Suffoletto Brian, Miller Thomas, Shah Rahul, Callaway Clifton, Yealy Donald M
Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, USA.
University of Pittsburgh School of Medicine, Pittsburgh, USA.
Emerg Med J. 2016 Jan;33(1):4-9. doi: 10.1136/emermed-2014-203936. Epub 2015 May 18.
We sought to evaluate the ability of the Identification of Seniors At Risk (ISAR) tool to differentiate between older adult patients having a poor outcome within 30 days of emergency department (ED) care and those who do not. We compare prognostic accuracy of subjective versus objective risk factors.
202 community-dwelling patients age 65 years and older presenting to two EDs were prospectively enrolled. Participants completed the six-question ISAR and objective testing (cognition, ambulation, vision). We reviewed electronic medical records for current medications, hospitalisations in the past six months, ED disposition, length of hospital stay, subsequent ED visits or inpatient admissions or death at 30 days. Participants were given a point for each risk factor present; subjective and objective risk factors were scored separately. We tested ability of individual risk factors and scores to predict a composite outcome of subsequent ED visit, postdischarge hospitalisation or death by day 30 after the index ED visit. We computed receiver operating curve area under the curves (AUC) to determine tool discrimination.
23% of participants had a poor 30-day outcome. The optimum subjective ISAR cut-off score for screening was ≥2, which was present in 84% of participants, had a sensitivity of 91% and specificity of 19%. Using the subjective ISAR tool, the AUC was 0.66. The optimum objective ISAR-related risk cut-off score for screening was ≥3, which was present in 82% of participants, had a sensitivity of 87% and specificity of 40%. Using the objective ISAR-related tool, the AUC was 0.69.
The self-reported ISAR tool did not discriminate well between older adults with or without 30-day hospital revisit or death. An optimum score of ≥2 would identify many older adults at no apparent increased risk of poor outcomes at 30 days. Using objective ISAR-related risk factors did not improve overall discrimination.
我们旨在评估“高危老年人识别（ISAR）”工具区分急诊科（ED）就诊后30天内预后不良的老年患者和预后良好患者的能力。我们比较主观与客观风险因素的预后准确性。
前瞻性纳入202名年龄在65岁及以上、前往两家急诊科就诊的社区居住患者。参与者完成了包含六个问题的ISAR问卷以及客观测试（认知、行走能力、视力）。我们查阅电子病历，了解当前用药情况、过去六个月的住院情况、ED处置情况、住院时间、随后的ED复诊或住院治疗或30天内的死亡情况。每个存在的风险因素给参与者计1分；主观和客观风险因素分别计分。我们测试了个体风险因素和分数预测首次ED就诊后30天内后续ED复诊、出院后住院或死亡这一综合结局的能力。我们计算曲线下面积（AUC）以确定工具的区分度。
23%的参与者30天预后不良。筛查的最佳主观ISAR截止分数为≥2分，84%的参与者达到该分数，其敏感性为91%，特异性为19%。使用主观ISAR工具，AUC为0.66。筛查的最佳客观ISAR相关风险截止分数为≥3分，82%的参与者达到该分数，其敏感性为87%，特异性为40%。使用客观ISAR相关工具，AUC为0.69。
自我报告的ISAR工具在区分30天内有或没有再次住院或死亡的老年人方面表现不佳。≥2分的最佳分数会识别出许多30天内结局不良风险未明显增加的老年人。使用客观ISAR相关风险因素并未改善总体区分度。
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