Heim et al; 2015

Type of study:

two consecutive observational prospective cohorts in four hospitals in the Netherlands

Setting:

General internal ward of a university teaching hospital

Inclusion criteria:

patients aged ≥70 years, electively or acutely hospitalised for ≥2 days.

Describe index test:

Screening instruments included in the Dutch Safety Management Programme [VeiligheidsManagementSysteem (VMS)]

on four geriatric domains (ADL, falls, undernutrition and delirium) were used and the Identification of Seniors At Risk, the 6-item Cognitive Impairment Test and the Mini-Mental State Examination were assessed. Three months later, adverse

outcomes including functional decline, high-healthcare demand or death were determined. Correlation and regression tree

analyses were performed and predictive capacities were assessed.

VMS+         ≥1

VMS          ≥2

ISAR           ≥2

MMSE       ≤23

6CIT           >10

Three months later, adverse

outcomes including functional decline, high-healthcare demand or death were determined

Three months later, adverse

outcomes including functional decline, high-healthcare demand or death were determined

Endpoint/outcome of follow-up:

Sensitivity, specificity Positive Predictive value, Negative Predictive value, AUC

VMS+: 89%, 35%, 33%, 90%, 0.60;

VMS:67%, 66%, 42%, 84%, 0.66;

ISAR: 73%, 49%, 34%, 83%, 0.61;

MMSE: 30%, 90%, 53%, 78%, 0.58;

6CIT: 24%, 91%, 50%, &&%, 0.58;

Hoogerduijn et al; 2010

Type of study:

Prospective cohort study

Setting:

General internal ward of a university teaching hospital

Country:

Netherlands

Source of funding

This study was financed by the Netherlands Organisation for Health Research and

Development (Zon Mw).

Inclusion criteria:

Acutely admitted 65 years and older

patients

Exclusion criteria:

too ill, came

from another ward or were admitted from another hospital, did not stay at least 48 hours or

did not speak or understand Dutch.

N=177

Mean age ± SD:

77,6 years

Sex: % M / % F

51,7 % M

Other important characteristics:

no

Describe index test:

ISAR: was developed to identify patients atrisk for mortality, functional decline, re-admission and institutionalisation, in the emergency departments (ED) of four university-affiliated hospitals in Montreal, Canada

HARP:  It includes 25 questions and consists of three types of variables derived from a larger study to determine the strongest predictors of functional decline: age, anabbreviated MMSE and seven ADL and IADL

Functions, classified as 0 = no risk, 1 = intermediate risk and 2 = high risk.

Cut-off point(s):

ISAR: cut off point is 2, indicating that patients with a score ≥2 are at risk of adverse health outcomes, including decrease in functional status.

HARP: The cut-off points in this instrument are <2 (low risk), 2–3 (intermediate risk) and >3 (high risk). The AUC (0·65) proved to be fair.

COMPRI: was developed to screen hospitalised patients at risk for complex care needs, poor discharge health status and an extended length of stay. It was derived from a list of 117 potential risk factors. The items most predictive for length of stay and some other indicators for hospital-based care use were selected: doctors’ and nurses’ expectations about care complexity, premorbid health status and health care use. The instrument has to be completed by three different respondents; four items are rated by the physician, three by the nurse and six by interviewing the patient.

Cut-off point(s):

COMPRI : the cut-off point is 6, indicating that a score ≥6 is a patient in need of complex  care

Describe reference test:

Three months after discharge, functional status was measured by telephone interview.

The Katz index was used to measure functional status (six activities). The index was scored per item as 0 = independent and 1 = dependent. The total

score ranged from 0 (total independence) to 6 (total dependence). Patients were asked to rate

their ADL status as it stood two weeks before hospital admission to eliminate the effects of  the illness that led to that admission

Cut-off point(s):

Functional decline was defined as a decline of at least one point on the Katz index at three

months after discharge compared to the pre-admission state.

Endpoint/outcome of follow-up:

Sensitivity, specificity and area under the curve of ISAR, HARP en COMPRI

Duration of follow-up:  3 months

For how many participants were no complete outcome data available?

N (%): 28%

Reasons for incomplete outcome data described: mortality or difficulties in contacting the patient or relative three months after discharge. These patients were significantly older. This selective loss of patients may have led to underestimation of the group of patients suffering from functional decline after

Hospitalisation

Outcome measures and effect size (include 95%CI and p-value if available): Sensitivity, specificity and area under the curve:

ISAR: 93%; 39% and  0,67

COMPRI: 70%; 62% and 0,69

HARP: 21%; 89% and 0,56

Hoogerduijn et al; 2012

Type of study:

Prospective cohort study

Setting: university teaching hospital

Country: The Netherlands

Source of funding: supported by the Netherlands Organization for Health Research and Development. This organization had no role in any part of the study

Inclusion criteria:

Aged 65 years and older, acutely admitted patients to a general internal ward of a university teaching hospital

Exclusion criteria:

Too ill to participate, transferred to another ward, transfer to ICU within 48h after admission, unable to speak or understand language, not able to demonstrate functional decline.

