Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana, USA.
Regenstrief Institute, Indianapolis, Indiana, USA.
Acad Emerg Med. 2023 Apr;30(4):349-358. doi: 10.1111/acem.14705. Epub 2023 Mar 28.
Frailty is a clinical syndrome characterized by decreased physiologic reserve that diminishes the ability to respond to stressors such as acute illness. Veterans Health Administration (VA) emergency departments (ED) are the primary venue of care for Veterans with acute illness and represent key sites for frailty recognition. As questionnaire-based frailty instruments can be cumbersome to implement in the ED, we examined two administratively derived frailty scores for use among VA ED patients.
This national retrospective cohort study included all VA ED visits (2017-2020). We evaluated two administratively derived scores: the Care Assessment Needs (CAN) score and the VA Frailty Index (VA-FI). We categorized all ED visits across four frailty groups and examined associations with outcomes of 30-day and 90-day hospitalization and 30-day, 90-day, and 1-year mortality. We used logistic regression to assess the model performance of the CAN score and the VA-FI.
The cohort included 9,213,571 ED visits. With the CAN score, 28.7% of the cohort were classified as severely frail; by VA-FI, 13.2% were severely frail. All outcome rates increased with progressive frailty (p-values for all comparisons < 0.001). For example, for 1-year mortality based on the CAN score frailty was determined as: robust, 1.4%; prefrail, 3.4%; moderately frail, 7.0%; and severely frail, 20.2%. Similarly, for 90-day hospitalization based on VA-FI, frailty was determined as prefrail, 8.3%; mildly frail, 15.3%; moderately frail, 29.5%; and severely frail, 55.4%. The c-statistics for CAN score models were higher than for VA-FI models across all outcomes (e.g., 1-year mortality, 0.721 vs. 0.659).
Frailty was common among VA ED patients. Increased frailty, whether measured by CAN score or VA-FI, was strongly associated with hospitalization and mortality and both can be used in the ED to identify Veterans at high risk for adverse outcomes. Having an effective automatic score in VA EDs to identify frail Veterans may allow for better targeting of scarce resources.
衰弱是一种以生理储备减少为特征的临床综合征，降低了应对急性疾病等压力源的能力。退伍军人健康管理局（VA）急诊部（ED）是患有急性疾病的退伍军人的主要治疗场所，也是识别衰弱的关键场所。由于基于问卷的衰弱工具在 ED 中实施起来可能很麻烦，因此我们研究了两种用于 VA ED 患者的行政衍生衰弱评分。
本项全国性回顾性队列研究纳入了所有 VA ED 就诊（2017-2020 年）。我们评估了两种行政衍生评分：护理评估需求（CAN）评分和 VA 衰弱指数（VA-FI）。我们将所有 ED 就诊分为四个衰弱组，并检查了与 30 天和 90 天住院以及 30 天、90 天和 1 年死亡率相关的关联。我们使用逻辑回归评估 CAN 评分和 VA-FI 的模型性能。
队列包括 9213571 次 ED 就诊。根据 CAN 评分，28.7%的患者被归类为严重衰弱；根据 VA-FI，13.2%的患者被归类为严重衰弱。所有结局发生率均随衰弱程度的增加而增加（所有比较的 p 值均<0.001）。例如，基于 CAN 评分的 1 年死亡率为：健壮者为 1.4%；虚弱前期者为 3.4%；中度虚弱者为 7.0%；严重虚弱者为 20.2%。同样，基于 VA-FI 的 90 天住院率为：虚弱前期者为 8.3%；轻度虚弱者为 15.3%；中度虚弱者为 29.5%；严重虚弱者为 55.4%。在所有结局中，CAN 评分模型的 C 统计量均高于 VA-FI 模型（例如，1 年死亡率为 0.721 比 0.659）。
VA ED 患者中衰弱很常见。无论使用 CAN 评分还是 VA-FI 来衡量，衰弱程度的增加都与住院和死亡密切相关，这两种方法都可以在 ED 中使用，以识别有不良预后风险的退伍军人。在 VA ED 中使用有效的自动评分来识别虚弱的退伍军人，可能有助于更好地定位稀缺资源。
