The Accuracy of Four Frequently Used Frailty Instruments for the Prediction of Adverse Health Outcomes Among Older Adults at Two Dutch Emergency Departments: Findings of the AmsterGEM Study

Abstract

Older adults presenting to the emergency department (ED) are at high risk of adverse health outcomes. This study aimed to evaluate the accuracy of 4 frequently used screening instruments for the prediction of adverse health outcomes among older adults in the ED.Methods: This was a prospective cohort study in patients 70 years of age presenting to the ED in 2 hospitals in the Netherlands. Screening instruments included the acutely presenting older patient screening program (APOP) (providing 2 risk scores-functional decline [APOP1] and mortality [APOP2]), the International Resident Assessment Instrument Emergendy Department screener (InterRAI ED), the Identification of Seniors At Risk-Hospitalized Patients (ISAR-HP), and the safety management system (VMS). The primary outcome measure was a composite outcome encompassing functional decline, institutionalization, and mortality at 3 months after ED presentation. Other follow-up time points were 1 and 6 months. Analyses were performed to assess prognostic accuracy.Results: In total, 889 patients were included. After 3 months, 267 (31%) patients experienced at least 1 adverse outcome. The positive likelihood ratio ranged from 1.67 (VMS) to 3.33 (APOP1), and the negative likelihood ratio ranged from 0.41 (ISAR-HP) to 0.88 (APOP2). Sensitivity ranged from 17% (APOP2) to 74% (ISAR-HP), and specificity ranged from 63% (ISAR-HP) to 94% (APOP2). The area under the curve ranged from 0.62 (APOP2) to 0.72 (APOP1 and ISAR-HP). Calibration was reasonable for APOP1 and VMS. The prognostic accuracy was comparable across all outcomes and at all follow-up time points. Conclusion:The frailty screening instruments assessed in this study showed poor to moderate prognostic accuracy, which brings into question their usability in the prediction of adverse health outcomes among older adults who present to the ED.

The feasibility and acceptability of frailty screening tools in the Emergency Department and the additional value of clinical judgment for frailty detection

“…The results of this study show that successful implementation of frailty screening tools in the ED does not depend on the type of screener because all frailty screening tools were easy, quick to perform and generally well accepted by healthcare professionals working in the ED. This is similar to the results of prior studies as shown in the review by van Dam et al [9]. However, participants did mention barriers like workload and lack of clear benefits in using a screening tool.…”

“…This is similar to the results of prior studies as shown in the review by van Dam et al . [9]. However, participants did mention barriers like workload and lack of clear benefits in using a screening tool.…”

Polypharmacy, comorbidity and frailty: a complex interplay in older patients at the emergency department

“…This prospective cohort study—the Amsterdam Geriatric Emergency Medicine study (AmsterGEM) [ 14 ]—was conducted at the ED of two Dutch hospitals: tertiary academic hospital Amsterdam UMC location VUmc in Amsterdam and the general community hospital Amstelland in Amstelveen. Data were collected on a daily basis from November 2017 to June 2018, mostly during office hours, and during a limited number of evenings and weekend days.…”

“…For the AmsterGEM study [ 14 ], research students screened every patient aged ≥ 70 years attending the ED for eligibility, regardless of the reason for presentation and/or specialty they presented for. Exclusion criteria were patients labeled as high urgency (according to the Manchester Triage System—code red [ 15 ]), language barrier, unknown number of prescriptions, limited length of stay at the ED, or inability to give informed consent (for example due to altered mental status in the absence of a caregiver who could provide informed consent by proxy).…”

Validating administratively derived frailty scores for use in Veterans Health Administration emergency departments

“…Screens performed in the ED for health‐related social needs, substance abuse disorders, or behavioral health problems have led to successful intervention to address identified patient problems 23–25 . Previous studies of frailty scores performed in the ED found that individuals identified as severely frail had increased risk of repeat ED visits, admission, and mortality 26–28 . To date there have been no published studies on the application of frailty scores within the VA ED population.…”