N= 492 in cohort and 484 in validation study

Mean age ± SD:

Cohort: 78±8

Validation: 78±8

Sex:

Cohort: 44% M / 56% F

Validation: 47% M / 53% F

Describe index test:

ISAR-HP. Development and validation of the screening instrument

Describe reference test:

Describe reference test:

Katz index

Cut-off point(s):

One point decline on Katz index was defined as functional decline (2 weeks before admission vs 3 months after admission

Time between the index test en Describe reference test:

Katz index

Cut-off point(s):

One point decline on Katz index was defined as functional decline (2 weeks before admission vs 3 months after admission

Outcome measures and effect Endpoint/outcome of follow-up:

Sensitivity, specificity, positive and negative predictive values

Duration of follow-up: 

3 months after admission

For how many participants were no complete outcome data available? N (%): NR

Outcome measures and effect size (include 95%CI and p-value if available):

35% Functional decline in development cohort

32% functional decline in validation cohort

AUC of 0.71.

At threshold 2 sensitivity,

specificity, positive and negative predictive values were 87, 39, 43 and 85%, respectively.

In the validation study, this was 68, 89, 41, 41 and 89% respectively

Geyskens et al; 2008

Type of study: Prospective quality cohort study

Setting:

ED from Universitary hospital in Leuven,

Country:

Belgium

Inclusion criteria: 65 year of older; not resident in a nursing home; contact by Phone is possible;  Dutch speaking.

Exclusion criteria: length of stay on ED longer than 24 hour.  Transfer to an other hospital,  terminal illness.

N= 83

Mean age ± SD:

74 years (70-79 years)

Sex: % M / % F:

45,8 % M

Other important characteristics:

A little bit more than 50% from the patients had moderate or severe cognitive dysfunction

Describe index test:

The Identification of Seniors at Risk (ISAR): was developed to identify patients at risk for mortality, functional decline, re-admission and institutionalisation. It includes 6 questions.

Triage Risk Screening Tool (TRST): a six-item tool comprised of yes/no questions.  It evaluates the presence of cognitive impairment, difficulty walking or transferring, recent falls, living alone with no available caregiver, taking five or more prescription medications.

Questionnaire of Runciman: 8 items questionary (cognition; use of diuretics; urinary problems; use an equipment  for walking; soft tissue injury;  activity such as shopping and use of  public transport and to dress)

Questionnaire of Rowland: 7 items questionary (use an equipment  for walking; help by  activity such as shopping; financial administration, cooking, housekeeping, dressing and participation at daily activity.)

Variable Indicative of Placement risk (VIP): with three yes/no questions the patients living situation, functional status and cognitive status can be evaluated.

Cut-off point(s):

ISAR: cut off point is 2, indicating that patients with a score ≥2 are at risk of adverse health outcomes

TRST: Two or more risk factors or the presence of cognitive impairment leads to a designation of “high risk”.

Questionnaire of Runciman: cut off point ≥3

Questionnaire of Rowland: cut off point ≥4

VIP: cut off point is 2

Describe reference test:

Functional decline was derived from the Katz-scale, reflecting the condition 14 days before admission.,

Cut-off point(s): Functional decline was defined as a decline of at least one point on the Katz index at admission, 14, 30 and 90 days after discharge.

Endpoint/outcome of follow-up:

Sensitivity (sens) , specificity (spec), positive predictive value (PPV), negative predictive value NPV), accuracy (ACC) and   likelihood ratio (LHR)  from the 5 instruments at 14, 30 and 90 day after discharge.

Duration of follow-up:

90 days

For how many participants were no complete outcome data available? N (%)/Reasons for incomplete outcome data described:

After14 days 3 patients ( 3,7% refused the participation on the study.  (reason: no motivation; delirium; language problem ; afasie)

Study population after  30 days 79/83 en after 90 days  77/83 ( reason of loose participants not mentioned)

Outcome measures and effect size (include 95%CI and p-value if available:

ISAR

Sens  (after14/30 /90 days):: 78,57/94,12/100%

Spec (after14/30 /90 days): 38,46/40,98/44,07%

PPW (after14/30 /90 days): 21,57/30,77/35,29%

NPW (after14/30 /90 days): 89,29/96,15/100%

LHR (after14/30 /90 days): 1,277/1,595/1,788

Triage Risk Screening Tool (TRST):

•              Sens  (after14/30 /90 days):: 71,43/82,35/88,24%

•              Spec (after14/30 /90 days): 50,77/54,10/55,93%

•              PPW (after14/30 /90 days): 23,81/33,33/36,59%

•              NPW (after14/30 /90 days): 89,19/91,67/94,29%

•              LHR (after14/30 /90 days): 1,451/1,794/2002

Qquestionnaire of Runciman:

•              Sens  (after14/30 /90 days):: 75/91,67/93,33%

•              Spec (after14/30 /90 days): 45/48,21/50,94%

•              PPW (after14/30 /90 days): 15,38/27,50/35%

•              NPW (after14/30 /90 days): 93,1/96,43/96,43%

•              LHR (after14/30 /90 days): 1,364/1,770/1,903

Questionnaire of Rowland:

•              Sens  (after14/30 /90 days):: 80/83,33/83,33%

•              Spec (after14/30 /90 days): 50/51,67/51,72%

•              PPW (after14/30 /90 days): 27,27/34,09/34,88%

•              NPW (after14/30 /90 days): 91,43/91,18/90,91%

•              LHR (after14/30 /90 days): 1,600/1,724/1,726

VIP

•              Sens  (after14/30 /90 days):: 66,67/61,11/61,11%

•              Spec (after14/30 /90 days): 46,15/45,9/45,76%

•              PPW (after14/30 /90 days): 22,22/25/25,58%

•              NPW (after14/30 /90 days): 85,71/80/79,41%

•              LHR (after14/30 /90 days): 1,238/1,130/1,127

Moons P. et al; 2007

Type of study: Prospective quality cohort study

Setting:

ED from Universitary hospital in Leuven,

Country:

Belgium

Inclusion criteria: 65 year of older; , not resident in a nursing home; contact by Phone is possible;  Dutch speaking.

