CIRS Severity Index Research Articles

The Role of the Cumulative Illness Rating Scale (CIRS) in Estimating the Impact of Comorbidities on Chronic Obstructive Pulmonary Disease (COPD) Outcomes: A Pilot Study of the MACH (Multidimensional Approach for COPD and High Complexity) Study.

Chronic obstructive pulmonary disease (COPD) is a heterogeneous systemic syndrome that often coexists with multiple comorbidities. In highly complex COPD patients, the role of the Cumulative Illness Rating Scale (CIRS) as a risk predictor of COPD exacerbation is not known. The objective of this study was determine the effectiveness of the CIRS score in detecting the association of comorbidities and disease severity with the risk of acute exacerbations in COPD patients. In total, 105 adults with COPD (mean age 72.1 ± 9.0 years) were included in this prospective study. All participants at baseline had at least two moderate exacerbations or one leading to hospitalization. The primary outcome was a composite of moderate or severe COPD exacerbation during the 12 months of follow-up. The CIRS indices (CIRS total score, Severity Index and Comorbidity Index) showed a positive correlation with modified Medical Research Council (mMRC), COPD assessment test (CAT) and a negative correlation with forced expiratory volume in the first second (FEV1), Forced Vital Capacity (FVC), and FEV1/FVC. The three CIRS indices were able to predict the 12-month rate of moderate or severe exacerbation (CIRS Total Score: Hazard Ratio (HR) = 1.12 (95% CI: 1.08-1.21); CIRS Severity Index: HR = 1.21 (95% CI: 1.12-1.31); CIRS Comorbidity Index = 1.58 (95% CI: 1.33-1.89)). Among patients with COPD, the comorbidity number and severity, as assessed by the CIRS score, influence the risk in moderate-to-severe exacerbations. The CIRS score also correlates with the severity of respiratory symptoms and lung function.

Long-term use of glucocorticoids in patients with active rheumatoid arthritis: therapeutic "freeze frame"

In Russia, as well as throughout the world, the use of glucocorticoids (GC) in the treatment of rheumatoid arthritis (RA) is widespread, often going beyond the recommendations for both duration and dose regimen, which makes it relevant to study the long-term consequences of such a "wrong" (EULAR, 2022) use of GC in RA therapy. Of 1143 patients with active RA (ACR/EULAR 2010), two groups were formed: A (n=782) RA patients with more than 6 months of experience with systemic GC; group B (n=245) - no experience of taking GC. The cumulative disease index (CIRS) was used to assess the comorbidity profile. Patients in group A were older (p<0.0001), with a longer duration of RA (p=0.0004) and more often with IV radiological stage (p=0.02). With comparable (DAS28) RA activity, the D2T variant of RA was more often detected in them (p=0.036). RA therapy in group A was characterized by a large number of used disease-modifying anti-rheumatic drugs (p=0.0003), more frequent development of methotrexate-induced hepatitis (p=0.03). In group A, the time interval between the onset of RA and the initiation of biological therapy was longer (p=0.0001) and directly correlated with the duration of GC therapy (Rs=0.38) with a comparable qualitative structure of the used b/tsDMARDs. In the same group, tuberculosis, hypertension, chronic kidney disease, cataract and osteoporosis (p<0.05) and its complications were diagnosed significantly more often with a comparable frequency of cardiovascular disease, diabetes, and gastrointestinal lesions. In group A, a higher CIRS multimorbidity index was detected, and the CIRS severity index was lower than in group B (p<0.05). Long-term use of GC did not lead to a decrease in disease activity, inhibition of radiographic progression, delayed the timely administration of b/tsDMARDS and was accompanied by an increase in the multimorbid load.

What kind of patient benefits the most from an intensive physiotherapy after total hip replacement?

