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      Use of an electronic administrative database to identify older community dwelling adults at high-risk for hospitalization or emergency department visits: The elders risk assessment index

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          Abstract

          Background

          The prevention of recurrent hospitalizations in the frail elderly requires the implementation of high-intensity interventions such as case management. In order to be practically and financially sustainable, these programs require a method of identifying those patients most at risk for hospitalization, and therefore most likely to benefit from an intervention. The goal of this study is to demonstrate the use of an electronic medical record to create an administrative index which is able to risk-stratify this heterogeneous population.

          Methods

          We conducted a retrospective cohort study at a single tertiary care facility in Rochester, Minnesota. Patients included all 12,650 community-dwelling adults age 60 and older assigned to a primary care internal medicine provider on January 1, 2005. Patient risk factors over the previous two years, including demographic characteristics, comorbid diseases, and hospitalizations, were evaluated for significance in a logistic regression model. The primary outcome was the total number of emergency room visits and hospitalizations in the subsequent two years. Risk factors were assigned a score based on their regression coefficient estimate and a total risk score created. This score was evaluated for sensitivity and specificity.

          Results

          The final model had an AUC of 0.678 for the primary outcome. Patients in the highest 10% of the risk group had a relative risk of 9.5 for either hospitalization or emergency room visits, and a relative risk of 13.3 for hospitalization in the subsequent two year period.

          Conclusions

          It is possible to create a screening tool which identifies an elderly population at high risk for hospital and emergency room admission using clinical and administrative data readily available within an electronic medical record.

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          Most cited references 13

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          Geriatric care management for low-income seniors: a randomized controlled trial.

          Low-income seniors frequently have multiple chronic medical conditions for which they often fail to receive the recommended standard of care. To test the effectiveness of a geriatric care management model on improving the quality of care for low-income seniors in primary care. Controlled clinical trial of 951 adults 65 years or older with an annual income less than 200% of the federal poverty level, whose primary care physicians were randomized from January 2002 through August 2004 to participate in the intervention (474 patients) or usual care (477 patients) in community-based health centers. Patients received 2 years of home-based care management by a nurse practitioner and social worker who collaborated with the primary care physician and a geriatrics interdisciplinary team and were guided by 12 care protocols for common geriatric conditions. The Medical Outcomes 36-Item Short-Form (SF-36) scales and summary measures; instrumental and basic activities of daily living (ADLs); and emergency department (ED) visits not resulting in hospitalization and hospitalizations. Intention-to-treat analysis revealed significant improvements for intervention patients compared with usual care at 24 months in 4 of 8 SF-36 scales: general health (0.2 vs -2.3, P = .045), vitality (2.6 vs -2.6, P < .001), social functioning (3.0 vs -2.3, P = .008), and mental health (3.6 vs -0.3, P = .001); and in the Mental Component Summary (2.1 vs -0.3, P < .001). No group differences were found for ADLs or death. The cumulative 2-year ED visit rate per 1000 was lower in the intervention group (1445 [n = 474] vs 1748 [n = 477], P = .03) but hospital admission rates per 1000 were not significantly different between groups (700 [n = 474] vs 740 [n = 477], P = .66). In a predefined group at high risk of hospitalization (comprising 112 intervention and 114 usual-care patients), ED visit and hospital admission rates were lower for intervention patients in the second year (848 [n = 106] vs 1314 [n = 105]; P = .03 and 396 [n = 106] vs 705 [n = 105]; P = .03, respectively). Integrated and home-based geriatric care management resulted in improved quality of care and reduced acute care utilization among a high-risk group. Improvements in health-related quality of life were mixed and physical function outcomes did not differ between groups. Future studies are needed to determine whether more specific targeting will improve the program's effectiveness and whether reductions in acute care utilization will offset program costs. clinicaltrials.gov Identifier: NCT00182962.
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            A randomized, controlled trial of comprehensive geriatric assessment and multidisciplinary intervention after discharge of elderly from the emergency department--the DEED II study.

