Screening for frailty in elderly emergency department patients by using the Identification of Seniors At Risk (ISAR)

Salvi, F.; Morichi, Valeria; Grilli, Annalisa; Lancioni, L.; Spazzafumo, Liana; Polonara, Stefano; Abbatecola, Angela Marie; Tommaso, G. De; Dessı̀-Fulgheri, Paolo; Lattanzio, Fabrizia

doi:10.1007/s12603-011-0155-9

Cited by 104 publications

(96 citation statements)

References 35 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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“…In a recent study the ISAR identified frail patients in the emergency departments with an increased vulnerability to internal and external stressors [15]. …”

Section: Discussionmentioning

confidence: 99%

Predictive Validity of the Identification of Seniors at Risk Screening Tool in a German Emergency Department Setting

et al. 2014

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Background: The identification of patients at high risk for adverse outcomes [death, unplanned readmission to emergency department (ED)/hospital, functional decline] plays an important role in emergency medicine. The Identification of Seniors at Risk (ISAR) instrument is one of the most commonly used and best-validated screening tools. As to the authors' knowledge so far there are no data on any screening tool for the identification of older patients at risk for a negative outcome in Germany. Objectives: To evaluate the validity of the ISAR screening tool in a German ED. Design: This was a prospective single-center observational cohort study in an ED of an urban university-affiliated hospital. Participants were 520 patients aged ≥75 years consecutively admitted to the ED. Measurements: The German version of the ISAR screening tool was administered directly after triage of the patients. Follow-up telephone interviews to assess outcome variables were conducted 28 and 180 days after the index visit in the ED. The primary end point was death from any cause or hospitalization or recurrent ED visit or change of residency into a long-term care facility on day 28 after the index ED visit. Results: The mean age ± SD was 82.8 ± 5.0 years. According to ISAR, 425 patients (81.7%) scored ≥2 points, and 315 patients (60.5%) scored ≥3 points. The combined primary end point was observed in 250 of 520 patients (48.1%) on day 28 and in 260 patients (50.0%) on day 180. Using a continuous ISAR score the area under the curve on day 28 was 0.621 (95% confidence interval, CI 0.573-0.669) and 0.661 (95% CI 0.615-0.708) on day 180, respectively. Conclusion: The German version of the ISAR screening tool acceptably identified elderly patients in the ED with an increased risk of a negative outcome. Using the cutoff ≥3 points instead of ≥2 points yielded better overall results.

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“…Several studies reported composite outcomes of various combinations of undesired outcomes as "any adverse outcome." 66,67,70,76,77,79 The ISAR studies assessed the instrument's prognostic accuracy for ED return visits at 30 to 180 days, functional decline at 30 to 90 days, and hospital readmission at 30 to 180 days. In addition, multiple studies reported composite outcomes of "any adverse outcome" at 30 to 180 days, although the components of the combined endpoint varied from study to study.…”

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

259

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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Screening for frailty in elderly emergency department patients by using the Identification of Seniors At Risk (ISAR)

Abstract: ISAR is a useful screening tool for frailty and identifies elderly patients at risk of adverse outcomes after an ED visit. ISAR can also be used to select high-risk patients more likely to benefit from a geriatric approach or intervention, independently of admission or discharge.

Cited by 104 publications

References 35 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

Predictive Validity of the Identification of Seniors at Risk Screening Tool in a German Emergency Department Setting

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

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