Abstract Background Hip replacement is a common orthopaedic surgery procedure that produces great improvement in the quality of life. Despite this, a globally standardized post-operative physiotherapy protocol still does not exist. The aim of this study is to identify the factors that influence the motor and functional outcome after early, intensive, hospitalized treatment. Methods A retrospective study was conducted in 2019 on 509 patients admitted to an Italian private clinic specialized in post-surgery rehabilitation, which applies an original bio-psycho-social-environmental protocol and individual rehabilitation plans. Data regarding each patient were collected from medical records: age, haemoglobin, Body Mass Index (BMI), Cumulative Illness Rating Scale (CIRS), Tinetti scale (TS) and Barthel scale (BS) at admission and discharge. The outcome was measured as the difference (Δ) between the values at discharge and admission of BS (ΔBS) and TS (ΔTS). We performed a univariate linear regression using STATA, to determine which factors influence the outcome. A p &amp;lt; 0.05 was considered statistically significant. Results Our sample (57.4% female) was 70.1 ± 10.4 years old. ΔBS was significantly influenced by motor performance at admission (BS: Coef. - 0.708, CI 95% [- 0.743 - - 0.673]; TS: Coef. - 1.697, CI 95% [- 1.849 - - 1.544]), global health conditions (CIRS Severity index: Coef. 4.925, CI 95% [1.037 - 8.814]) and age (Coef. 0.312, CI 95% [0.221 - 0,403]). ΔTS was significantly influenced by the same factors, BS: Coef. - 0.167, CI 95% [- 0.184 - - 0.149]; TS: Coef. - 0.667, CI 95% [- 0.703 - - 0.631]; CIRS Severity index: Coef. 1.254, CI 95% [0.012 - 2.511]; age: Coef. 0.090, CI 95% [0.061 - 0.120]. BMI and haemoglobin did not influence the studied outcomes. Conclusions Patients with worse health conditions, advanced age and lower motor performance at admission obtain a higher outcome. Key messages • A broader knowledge of rehabilitation influencing factors would provide higher outcomes. • The diffusion of individual rehabilitation plans would allow the achievement of better results.

Green Line Hospital-Territory Study: A Single-Blind Randomized Clinical Trial for Evaluation of Technological Challenges of Continuous Wireless Monitoring in Internal Medicine, Preliminary Results.

Background: Wireless vital parameter continuous monitoring (WVPCM) after discharge is compared to regular monitoring to provide data on the clinical-economic impact of complex patients (CPs) discharged from Internal Medicine Units of Ospedale dei Castelli, Lazio. Primary outcome: Major complications (MC) reduction. Secondary outcomes: Patients who reached discharge criteria within the 7th day from admission; difference in MC incidence at the conclusion of the standard telemonitoring/clinical monitoring phase, 5 and 30 days after discharge; and conditions predisposing to MC occurrence. Methods: Open label randomized controlled trial with wearable wireless system that creates alerts on portable devices. Continuous glycemic monitoring is performed for patients with diabetes mellitus. Results: There were 110 patients enrolled (mean age: 76.2 years). Comorbidity: Cumulative Illness Rating Scale CIRS-CI (comorbidities index): 3.93, CIRS SI (severity index): 1.93. About 19% scored a BRASS (Blaylock Risk Assessment Screening Score) ≥20 indicating need for discharge planning requiring step-down care. Globally, 48% of patients in the control group had major complications (27 out of 56 patients), in contrast to 22% in the intervention group (12 out of 54 patients). Conclusions: Since WVPCM detects early complications during the post-discharge CPs monitoring, it increases safety and reduces inappropriate access to the Emergency Room, preventing avoidable re-hospitalizations.

Safety and efficacy of retrograde intrarenal surgery in geriatric patients by age groups.