Exclusion criteria: length of stay on ED longer than 24 hour.  Transfer to another hospital,  terminal illness.

N= 83

Mean age ± SD:

74 years (70-79 years)

Sex: % M / % F:

45,8 % M

Other important characteristics:

A little bit more than 50% from the patients had moderate or severe cognitive dysfunction

Describe index test:

The Identification of Seniors at Risk (ISAR): was developed to identify patients at risk for mortality, functional decline, re-admission and institutionalisation. It includes 6 questions.

Triage Risk Screening Tool (TRST): a six-item tool comprised of yes/no questions.  It evaluates the presence of cognitive impairment, difficulty walking or transferring, recent falls, living alone with no available caregiver, taking five or more prescription medications.

Qquestionnaire of Runciman: 8 items questionary (cognition; use of diuretics; urinary problems; use an equipment  for walking; soft tissue injury;  activity such as shopping and use of  public transport and to dress)

Questionnaire of Rowland: 7 items questionary (use an equipment  for walking; help by  activity such as shopping; financial administration, cooking, housekeeping, dressing and participation at daily activity.)

Cut-off point(s):

ISAR: cut off point is 2, indicating that patients with a score ≥2 are at risk of adverse health outcomes

TRST: Two or more risk factors or the presence of cognitive impairment leads to a designation of “high risk”.

Qquestionnaire of Runciman: cut off point ≥3

Questionnaire of Rowland: cut off point ≥4

Describe reference test:

By telephone follow-up 14, 30, and 90

days after discharge from the ED, we asked the patients

(or their families) whether readmission had occurred since

their initial discharge from the ED.

Endpoint/outcome of follow-up:

Sensitivity/Specificity, negative predictive value

Duration of follow-up:

90 days

For how many participants were no complete outcome data available? N (%):

Completed follow up after 90 days N=74 (89.2%)

Reasons for incomplete outcome data described:

NR

Outcome measures and effect size (include 95%CI and p-value if available):

Readmission rates were 10%, 15.8%, and 32.5%

after 14, 30, and 90 days, respectively.

The Rowland questionnaire proved to be the most accurate predictive tool with a sensitivity of 88%, specificity of 72%, and

negative predictive value of 98% at 14 days after discharge.

30 days after discharge, the sensitivity was 73%, specificity was 75%, and negative predictive value was 92%.

Cornette et al; 2006

Type of study:

Prospective cohort study

Setting: Two general academic hospitals

Country:Belgium

Source of funding: supported by a grant from the Commission Communautaire

Fran¸caise (CoCoF) of Belgium

nclusion criteria:

age ≥ 70; hospitalized at least 48 hours by the way of the emergency department

Exclusion criteria: terminal illness; admission to the IC; admission for a stroke; length of stay shorter than 48 hours; dependence for the six activites of daily living

N= 625

Mean age ± SD:

80±5.6

Sex: 43.4% M / 56.6% F

Other important characteristics: no

Describe index test:

SHERPA: a predicitive tool to identify older hospitalized people at risk of functional decline.

Cut-off point(s): Univariate analyses were used to select variables associated with functional decline. Those were age, impairment in premorbid instrumental ADLs, falls in the year before hospitalization, cognitive impairment (AbbreviatedMiniMentalState below 15/21) and poor self-rated health.

 A logistic regression model was constructed to predict functional status 3 months after discharge.

Describe reference test:

Functional decline 3 months after discharge

Cut-off point(s): Functional decline was defined as the loss of at least one point on the ADL scale between the premorbid and 3-month evaluation.

Endpoint/outcome of follow-up:

Sensitivity and specificity of SHERPA

Duration of follow-up: 3 months

For how many participants were no complete outcome data available? N (%): 75

Reasons for incomplete outcome data described: 73 died (29 during hospitalization and 44 within 3 months after discharge), 2 had missing data.

Outcome measures and effect size (include 95%CI and p-value if available):

Sensitivity and specificity were 67.9% and 70.8%, respectively.

Dendukuri  et al;

2004

Type of study:

Review  from 2 studies

Setting:

Four university-affiliated hospitals in Montreal.

Country:

Canada

Source of funding:

This work was supported in part by a grant from the Health Transition Fund,

HealthCanada andGrant 201265 from theNational Science andEngineering

Research Council, Canada

Inclusion criteria:

65 years or older ; stable (noncritical) medical status and orientation to time and place or availability of an

informant, English or French speaking, resident in Montreal, not resident in a nursing home, and not transferred from another hospital.

Exclusion criteria:

NR

N=

Study 1, in which the ISAR scale was developed

(n=1,122)

Study 2, in which it was used to identify patients for a randomized trial of a nursing intervention (n=1,889 with administrative data, of which 520 also had clinical data)

Describe index test:

Identification of Seniors

at Risk (ISAR) screening tool six-item, self-adminis-tered questionnaire was developed to identify seniors in an ED setting at high risk of subsequent functional decline (including institutionalization or death).

