is comparable with that obtained with direct patient evaluation. The SC, previously validated in hospitalized patients, predicts ED readmissions and future hospitalizations even in patients discharged directly from the ED.

Cited by 48 publications

References 16 publications

The Identification Of Seniors At Risk (ISAR) Score to predict clinical outcomes and health service costs in older people discharged from UK acute medical units

The Identification Of Seniors At Risk (ISAR) Score to predict clinical outcomes and health service costs in older people discharged from UK acute medical units

Risk Factors and Screening Instruments to Predict Adverse Outcomes for Undifferentiated Older Emergency Department Patients: A Systematic Review and Meta‐analysis

Performa Rapid Emergency Medicine Score (REMS) dalam Memprediksi Mortalitas 30 Hari Pasien Usia Lanjut di Instalasi Gawat Darurat

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