To evaluate the effects of aging on the success rate of retrograde intrarenal surgery (RIRS) and the development of medical and surgical complications by dividing geriatric patients into subgroups based on their chronological age. Data of the patients who underwent RIRS due to kidney stones at our clinic between June 2014 and January 2020 were retrospectively reviewed. Patients were divided into three groups based on age: 65-74years (Group 1), 75-84years (Group 2), and ≥ 85years (Group 3). The comorbid diseases of patients were evaluated using the Charlson Comorbidity Index (CCI), total Cumulative Illness Rating Scale for Geriatrics (CIRS-G) score, and CIRS severity index (CIRS-G SI). RIRS success rates and complications were evaluated based on age groups. A total of 336 patients were included in the study. The mean age of the patients was 72.7 ± 6.59years. Stone-free rate was 81.5% in patients aged > 65years and did not change with age. The modified Clavien-Dindo grade I/II complication rates for surgical complications were similar in all three groups (p = 0.818). In the evaluation of ROC analysis for medical complications, it was observed that the cut-off values were 76.5years, CIRS-G score of 4.5, CCI score of 2.5, and CIRS-SI score of 1.18 (p < 0.001). RIRS is an effective and safe treatment option for kidney and proximal ureteral stones in geriatric patients. Although there is an increase in medical complications post-RIRS with aging, surgical complications and stone-free rates remain unchanged.

Comorbidity does not mean clinical complexity: evidence from the RePoSI register.

In the last 2-3decades internists have confronted dramatic changes in the pattern of patients acutely admitted to hospital wards. Internists observed a shift from younger subjects affected by a single organ disease to more complex patients, usually older, with multiple chronic conditions, attended by different specialists, with poor integration and treated with multiple drugs. In this regard, the concept of complex patients is addressed daily in clinical practice even if there is no agreed definition of patient complexity. To try to evaluate clinical complexity different instruments have been proposed. Among these, the number of comorbidities (NoC) was considered a marker of clinical complexity. However, this instrument would not give information about the clinical relevance of each condition. On the contrary, cumulative illness rating scale (CIRS) addresses the problem calculating both CIRS severity index (CIRS-SI) and CIRS comorbidity index (CIRS-CI). In light of this, 4714 patients from the RePoSI register were retrospectively analyzed to show if CIRS assessment of comorbidity burden is different from the simple count of comorbidities in predicting the length of hospital stay (LOS) and all-cause of mortality in hospitalized elderly patients and if NoC could be a valid tool to measure patient's complexity. CIRS-SI resulted the best predictor of all-cause in-hospital mortality [OR: 2.66 (1.88-3.77)] in comparison with NoC that did not result statistically significant (p = 0.551). CIRS-SI was also the best predictor of all-cause of post-discharge mortality corrected for age and sex [OR: 2.12 (1.53-2.95)]. CIRS-SI (coefficient ± standard error: 1.23 ± 0.59; p < 0.0381) and CIRS-CI (coefficient ± standard error: 0.27 ± 0.10; p < 0.011) were strong predictors of LOS in comparison with NoC that did not result statistically significant (coefficient ± standard error: 0.04 ± 0.06 p < 0.0561). In conclusion, CIRS assessment of comorbidity burden is a better clinical tool in comparison with the simple count of comorbidities especially considering the length of hospital stay and all-cause mortality in hospitalized elderly patients.

P4517Heart failure in elderly and very elderly hospitalized patients: an epidemiological analysis from the REPOSI registry

Abstract Introduction Epidemiological data about heart failure (HF) in the elderly and, in particular, very elderly patients are lacking. Purpose To provide the epidemiological profile of elderly and very elderly HF patients in terms of prevalence, associated clinical factors, burden of multimorbidity and functional status. Methods Overall cohort of the REgistro POliterapie SIMI (REPOSI) was used to assess study aims. REPOSI is an Italian Nationwide Registry of elderly hospitalized patients in Internal Medicine and Geriatric wards. HF diagnosis was assessed at hospital admission according to ICD-9 code 428.XX. Results Among the 7003 patients originally enrolled, a total of 1095 (15.6%) patients reported a diagnosis of HF at hospital admission. Prevalence of HF progressively increased according to age strata, up to 26.8% in patients ≥90 [Figure]. A logistic regression analysis found that increasing age, body mass index and total cumulative illness rating scale (CIRS) were associated with HF (Table). Moreover, atrial fibrillation, chronic kidney disease, chronic obstructive pulmonary disease and polypharmacy (≥5 drugs) were associated with HF, while liver disease and neoplasm were inversely associated (Table). According to CIRS severity index and comorbidity index quartile, HF patients reported more likely values in the highest quartile than those without HF (47.4% vs. 26.6%, p&lt;0.001 and 34.4% vs. 18.5%, p&lt;0.001 respectively). According to short blessed test, geriatric depression scale and Barthel index, patients with HF had significantly more cognitive impairment and dementia, depression and dependent from others in daily activities than those without HF (all p&lt;0.001). Prevalence of HF according to Age Strata Conclusions In a cohort of elderly patients hospitalized in Internal Medicine and Geriatric wards HF was highly prevalent, in particular in those very elderly. HF was associated with several clinical factors, emphasizing a stronger clinical complexity. HF patients were more burdened with multimorbidity and showed an impaired functional status. Acknowledgement/Funding None