Cut-off point(s):

Cut of point of 2

Chi-square tests were used to compare the distribution of

patient characteristics between Study 1 and Study 2 and

between patients with an ISAR score of 0 to 1 with and

without clinical data in Study 2.

Statistical analyses were conducted using SAS (SAS Institute, Inc., Cary, NC) and WinBUGS software (MRC Biostatistics Unit, Cambridge, UK)

Describe reference test:

Older American Resources and Services activities of daily living (ADL) scale.

Depression at the ED visit was assessed in Study 2 using the 15-item version of the Geriatric Depression Scale (GDS).

Cut-off point(s):

Severe premorbid impairment

was defined as partial or complete dependence in three or more basic ADLs.

A score of six or more on the GDS at baseline was taken to indicate depression. Increase in depressive symptoms was defined as an increase of three or more points on the 15-item

GDS scale during the 4-month follow-up period.

Endpoint/outcome of follow-up:

Sensitivity, specificity,  and

likelihood ratios were estimated for each outcome at each

cut of point on the ISAR scale.

Duration of follow-up:

Study 1à 6 months

Study 2à4 months

For how many participants were no complete outcome data available?

N (%): NR

Outcome measures and effect size (include 95%CI and p-value if available):

the sensitivity and specificity of the ISAR

for detecting depression were 83% and 63%, respectively.

At the same cutpoint, the sensitivity and specificity for

detecting increased depressive symptoms were 73% and

57%, respectively

McCusker et al;

2000

Type of study: Prospective cohort study

Setting:

four urban, university affiliated

hospitals

two hospitals provided tertiary care and two were

community hospitals.

Country:

Canada

Source of funding

Supported by grants from the Ministry of Health and Social

Services of the Province of Quebec, the Montreal Regional

Board for Health and Social Services, and the St. Mary’s Hospital Foundation.

Inclusion criteria:

patients aged 65 years or more who visited

the EDs of four Canadian hospitals during the weekday shift over a three-month recruitment period who were discharged

Exclusion criteria:

Could not be interviewed,

due either to their medical conditions or to cognitive

impairment, and no other informant was available;

refused linkage of study data; or were admitted to

hospital at the initial (index) visit

N=1,122

Mean age ± SD:

Just over the half of the sample was aged

65 to 74 years

Sex: % M / % F:

43% M; 57% F

Other important characteristics:

76,8% mild or no cognitive impairment.

Describe index test:

27 self-report screening

questions on social, physical, and mental risk factors,

medical history, use of hospital services, medications,

and alcohol. Six of these questions comprised the

ISAR scale.

Objectives:

1) To describe the pattern of

return visits to the emergency department (ED) among elders over the six months following an index visit;

 2) to identify the predictors of early return (within 30 days) and frequent return (three or more

return visits in six months)

3) to evaluate a newly developed screening tool for functional decline,Identification of Seniors At Risk (ISAR), with regard

to its ability to predict return visits.

Describe reference test:

Return visits and diagnoses during the

six months after the index visit were abstracted from

the utilization database

Cut-off point(s):

early return as return within 30 days of the first day of the index episode;

frequent return was defined as three or more episodes of ED care, excluding the index episode, during the six-month follow-up period.

Endpoint/outcome of follow-up:

The pattern of the return visit to the ED.

Predictors of early return and frequent return were analyzed first using contingency tables and

then with stepwise multivariate logistic regression analyses, using a p-value of 0.05 to enter the

model. For each outcome variable, were first constructed a model using only the 27 screening items; then were added other variables that contributed

significantly, from among the OARS ADL, SPMSQ, demographic variables, and diagnosis at index

visit.

Duration of follow-up:

6months

Outcome measures and effect size (include 95%CI and p-value if available):

Among N=1,122 patients, 492 (43.9%) made one or more re-turn visits; 216 (19.3%) returned during the follow-ing 30 days and 84 (7.5%) returned frequently, making three or more repeat visits during the following six months.

Among patients who made return visits, the

first return was within the first month for 43.9%. An earlier return was more likely to be for the same diagnosis than a later first return (chi-square trend test p-value = 0.003).

By the ISAR scale only the item “recent hospitalization” significantly  predicted return.

Buurman et al;

2011

Type of study:

Prospective cohort study

Setting:

ED of a  university teaching hospital

Country:

Nederlands

Source of funding:

none

Inclusion criteria:

patients of at least 65 years discharged from the ED of a university teaching hospital in the Netherlands, between 1 December 2005, and 1 November 2006.

Exclusion criteria:

Unable to contact shortly after discharge (not able to contact them within 4 days)

N= 381

Mean age ± SD:

79,1

Sex: % M / % F

38,8% M

Other important characteristics:

none

Describe index test:

ISAR

TRST

Runciman questionaries ( 11 items)

Rowland questionaries

 Cut-off point(s

ISAR ≥2

TRST ≥2

Runciman questionaries ( 11 items) ≥3

Rowland questionaries  ≥4

Describe reference test:

none

Cut-off point(s):

Endpoint/outcome of follow-up:

Prognostic value of four screening instruments

Recurrent ED visits, subsequent hospitalization, and mortality within 30 and 120 days after the index visit were collected from administrative data.

Duration of follow-up:

120 days

For how many participants were no complete outcome data available?

