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Association of Emergency Clinicians' Assessment of Mortality Risk With Actual 1-Month Mortality Among Older Adults Admitted to the Hospital.

ABSTRACT: Importance:The accuracy of mortality assessment by emergency clinicians is unknown and may affect subsequent medical decision-making. Objective:To determine the association of the question, "Would you be surprised if your patient died in the next one month?" (known as the surprise question) asked of emergency clinicians with actual 1-month mortality among undifferentiated older adults who visited the emergency department (ED). Design, Setting, and Participants:This prospective cohort study at a single academic medical center in Portland, Maine, included consecutive patients 65 years or older who received care in the ED and were subsequently admitted to the hospital from January 1, 2014, to December 31, 2015. Data analyses were conducted from January 2018 to March 2019. Exposures:Treating emergency clinicians were required to answer the surprise question, "Would you be surprised if your patient died in the next one month?" in the electronic medical record when placing a bed request for all patients who were being admitted to the hospital. Main Outcomes and Measures:The primary outcome was mortality at 1 month, assessed from the National Death Index. The secondary outcomes included accuracies of responses by both emergency clinicians and admitting internal medicine clinicians to the surprise question in identifying older patients with high 6-month and 12-month mortality. Results:The full cohort included 10?737 older adults (mean [SD] age, 75.9 [8.8] years; 5532 [52%] women; 10?157 [94.6%] white) in 16?223 visits treated in the ED and admitted to the hospital. There were 5132 patients (31.6%) with a Charlson Comorbidity Index score of 2 or more. Mortality rates were 8.3% at 1 month, 17.2% at 6 months, and 22.5% at 12 months. Emergency clinicians stated that they would not be surprised if the patient died in the next month for 2104 patients (19.6%). In multivariable analysis controlling for age, sex, race, admission diagnosis, and comorbid conditions, the odds of death at 1 month were higher in patients for whom clinicians answered that they would not be surprised if the patient died in the next 1 month compared with patients for whom clinicians answered that they would be surprised if the patient died in the next 1 month (odds ratio, 2.4 [95% CI, 2.2-2.7]; P?

SUBMITTER: Ouchi K

PROVIDER: S-EPMC6745053 | biostudies-literature | 2019 Sep

REPOSITORIES: biostudies-literature

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Association of Emergency Clinicians' Assessment of Mortality Risk With Actual 1-Month Mortality Among Older Adults Admitted to the Hospital.

Ouchi Kei K Strout Tania T Haydar Samir S Baker Olesya O Wang Wei W Bernacki Rachelle R Sudore Rebecca R Schuur Jeremiah D JD Schonberg Mara A MA Block Susan D SD Tulsky James A JA

JAMA network open 20190904 9

<h4>Importance</h4>The accuracy of mortality assessment by emergency clinicians is unknown and may affect subsequent medical decision-making.<h4>Objective</h4>To determine the association of the question, "Would you be surprised if your patient died in the next one month?" (known as the surprise question) asked of emergency clinicians with actual 1-month mortality among undifferentiated older adults who visited the emergency department (ED).<h4>Design, setting, and participants</h4>This prospect ...[more]

PMID: 31517962

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Project description:ObjectiveTo evaluate the effectiveness of comprehensive geriatric assessment in hospital for older adults admitted as an emergency.Search strategyWe searched the EPOC Register, Cochrane's Controlled Trials Register, the Database of Abstracts of Reviews of Effects (DARE), Medline, Embase, CINAHL, AARP Ageline, and handsearched high yield journals.Selection criteriaRandomised controlled trials of comprehensive geriatric assessment (whether by mobile teams or in designated wards) compared with usual care. Comprehensive geriatric assessment is a multidimensional interdisciplinary diagnostic process used to determine the medical, psychological, and functional capabilities of a frail elderly person to develop a coordinated and integrated plan for treatment and long term follow-up.Data collection and analysisThree independent reviewers assessed eligibility and trial quality and extracted published data. Two additional reviewers moderated.ResultsTwenty two trials evaluating 10,315 participants in six countries were identified. For the primary outcome "living at home," patients who underwent comprehensive geriatric assessment were more likely to be alive and in their own homes at the end of scheduled follow-up (odds ratio 1.16 (95% confidence interval 1.05 to 1.28; P = 0.003; number needed to treat 33) at a median follow-up of 12 months versus 1.25 (1.11 to 1.42; P < 0.001; number needed to treat 17) at a median follow-up of six months) compared with patients who received general medical care. In addition, patients were less likely to be living in residential care (0.78, 0.69 to 0.88; P < 0.001). Subgroup interaction suggested differences between the subgroups "wards" and "teams" in favour of wards. Patients were also less likely to die or experience deterioration (0.76, 0.64 to 0.90; P = 0.001) and were more likely to experience improved cognition (standardised mean difference 0.08, 0.01 to 0.15; P = 0.02) in the comprehensive geriatric assessment group.ConclusionsComprehensive geriatric assessment increases patients' likelihood of being alive and in their own homes after an emergency admission to hospital. This seems to be especially true for trials of wards designated for comprehensive geriatric assessment and is associated with a potential cost reduction compared with general medical care.