            To study the effects of comprehensive geriatric assessment (CGA) and multidisciplinary intervention on elderly patients sent home from the emergency department (ED). Prospective, randomized, controlled trial with 18 months of follow-up. Large medical school-affiliated public hospital in an urban setting in Sydney, Australia. A total of 739 patients aged 75 and older discharged home from the ED were randomized into two groups. Patients randomized to the treatment group underwent initial CGA and were followed at home for up to 28 days by a hospital-based multidisciplinary outreach team. The team implemented or coordinated recommendations. The control group received usual care. The primary outcome measure was all admissions, to the hospital within 30 days of the initial ED visit. Secondary outcome measures were elective and emergency admissions, and nursing home admissions and mortality. Additional outcomes included physical function (Barthel Index (total possible score=20) and instrumental activities of daily living (/12) and cognitive function (mental status questionnaire (/10)). Intervention patients had a lower rate of all admissions to the hospital during the first 30 days after the initial ED visit (16.5% vs 22.2%; P=.048), a lower rate of emergency admissions during the 18-month follow-up (44.4% vs 54.3%; P=.007), and longer time to first emergency admission (382 vs 348 days; P=.011). There was no difference in admission to nursing homes or mortality. Patients randomized to the intervention group maintained a greater degree of physical and mental function (Barthel Index change from baseline at 6 months: -0.25 vs -0.75; P<.001; mental status questionnaire change from baseline at 12 months: -0.21 vs -0.64; P<.001). CGA and multidisciplinary intervention can improve health outcomes of older people at risk of deteriorating health and admission to hospital. Patients aged 75 and older should be referred for CGA after an ED visit. Copyright 2004 American Geriatrics Society
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              Screening elders for risk of hospital admission.

               B Dowd,  L Boult,  Chad Boult (1993)
              To define a set of screening criteria that identifies elders who are at high risk for repeated hospital admission in the future. Longitudinal cohort study. Logistic regression analysis of data from half of the subjects was used to identify risk factors for repeated hospital admission. The ability of these risk factors to identify elders who are at high risk for repeated hospitalization in the future was then tested using data from the other half of the subjects. United States. A subsample (n = 5876) of a multistage probability sample of all non-institutionalized U.S. civilians who were 70 years or older in 1984. At baseline (1984), elderly subjects were asked about their demographic, socioeconomic, medical, and functional characteristics and about their recent use of health services. Their subsequent hospital admissions and mortality were then monitored through the records of the Medicare program and the National Death Index (1985-88). Among the subjects in the first half of the sample, eight factors emerged as risk factors for repeated admission: older age, male sex, poor self-rated general health, availability of an informal caregiver, having ever had coronary artery disease, and having had, during the previous year, a hospital admission, more than six doctor visits, or diabetes. Based on the presence or absence of these factors in 1984, 7.2% of the subjects in the second half of the sample were estimated to have a high probability of repeated admission (Pra > or = 0.5) during 1985-1988. In comparison with subjects estimated to have a low risk (Pra < 0.5), this high-risk group's actual experiences during 1985-1988 included a higher cumulative incidence of repeated admission (41.8% vs 26.2%, P < 0.0001), a higher cumulative rate of mortality (44.2% vs 19.0%, P < 0.0001), more hospital days per person-year survived (5.2 vs 2.6), and higher hospital charges per person-year survived ($3731 vs $1841). Eight easily ascertained risk factors affect elders' probability of being hospitalized repeatedly within four years. In the future, brief surveys about the presence of these factors could be used to estimate elders' risk of future hospitalization and, thereby, to identify some of those who may derive the greatest benefit from interventions designed to avert the need for hospitalization.
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                Author and article information

                Journal
                BMC Health Serv Res
                BMC Health Services Research
                BioMed Central
                1472-6963
                2010
                13 December 2010
                : 10
                : 338
                Affiliations
                [1 ]Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55905, USA
                [2 ]Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55905, USA
                Article
                1472-6963-10-338
                10.1186/1472-6963-10-338
                3019201
                21144042
                Copyright ©2010 Crane et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License (<url>http://creativecommons.org/licenses/by/2.0</url>), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
                Research Article

                Health & Social care

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