N (%): after inclusion there was no attrition of patients in the follow-up period.

Outcome measures and effect size (include 95%CI and p-value if available):

Within 120 days, 14.7% of the patients returned to ED, 17.2% were hospitalized, and 2.9% died. The area under the curve was low for all instruments (between 0.43 and 0.60), indicating poor discriminatory power.

None of the instruments were able to clearly discriminate between patients with and without poor outcomes.

Braes et al;

2010

Type of study:

Prospective cohort study

Setting:

ED

Country:

Belgium

Source of funding:

none

Inclusion criteria:

Patients aged 65 years or older

Exclusion criteria:

Refusal to participation, delirium, severe illness, speech impediment, inability to speech Dutch, or pain

N= 213

Mean age ± SD:

76 years

Sex:  50,2% M 49,8/ % F

Other important characteristics

Premorbid ADl niveau –mean  5.0 (SD=1,5)

Describe index test:

Identification of Seniors at Risk (ISAR)

Flemish version of  Triage Risk Screening Tool (TRST)

Variable Indicative of Placement risk (VIP)

Cut-off point(s):

By each screening tool cut of point is  ≥2

Describe reference test:

none

Unplanned readmissions were registered by telephone follow-up 14, 30 and 90 days post-discharge.

Endpoint/outcome of follow-up:

Compared the predictive accuracy of ISAR, TRSt, VIP in assessing unplanned readmissions.

Duration of follow-up:

90 days

For how many participants were no complete outcome data available?

After 14 days n=22 (refusal n=8; deceased n=2; incomplete readmission date n=12)

After 30 days n=22 (refusal n=8; deceased n=7; incomplete readmission date n=7)

After 90 days n=30 (refusal n=10; deceased n=13; incomplete readmission date n=7)

Outcome measures and effect size (include 95%CI and p-value if available):

Unplanned readmission rates were 6.8%, 14.7% and 23.5% after 14, 30, and 90 days, respectively. The ISAR showed low to moderate sensitivity (54%-69%) and a high negative predictive value (>=78%) at all measurement points. Specificity and positive predictive value were low (<=33% and <=24%, respectively). The TRST had low to moderate sensitivity (42%-67%) and a high negative predictive value (>=82%). Specificity and positive predictive value were low (<=45% and <=27%, respectively). The VIP had very low sensitivity (<=26%) and high specificity (>=80%). Its negative predictive value was high (>=79%) and its positive predictive value was low (<=22%).

Lee et al;

2008

Type of study:

Prospective, observational study.

Setting:

EDs of three hospitals in Toronto

Country:

Canada

Source of funding

none

Inclusion criteria:

Patients aged 65 to 101 who presented to the ED and were discharged home from the ED.

Exclusion criteria:

Patients admitted to nursing home after ED discharge.

Patients who need hospital admission

N= 788

Mean age ± SD:

76.6,

Sex: % M / % F

58.5% female

Describe index test:

 Triage Risk Screening Tool (TRST)

Cut-off point(s): ≥2

Describe reference test:

None

Patients who subsequently returned to the ED or were admitted to the hospital were identified using hospital information systems and classified as experiencing the composite endpoint at 30, 120, and 365 days

Endpoint/outcome of follow-up:

Sensitivity, specificity  and likelihood ratio  of  TRST to predict return to ED or admission to hospital within 30, 120, and 365 days after discharge from the ED.

Duration of follow-up:

1-year follow-up (endpoint at 30, 120, and 365 days).

For how many participants were no complete outcome data available? Of the 788 subjects, the composite endpoint occurredin 147 (18.7%) by 30 days, 245 (31.1%) by 120 days,and 346 (43.9%) by 365 days.

Outcome measures and effect size (include 95%CI and p-value if available):

The sensitivity of a TRST score of 2 or greater was 62%, (95% confidence interval (CI)=54-70%), specificity was 57% (95% CI=53-61%), and likelihood ratio was 1.44 (95% CI=1.23-1.66). The area under the curve was 0.61 using a cutoff score of 2.

The TRST demonstrated only moderate predictive ability

Hustey et al;

2007

Type of study:

Secondary data analysis of a randomized, controlled trial

Setting:

EDs of two urban academic hospitals.

Country:

Ohio, USA

Source of funding:

Supported by grants from the Agency

for Healthcare Research and Quality (HS09725), the

Robert Wood Johnson Foundation (032300), the M.E. and F.J. Callahan Foundation, and the Cleveland Foundation.

Fredric M. Hustey is supported in part by an American

Geriatrics Society/Hartford Foundation/Atlantic Philanthro-pies Jahnigen Career Development Scholar Award.

Inclusion criteria:

Community-dwelling adults aged 65 and older presenting to the ED and discharged home

Exclusion criteria:

residence outside the geographic

service area, no telephone access, difficulty hearing, severe

cognitive impairment with no primary caregiver willing to serve as a proxy respondent, and unable to speak English.

N=650

Mean age ± SD:

74 years, SD 6,9

Sex: % M / % F

59% F

Other important characteristics

At baseline, 10% reported having required assistance with at least one ADL, and 20% had required assistance with at least one IADL in the 4 weeks before the ED visit.

Describe index test:

Triage Risk Screening Tool (TRST)

Cut-off point(s): ≥1 and ≥2

Describe reference test:

Short-Form Health Survey (SF-36):

consists of 36 items that assesses eight health concepts, including physical health.

