Christopher R. Carpenter|Erica Shelton|Susan A. Fowler|Brian Suffoletto|Timothy F. Platts?Mills|Richard E. Rothman|Teresita M. Hogan
Risk Factors and Screening Instruments to Predict Adverse Outcomes for Undifferentiated Older Emergency Department Patients: A Systematic Review and Meta?analysis
Washington University in St. Louis|Johns Hopkins University|Washington University in St. Louis|University of Pittsburgh Medical Center|University of North Carolina at Chapel Hill|Johns Hopkins University|University of Chicago
significant proportion geriatric patients experience suboptimal outcomes following episodes emergency department ed care risk stratification screening instruments exist distinguish vulnerable subsets prognostic accuracy varies systematic review quantifies prognostic accuracy individual risk factors edvalidated screening instruments distinguish patients less likely experience shortterm adverse outcomes like unanticipated ed returns hospital readmissions functional decline deatha medical librarian two emergency physicians conducted medical literature search pubmed embase scopus central clinicaltrialsgov using numerous combinations search terms including emergency medical services risk stratification geriatric multiple related mesh terms hundreds combinations two authors handsearched relevant specialty society research abstracts two physicians independently reviewed abstracts used revised quality assessment diagnostic accuracy studies instrument assess individual study quality two qualitatively similar studies identified metaanalysis conducted using metadisc software primary outcomes sensitivity specificity positive likelihood ratio lr negative likelihood ratio lr predictors adverse outcomes 1 12 months ed encounters hypothetical testtreatment threshold analysis constructed based metaanalytic summary estimate prognostic accuracy one outcomea total 7940 unique citations identified yielding 34 studies inclusion systematic review studies significantly heterogeneous terms country outcomes assessed timing posted outcome assessments studies occurred ed settings none used published clinical decision rule derivation methodology individual risk factors assessed included dementia delirium age dependency malnutrition pressure sore risk selfrated health none risk factors significantly increased risk adverse outcome lr range 078 284 absence dependency reduces risk 1year mortality lr 027 nursing home placement lr 027 five constructs frailty evaluated none increased decreased risk adverse outcome three instruments evaluated metaanalysis identification seniors risk triage risk screening tool variables indicative placement risk none instruments significantly increased lr range various outcomes 098 140 decreased lr range 053 111 risk adverse outcomes test threshold 3month functional decline based accurate instrument 42 treatment threshold 61risk stratification geriatric adults following ed care limited lack pragmatic accurate reliable instruments although absence dependency reduces risk 1year mortality individual risk factor frailty construct risk assessment instrument accurately predicts risk adverse outcomes older ed patients existing instruments designed risk stratify older ed patients accurately distinguish high lowrisk subsets clinicians educators policymakers use instruments valid predictors posted adverse outcomes future research derive validate feasible ed instruments distinguish vulnerable elders employ published decision instrument methods examine contributions alternative variables health literacy dementia often remain clinically occult