Developing a new predictor of health expenditure: preliminary results from a primary healthcare setting.

Risk adjustment is a widely used tool for health expenditure prediction and control. Early approaches for estimating health expenditure were based on patient demographic variables alone, whereas more recent models incorporate patient information, such as chronic medical conditions, clinical diagnoses, and self-reported health status. Many studies have investigated the health expenditure predictive capacity of single demographic, morbidity, or health-related quality of life measures, but the best models prove to be those that include them all. The aim of this study was to develop an index that combines measures of perceived health and disease severity and to compare its efficacy in predicting health expenditure with that of the measures taken individually. This is a linked cross-sectional study. In 2009 and 2010, the health-related quality of life questionnaire SF-36 (8 scales, two indices: Physical Component Summary [PCS] and Mental Component Summary [MCS]) was distributed to 886 patients of general practitioners in the Province of Siena, Italy. Severity of diseases was calculated for each patient using the Charlson Index (CH-I) and Cumulative Illness Rating Scale Severity Index (CIRS-SI). Siena Local Health Unit 2012 data on health expenditure were obtained for each patient. Multivariate linear regression was applied to test the performance of severity (CH-I, CIRS-SI) and perceived health (PCS and MCS) measures in predicting health expenditure. The indexes that predicted health expenditure best were then combined in a new tool, and its expenditure predictive capacity was tested. The best health expenditure predictors proved to be PCS and SI (R2=0.15 and R2=0.17, respectively). When combined in a new index (PCS-SI), better predictive capacity of health expenditure was obtained than with the two single measures separately (R2=0.19). A multidimensional indicator proved to be a better predictor of healthcare expenditure than single health measures.

Gender differences in health expenditure determinants: A follow-up study

ABSTRACTResearchers' aim was to investigate if patients/physicians characteristics could differently affect males/females health care expenditure.In 2009/2010, a health-related-quality-of-life (HRQL) measure was distributed to 887 general practitioners' (GP) patients in Siena's province-Italy. Severity of diseases was calculated through Cumulative Illness Rating Scale Severity Index (CIRS-SI). Information about GPs' gender and age and patients' gender, age, and socio-economic variables were recorded. 2012 data about pharmaceutical, outpatient and hospital expenditure were obtained. Multivariate regression was carried out.In males, hospital expenditure increased with higher CIRS-SI and female GP whilst in females it was not influenced by any of the variables. Outpatient and pharmaceutical expenditure increased with aging, higher CIRS-SI, and lower HRQL and education, both in males and females.Gender differences in health expenditure determinants emerged for hospital expenditure.

An investigation of multimorbidity measures as risk factors for pneumonia in elderly frail patients admitted to hospital