ADL:  (bathing, dressing, transferring from bed/chair,

and eating

IADL: using the telephone, shopping, driving or taking

public transportation, taking medications, banking, cook-ing, and doing laundry).

SF-36 , ADL and IADL item was rated as able to perform independently or requiring assistance in the 4 weeks before the ED visit.

Cut-off point(s):

Functional decline:

loss of one or more ADLs and one or more IADLs from ED baseline at 30 and 120 days.

SF-36 standardized physical health component scores that were four or more points lower than at baseline.

Endpoint/outcome of follow-up:

To determine whether the TRST could serve as a proxy

measure of functional status, Spearman correlation tests

with 95% CIs were conducted with the ADL and IADL

summed scores and the SF-36 physical health subscale

component.

 In addition, patients were categorized as high

risk or low risk according to the TRST. Group comparisons

were made on the ADL, IADL, and SF-36 standardized

physical health component scores using Wilcoxon rank sum tests for nonparametrically distributed interval variables.

To determine the extent to which the TRST was useful

in identifying those likely to have ADL or IADL functional

declines, sensitivity, specificity, and odds ratios with 95%

CIs were calculated for each TRST cutoff score and for the

high-risk designation, and receiver operator characteristic

curves were constructed.

Duration of follow-up:

120 days

For how many participants were no complete outcome data available?

Follow-up interviews were avail-able for 568 participants at 30 days and for 541 participants at 120 days.

Reasons for incomplete data described: no

Outcome measures and effect size (include 95%CI and p-value if available):

TRST scores correlated with baseline ADL impairments, IADL impairments, and self-perceived physical health at all endpoints (P<.001). A TRST score of two or more was moderately predictive of decline in ADLs or IADLs (30-day ADL area under the receiver operating characteristic curve (AUC)=0.64; 95% confidence interval (CI)=0.56-0.72; 120-day ADL AUC=0.66; 95% CI=0.58-0.74) but not perceived physical health

Fan et al;

2006

Type of study:

A prospective, observational cohort study.

Setting:

ED

Country:

Canada.

Source of funding:

Type of study:

none

Inclusion criteria:

patients more than 64 years old

Exclusion criteria:

Resident in a long term community (LTC), cognitively impaired, simultaneously has no available proxy to answer that TRST screening questions.

Excluded from the follow up if they were admitted to a hospital.

N= 120

Mean age ± SD:

75 years

Sex: % M / % F

53 % M

Other important characteristics

none

Describe index test:

Triage Risk Screening Tool (TRST)

Cut-off point(s): ≥2

Describe reference test:

none

Revisit ED, hospital admission, or long-term care placement at 30 and 120 days was measured.

Endpoint/outcome of follow-up:

Primary outcome: ED revisit, hospital admission en LTC placement at 30 and 120 days

Secondary outcome: individual outcome of the primary outcome for each time interval

Likelihood ratios (LRs) and 95% confidence intervals (CIs) were calculated.

Duration of follow-up:

120 days

For how many participants were no complete outcome data available?

ED revisit outcomes :

30 days : n=119 ( 1 patient died 120 days: n= 116 ( 2 patients lost to follow up and 2 patients died)

Hospital admission outcome:

30  days: n= 119 ( 1 patient died)

120 days: n=117 ( 3 patients died)

LTC placement outcome: 30 days: n=117 (1 patient died,  2 patients lost to follow up)

120 days: n=113 ( 4 patients died, 3 patients lost to follow up)

Outcome measures and effect size (include 95%CI and p-value if available):

Positive en negative  LRs

30 days LR+

ED revisit 1.31 (0,78-1,81)

Hospital readmission: 1,57 ( 0,84-2,00)

LTC placement: 1,03 ( 0,11-1,96)

30 days LR-

ED revisit 0,67 ( 0,35-1,30)

Hospital readmission: 0,72 ( 0,35-1,22)

LTC placement: 0,48 ( 0,14-1,16)

120 days LR+

ED revisit 1.31 (0,89-1,81)

Hospital readmission: 1,54 ( 1,01-2,00)

LTC placement: 1,81 ( 0,74-2,10

120 days LR-

ED revisit 0,74 ( 0,46-1,11)

Hospital readmission: 0,55 ( 0,26-0,99)

LTC placement: 0,27 ( 0,03-125)

Vandewoude et al;

2006

Type of study:

Prospective cohort study

Setting:

non-geriatric departments of a general hospital

Country:

Belgium

Source of fundin

none

Inclusion criteria:

older adults (> 70 year) hospitalised

Exclusion criteria:

N= 618

Mean age ± SD:

78,2 ; SD 6,2 years

Sex: % M / % F

55% F

Other important characteristics:

none

Describe index test:

Variable Indicative of Placement risk" (VIP)

Cut-off point(s): <2

Describe reference test:

none

VIP was validated during a period of 6 months

Endpoint/outcome of follow-up:

Sensitivity, specificity and negative Predictive Value  of VIP were calculated

Duration of follow-up:

6 months

For how many participants were no complete outcome data available?

N (%): NR

Outcome measures and effect size (include 95%CI and p-value if available):

Sensitivity (81%) and specificity (86%) .

Negative Predictive Value (97%).

Furthermore, it shows a significant positive correlation with the length of stay (p < 0.001).

