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

Dam, Carmen S. van; Trappenburg, Marijke C.; Wee, Marieke M. ter; Hoogendijk, Emiel O.; Vet, Riekie de; Smulders, Yvo M.; Nanayakkara, Prabath B.; Muller, Majon; Peters, Mike

doi:10.1016/j.annemergmed.2022.04.039

Cited by 6 publications

(9 citation statements)

References 39 publications

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“…Inouye et al delineated that the final common pathway of these syndromes was frailty, which in turn can lead to poor outcomes such as disability or dependence, nursing home placement, and death. Yet even the definition of frailty varied across screening instruments, and 1 ED-based study found little agreement on frailty as defined by physician perception, patient perception, and a standardized screening instrument . We believe that this study alleviates this definition challenge by highlighting key characteristics among older patients that are associated with greater rates of admission.…”

Section: Discussionmentioning

confidence: 99%

Association of Functional Status, Cognition, Social Support, and Geriatric Syndrome With Admission From the Emergency Department

et al. 2023

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ImportanceThe role of patient-level factors that are unrelated to the specific clinical condition leading to an emergency department (ED) visit, such as functional status, cognitive status, social supports, and geriatric syndromes, in admission decisions is not well understood, partly because these data are not available in administrative databases.ObjectiveTo determine the extent to which patient-level factors are associated with rates of hospital admission from the ED.Design, Setting, and ParticipantsThis cohort study analyzed survey data collected from participants (or their proxies, such as family members) enrolled in the Health and Retirement Study (HRS) from January 1, 2000, to December 31, 2018. These HRS data were linked to Medicare fee-for-service claims data from January 1, 1999, to December 31, 2018. Information on functional status, cognitive status, social supports, and geriatric syndromes was obtained from the HRS data, whereas ED visits, subsequent hospital admission or ED discharge, and other claims-derived comorbidities and sociodemographic characteristics were obtained from Medicare data. Data were analyzed from September 2021 to April 2023.Main Outcomes and MeasuresThe primary outcome measure was hospital admission after an ED visit. A baseline logistic regression model was estimated, with a binary indicator of admission as the dependent variable of interest. For each primary variable of interest derived from the HRS data, the model was reestimated, including the HRS variable of interest as an independent variable. For each of these models, the odds ratio (OR) and average marginal effect (AME) of changing the value of the variable of interest were calculated.ResultsA total of 42 392 ED visits by 11 783 unique patients were included. At the time of the ED visit, patients had a mean (SD) age of 77.4 (9.6) years, and visits were predominantly for female (25 719 visits [60.7%]) and White (32 148 visits [75.8%]) individuals. The overall percentage of patients admitted was 42.5%. After controlling for ED diagnosis and demographic characteristics, functional status, cognition status, and social supports all were associated with the likelihood of admission. For instance, difficulty performing 5 activities of daily living was associated with an 8.5–percentage point (OR, 1.47; 95% CI, 1.29-1.66) AME increase in the likelihood of admission. Having dementia was associated with an AME increase in the likelihood of admission of 4.6 percentage points (OR, 1.23; 95% CI, 1.14-1.33). Living with a spouse was associated with an AME decrease in the likelihood of admission of 3.9 percentage points (OR, 0.84; 95% CI, 0.79-0.89), and having children living within 10 miles was associated with an AME decrease in the likelihood of admission of 5.0 percentage points (OR, 0.80; 95% CI, 0.71-0.89). Other common geriatric syndromes, including trouble falling asleep, waking early, trouble with vision, glaucoma or cataract, use of hearing aids or trouble with hearing, falls in past 2 years, incontinence, depression, and polypharmacy, were not meaningfully associated with the likelihood of admission.Conclusion and RelevanceResults of this cohort study suggest that the key patient-level characteristics, including social supports, cognitive status, and functional status, were associated with the decision to admit older patients to the hospital from the ED. These factors are critical to consider when devising strategies to reduce low-value admissions among older adult patients from the ED.

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Section: Discussionmentioning

confidence: 99%

Association of Functional Status, Cognition, Social Support, and Geriatric Syndrome With Admission From the Emergency Department

et al. 2023

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“…A recent systematic review and meta-analysis reported a prevalence of 12% using any physical definition and 24% using the deficit accumulation model among community-dwellers aged ≥50 years across 62 countries [ 4 ]. Older adults living with frailty are at particular risk after an ED visit, with longer admissions, high rates of functional and cognitive decline, greater risk of readmission and institutionalisation after discharge and higher mortality [ 5 , 6 ]. Frailty is also common among older ED attendees with studies suggesting up to 60% are frail [ 6 , 7 ].…”