Project description:Objective Patients admitted as emergencies to hospitals at the weekend have higher death rates than patients admitted on weekdays. This may be because the restricted service availability at weekends leads to selection of patients with greater average severity of illness. We examined volumes and rates of hospital admissions and deaths across the week for patients presenting to emergency services through two routes: (a) hospital Accident and Emergency departments, which are open throughout the week; and (b) services in the community, for which availability is more restricted at weekends. Method Retrospective observational study of all 140 non-specialist acute hospital Trusts in England analyzing 12,670,788 Accident and Emergency attendances and 4,656,586 emergency admissions (940,859 direct admissions from primary care and 3,715,727 admissions through Accident and Emergency) between April 2013 and February 2014.Emergency attendances and admissions to hospital and deaths in any hospital within 30 days of attendance or admission were compared for weekdays and weekends. Results Similar numbers of patients attended Accident and Emergency on weekends and weekdays. There were similar numbers of deaths amongst patients attending Accident and Emergency on weekend days compared with weekdays (378.0 vs. 388.3). Attending Accident and Emergency at the weekend was not associated with a significantly higher probability of death (risk-adjusted OR: 1.010). Proportionately fewer patients who attended Accident and Emergency at weekend were admitted to hospital (27.5% vs. 30.0%) and it is only amongst the subset of patients attending Accident and Emergency who were selected for admission to hospital that the probability of dying was significantly higher at the weekend (risk-adjusted OR: 1.054). The average volume of direct admissions from services in the community was 61% lower on weekend days compared to weekdays (1317 vs. 3404). There were fewer deaths following direct admission on weekend days than weekdays (35.9 vs. 80.8). The mortality rate was significantly higher at weekends amongst direct admissions (risk-adjusted OR: 1.212) due to the proportionately greater reduction in admissions relative to deaths. Conclusions There are fewer deaths following hospital admission at weekends. Higher mortality rates at weekends are found only amongst the subset of patients who are admitted. The reduced availability of primary care services and the higher Accident and Emergency admission threshold at weekends mean fewer and sicker patients are admitted at weekends than during the week. Extending services in hospitals and in the community at weekends may increase the number of emergency admissions and therefore lower mortality, but may not reduce the absolute number of deaths.

Project description:BackgroundA large body of research suggests that hospitals with intensive care units staffed by board-certified intensivists have lower mortality rates than those that do not.ObjectiveTo determine whether hospitals can reduce their mortality by adopting an intensivist staffing model.DesignRetrospective, longitudinal study using 2003-2010 Medicare data and the Leapfrog Group Hospital surveys.Setting and patientsIn total, 2,916,801 Medicare patients at 488 US hospitals.MeasurementsWe studied 30-day and in-hospital mortality among patients with several common medical and surgical conditions. We first compared risk-adjusted mortality rates of 3 groups of hospitals: those that were intensivist staffed throughout this time period, those that were not intensivist staffed, and those that transitioned to intensivist staffing somewhere during the period. We then examined rates of mortality improvement within each of the 3 groups and used difference-in-differences techniques to assess the independent effect of intensivist staffing among the subset of hospitals that transitioned.ResultsHospitals with intensivist staffing at the beginning of our study period had lower mortality rates than those without. However, hospitals that adopted intensivist staffing during the study period did not substantially improve their mortality rates. In our difference-in-differences analysis, there was no significant independent improvement in mortality after transitioning to intensivist staffing either overall [relative risk (RR), 0.96; 95% confidence interval (CI), 0.90-1.02] or in the medical (RR, 0.95; 95% CI, 0.89-1.02) or surgical populations (RR, 0.97; 95% CI, 0.84-1.10).LimitationsRisk adjustment was based on administrative data. Categorization of exposure was by survey response at the hospital level.ConclusionsAdoption of an intensivist staffing model was not associated with improved mortality in Medicare beneficiaries. These findings suggest that the lower mortality rates previously observed at hospitals with intensivist staffing may be attributable to other factors.

Dataset Information

Association of Emergency Clinicians' Assessment of Mortality Risk With Actual 1-Month Mortality Among Older Adults Admitted to the Hospital.

Publications

Association of Emergency Clinicians' Assessment of Mortality Risk With Actual 1-Month Mortality Among Older Adults Admitted to the Hospital.

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