Van Loon, 2015

Type of study:

Multicenter, prospective, cohort study

Inclusion criteria: total of 123 patients on incident dialysis $65 years old were

included,3weeks before to#2weeks after dialysis initiation, and all underwent a geriatric assessment. Patients

with impairment in two or more geriatric domains on the geriatric assessment were considered frail.

Describe index test:

Cut-off point(s):

VMS          ≥2

ISAR HP     ≥2

FFI             ≥3

G8             ≤14

GFI             ≥4

Describe reference test:

none

Endpoint/outcome of follow-up:

Sensitivity, specificity Positive Predictive value, Negative Predictive value

VMS: 90%, 38%, 78%, 60%;

ISAR HP: 72%, 79%, 91%, 48%;

FFI: 59%, 85%, 92%, 41%;

G8: 92%, 26%, 79%, 53%;

GFI: 74%, 52%, 82%, 40%;

Meldon SW et al;

2003

Type of study:

Prospective cohort study

Setting:

ED

Country:

Cleveland, USA

Source of funding:

Supported by AHRQ, Grant No. HS09725; The Robert Wood

Johnson Foundation, Grant No. 032300; The M.E. and F.J. Callahan

Foundation; and The Cleveland Foundation

Inclusion criteria:

community-dwelling elders (age 65 years or older)

Exclusion criteria:

N= 650

Mean age ± SD:

74 years, SD 6,9

Sex: % M / % F

59% F

Other important characteristics:

39% were white

Describe index test:

a simple six-item triage risk screening tool (TRST

Cut-off point(s): ≥2

Describe reference test:

none

Main outcome measurement was the ability of the TRST to predict the composite endpoint of subsequent ED use, hospital admission, or NH admission at 30 and 120 days. Individual outcomes of ED use, hospitalization, and NH admissions were also examined.

Endpoint/outcome of follow-up:

To evaluate the predictive ability of a simple six-item triage risk screening tool (TRST) to identify elder emergency department (ED) patients at risk for ED revisits, hospitalization, or nursing home (NH) placement within

30 and 120 days following ED discharge.

Receiver operating characteristic (ROC) curves were con-structed and the area under the curve (AUC) was calculated. The predictive value of the TRST for the composite endpoint and individual health care

utilization was also examined by calculating relative risks (RRs) for these outcome measures. Thirty-day and 120-day outcomes were examined using chi-square tests for categorical variables, Wilcoxon rank-sum for non-normally distributed variables, and t-tests for continuous variables. The Cochran-Armitagetrend test was used to examine trends by outcomes and TRST scores. Interobserver agreement was de-termined for the subset of subjects with both TRST and APN risk classification. Statistical software used

for analysis included S-PLUS 6.0 (Insightful, Inc.,

Seattle, WA) and SAS V8.0 (SAS Institute, Inc., Cary,

NC). All statistical tests were two-tailed and a p-value

less than 0.05 was considered to indicate statistical

significance. Relative risk and kappa are reported

with 95% confidence intervals (95% CIs

Duration of follow-up:

120 days

For how many participants were no complete outcome data available?

N (%): NR

Outcome measures and effect size (include 95%CI and p-value if available):

Increasing cumulative TRST scores were associated with significant trends for ED use, hospital admission, and composite outcome at both 30 and 120 days (p < 0.0001 for all, except 30-day ED use, p = 0.002). A simple, unweighted five-item TRST ("lives alone" item removed after logistic regression modeling) with a cut-off score of 2 was the most parsimonious model for predicting composite outcome (AUC = 0.64) and hospitalization at 30 days (AUC= 0.72). Patients defined as high-risk by the TRST (score > or = 2) were significantly more likely to require subsequent ED use (RR = 1.7; 95% CI = 1.2 to 2.3), hospital admission (RR =3.3; 95% CI = 2.2 to 5.1), or the composite outcome (RR = 1.9; 95% CI 1.7 to 2.9) at both 30 days and 120 days than the low-risk cohort

McCusker et al;

1999

Type of study:

Prospective  follow-up study of a cohort

Setting:

EDs of four acute-care hospitals

Country:

Canada

Source of funding

Supported by grants from the Ministery of Health and Social services of the Province of Quebec

Inclusion criteria:

Community-dwelling patients aged 65 and older who came to the EDs during the weekday shift over a 3-month recruitment

Exclusion criteria:

Patients were excluded if they could not be interviewed either because of their medical condition or because of cognitive impairment and no other informant was available.

N=1854

Mean age ± SD:

49% 65-74 years

Sex: 56 % M / 43,4% F

Describe index test:

Measures ascertained at the ED visit included: 27 self-report screening questions on social, physical, and mental risk factors; medical history; use of hospital services, medications, and alcohol; and the Older American Resources and Services (OARS) activities of daily living (ADL) scale

Describe reference test:

At follow-up, the OARS scale was readministered by telephone, and other adverse health outcomes were ascertained

Endpoint/outcome of follow-up:

To develop a self-report screening tool to identify older people in the emergency department (ED) of a hospital at increased risk of adverse health outcomes, including: death, admission to a nursing home or long-term hospitalization, or a clinically significant decrease in functional status.

Duration of follow-up:

6 months

For how many participants were no complete outcome data available?

N (%): 1673 (90,2%)

Reasons for incomplete outcome data described

There was no significant differences (p<0,05) between completers and noncompleters in their social, demographic and initial functional characteristics at enrolment.