Section: Introductionmentioning

confidence: 99%

“…Identifying frailty early is important to triage people to appropriate care pathways and more detailed comprehensive geriatric assessment (CGA) to improve outcomes [ 8 ]. Screening for frailty helps creates awareness among healthcare professionals regarding the complexity of older adults, which leads to more holistic, person-centred care [ 5 ]. Frailty risk stratification also allows faster and more efficient use of time and resources in a busy ED [ 5 ].…”

Section: Introductionmentioning

confidence: 99%

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Core requirements of frailty screening in the emergency department: an international Delphi consensus study

Moloney,

O’Donovan,

Carpenter

et al. 2024

Age and Ageing

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Introduction Frailty is associated with adverse outcomes among patients attending emergency departments (EDs). While multiple frailty screens are available, little is known about which variables are important to incorporate and how best to facilitate accurate, yet prompt ED screening. To understand the core requirements of frailty screening in ED, we conducted an international, modified, electronic two-round Delphi consensus study. Methods A two-round electronic Delphi involving 37 participants from 10 countries was undertaken. Statements were generated from a prior systematic review examining frailty screening instruments in ED (logistic, psychometric and clinimetric properties). Reflexive thematic analysis generated a list of 56 statements for Round 1 (August–September 2021). Four main themes identified were: (i) principles of frailty screening, (ii) practicalities and logistics, (iii) frailty domains and (iv) frailty risk factors. Results In Round 1, 13/56 statements (23%) were accepted. Following feedback, 22 new statements were created and 35 were re-circulated in Round 2 (October 2021). Of these, 19 (54%) were finally accepted. It was agreed that ideal frailty screens should be short (<5 min), multidimensional and well-calibrated across the spectrum of frailty, reflecting baseline status 2–4 weeks before presentation. Screening should ideally be routine, prompt (<4 h after arrival) and completed at first contact in ED. Functional ability, mobility, cognition, medication use and social factors were identified as the most important variables to include. Conclusions Although a clear consensus was reached on important requirements of frailty screening in ED, and variables to include in an ideal screen, more research is required to operationalise screening in clinical practice.

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“…[21] One study demonstrates that the unstructured "foot-of-the-bed" Medicine or "eyeball" tests (i.e., clinical gestalt) can lack reproducibility in assessing frailty. [21][22][23][24][25][26][27] Several authors have suggested the CFS framework is a superior replacement for unstructured foot-ofthe-bed assessments. [27][28][29][30] It provides a structure to summarize and communicate frailty as assessed from a clinical encounter.…”

Section: Introductionmentioning

confidence: 99%

Assessing frailty in elderly patients with hip fractures: A retrospective review comparing geriatrician and orthopedic trainee assessments

Moran,

Laaper,

Jones

et al. 2023

Medicine

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To assess the correlation of orthopedic surgery residents compared with expert geriatricians in the assessment of frailty stage using the Clinical Frailty Scale (CFS) in patients with hip fractures. A retrospective chart review was performed from January 1, 2015 to December 31, 2019. Patients admitted with a diagnosis of hip fracture were identified. Those patients with a CFS score completed by orthopedic residents with subsequent CFS score completed by a geriatrician during their admission were extracted. Six hundred and forty-eight patients over age 60 (mean 80.5 years, 73.5% female) were admitted during the study period. Orthopaedic residents completed 286 assessments in 44% of admissions. Geriatric medicine consultation was available for 215 patients such that 93 patients were assessed by both teams. Paired CFS data were extracted from the charts and tested for agreement between the 2 groups of raters. CFS assessments by orthopedic residents and geriatrician experts were significantly different at P < .05; orthopedic residents typically assessed patients to be one CFS grade less frail than geriatricians. Despite this, the CFS assessments showed good agreement between residents and geriatricians. Orthopaedic surgery residents are reliable assessors of frailty but tend to underestimate frailty level compared with specialist geriatricians. Given the evidence to support models such as orthogeriatrics to improve outcomes for frail patients, our findings suggest that orthopedic residents may be well positioned to identify patients who could benefit from such early interventions. Our findings also support recent evidence that frailty assessments by orthopedic surgeons may have predictive validity. Low rates of initial frailty assessment by orthopedic residents suggests that further work is required to integrate more global comprehensive care.

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

Cited by 6 publications

References 39 publications

Association of Functional Status, Cognition, Social Support, and Geriatric Syndrome With Admission From the Emergency Department

Association of Functional Status, Cognition, Social Support, and Geriatric Syndrome With Admission From the Emergency Department

Core requirements of frailty screening in the emergency department: an international Delphi consensus study

Assessing frailty in elderly patients with hip fractures: A retrospective review comparing geriatrician and orthopedic trainee assessments

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