Outcome measures and effect size (include 95%CI and p-value if available):

Among 1673 patients who completed the follow-up measures, 488 (29.2%) had an adverse health outcome. Scale development and selection methods included logistic regression, receiver operating characteristic curves, and expert judgment

Sager et al;

1996

Type of study:

Multi-centre prospective cohort study

Setting:

Four university and two private non-federal acute care hospital

Country:

California , USA

Source of funding.

By Grant No 92312-G from the John A. Hartford Foundation New York

Inclusion criteria:

aged 70 and older and who were hospitalized for acute medical illness

Exclusion criteria:

NR

N= The development cohort consists of 448 patients and the validation cohort consists of 379 patients

Mean age ± SD:

52% 75-84 years

Sex: % M / % F

63%F

Other important characteristics: no

Describe index test:

Within 48 hours of admission

ADL en IADL (asked to report retrospectively their ability 2 weeks before admission)

MMSE

Describe reference test:

At discharge ADL

3 months after discharge ADL, IADL and rehospitalisation.

Endpoint/outcome of follow-up:

To develop and validate an instrument for stratifying older patients at the time of hospital admission according to their risk of developing new disabilities in activities of daily living (ADL) following acute medical illness and hospitalization.

Logistic regression analysis identified three patient characteristics that were independent predictors of functional decline in the development cohort: increasing age, lower admission Mini-Mental Status Exam scores, and lower preadmission IADL function.

A scoring system was developed for each predictor variable and patients were assigned to low, intermediate, and high risk categories.

Duration of follow-up:

3 months

For how many participants were no complete outcome data available?

N (%): NR

Outcome measures and effect size (include 95%CI and p-value if available):

The rates of ADL decline at discharge for the low, intermediate, and high risk categories were 17%, 28%, and 56% in the development cohort and 19%, 31%, and 55% in the validation cohort, respectively.

Patients in the low risk category were significantly more likely to recover ADL function and to avoid nursing home placement during the 3 months after discharge.

Runciman et al; 1996

Type of study:

Prospective comparative cohort study and diagnostic test study

Setting: The royal infirmary of Edinburgh

Country: Scotland

Source of funding: Funded through the Health Services Research Committee of the Scottisch Office Home and Health Department

Inclusion criteria:

Age>75 discharged from SEH

Exclusion criteria:

NR

N= 289

Mean age ± SD: NR

Sex: % M / % F

NR

Describe index test:

First part of the study: Value of a health visitor intervention

Second part of the study: an assessment tool to identify the most vulnerable prior to discharge.

The second part will be further described here!

Describe reference test:

Home visit by a research occupational therapist using the original stage 1 schedule en being unaware of the questionnaire data

Endpoint/outcome of follow-up:

Sensitivity and specificity

Duration of follow-up:

4 weeks

For how many participants were no complete outcome data available?

N (%): 208

Reasons for incomplete data described:

Direct admission to ward (n=155)

Address outwith Edinburgh (n=32)

Non-residential address (n=21)

Outcome measures and effect size (include 95%CI and p-value if available):

Risk answers:

≥1: sens 95.4%, spec 11.5%

≥2: sens 86.4%, spec 38.5

≥3: sens 50%, spec 76.9%

≥4: sens 36.4%, spec 80.8%

≥5: sens 22.7%, spec 88.5%

≥6: 4.5%, spec 100%

≥7: 4.5%. spec 100%

Rowland et al; 1990

Type of study: Prospective cohort study

Setting: At home, 10-14 days following attendance  at Accident and Emergency Departments ( AED)

 Country: Newcastle, United Kingdom

 Source of funding: NR

nclusion criteria: Patients 75 years and older who attended AED and were discharged direct from AED to an address in Newcastle

Exclusion criteria: Moved away after discharge to stay with relatives, declined to be interviewed.

 N= 450

 Mean age ± SD: 81,6 ( 6.2) years

 Sex: % M / % F 73 % F

 Other important characteristics: no

Describe index test:

The home visit provided data on functional ability ( before and after attendance), support systems and cognitive performance.

Data were recorded on a six-part questionnaire:

Personal details( age, sex, marital status, career)

AED details ( date/time attendance, source of referral, diagnosis, disposal).

Primary health care team ( notification of attendance, visits to patient).

Readmitted patients ( speciality, reason for admission).

Home visit ( type of accommodation, access, mobility, functional activities daily living, services received, social interaction)

Abbreviated mental test score

Dependency was graded in to 4 categories

Independent

Does activity with help from friends and relatives

Does activity with help from professional agencies

Describe reference test:

Questions asked by nurse in AED

Does patients using walking aids?

Does patient needs assistance to dress after treatment?

Has patient recently relied on someone else to collect his/her pension?

Has patient recently relied on someone else to do his/her grocery shopping?

Does patient attend a Day Centre or Day Hospital

Does patient receive Meals on Wheels

Does patient have a Home Help?

Cut-off point(s): ≥ 4

Endpoint/outcome of follow-up:

Readmission to hospital

Duration of follow-up:  14 days following attendance

From 450 were 25 patients readmitted to hospital within 14 days

 For how many participants were no complete outcome data available?

N (%): 20%

Reasons for incomplete outcome data described: 5 patients day before questionnaire could be completed

Outcome measures and effect size (include 95%CI and p-value if available):

Sensitivity 85%, specificity 28%