ObjectivesTo investigate the association of different chronic comorbidities, considered singularly and together in Cumulative Illness Rating Scale (CIRS) indexes, with pneumonia diagnosis in a group of elderly frail hospitalized patients. Design and methodsWith a retrospective cohort design, all clinical records of frail (Rockwood ≥5) nonterminal patients ≥65years old acutely admitted over a 8-month span in an internal medicine ward were evaluated. Pneumonia status and its categorization (community-acquired, CAP, vs healthcare-associated, HCAP) were defined according to chest radiology findings and validated criteria. Chronic comorbidities, CIRS Comorbidity Score and CIRS Severity Index were collected for each participant through a standardized methodology. Multivariate logistic regression models were applied to assess the association of each comorbid condition or scores with pneumonia. Results1199 patients (546M, median age 81.9, IQR 72.8–87.9years), of whom 239 with pneumonia (180 CAP, 59 HCAP) were evaluated. CIRS Comorbidity Score was significantly associated with pneumonia, both at an age- and sex-adjusted model and at a multivariate model (OR for each unitary increase 1.03, 95% CI 1.001–1.062, p=0.04), together with provenience from nursing home (OR 1.96, 95% CI 1.41–2.73, p<0.001). Among single comorbidities, only COPD (OR 2.7, 95% CI 1.9–3.6, p<0.001) and dementia (OR 2.3, 95% CI 1.7–3.3, p<0.001) were associated with pneumonia, while stroke, cancer, cardiovascular, chronic liver and kidney disease were not. ConclusionsIn a small cohort of elderly frail hospitalized patients, measures of multimorbidity, like CIRS, are significantly associated with the risk of pneumonia. COPD and dementia are the main conditions concurring to define this risk.

Comorbidities and disease severity as risk factors for carbapenem-resistant Klebsiella pneumoniae colonization: report of an experience in an internal medicine unit.

BackgroundCarbapenem-resistant Klebsiella pneumoniae (CRKP) is an emerging multidrug-resistant nosocomial pathogen, spreading to hospitalized elderly patients. Risk factors in this setting are unclear. Our aims were to explore the contribution of multi-morbidity and disease severity in the onset of CRKP colonization/infection, and to describe changes in epidemiology after the institution of quarantine-ward managed by staff-cohorting.Methods and FindingsWith a case-control design, we evaluated 133 CRKP-positive patients (75 M, 58 F; mean age 79±10 years) and a control group of 400 CRKP-negative subjects (179 M, 221 F; mean age 79±12 years) admitted to Internal Medicine and Critical Subacute Care Unit of Parma University Hospital, Italy, during a 10-month period. Information about comorbidity type and severity, expressed through Cumulative Illness Rating Scale-CIRS, was collected in each patient. During an overall 5-month period, CRKP-positive patients were managed in an isolation ward with staff cohorting. A contact-bed isolation approach was established in the other 5 months. The effects of these strategies were evaluated with a cross-sectional study design. CRKP-positive subjects had higher CIRS comorbidity index (12.0±3.6 vs 9.1±3.5, p<0.0001) and CIRS severity index (3.2±0.4 vs 2.9±0.5, p<0.0001), along with higher cardiovascular, respiratory, renal and neurological disease burden than control group. CIRS severity index was associated with a higher risk for CRKP-colonization (OR 13.3, 95%CI6.88–25.93), independent of comorbidities. Isolation ward activation was associated with decreased monthly incidence of CRKP-positivity (from 16.9% to 1.2% of all admissions) and infection (from 36.6% to 22.5% of all positive cases; p = 0.04 derived by Wilcoxon signed-rank test). Mortality rate did not differ between cases and controls (21.8% vs 15.2%, p = 0.08). The main limitations of this study are observational design and lack of data about prior antibiotic exposure.ConclusionsComorbidities and disease severity are relevant risk factors for CRKP-colonization/infection in elderly frail patients. Sanitary measures may have contributed to limit epidemic spread and rate of infection also in internal medicine setting.

Vulnerability assessment of the elderly cancer patients: Concordance between screening tests and subjective physician evaluation

cancer seems to be better able to predict mortality both at 6-months (AUC=0.94, pb0.0001) and 12-months (AUC=0.87, pb0.0001) of follow-up. Conclusions: The present study confirms the prognostic value of the MPI in elderly patients with advanced cancer. This index may consequently be used in the daily practice for the proper risk assessment of ECP. Further studies are nonetheless needed to confirm these findings in larger populations and assess the potential for integrating the MPI with the CIRS severity index and the GDS.

Customer Satisfaction as a Quality Factor in Geriatric Rehabilitation

Customer satisfaction is relevant for geriatric rehabilitation, besides objective outcomes. We aimed at measur- ing customer satisfaction at discharge from our rehabilitative wards, and at singling out its predictive factors. We studied 506 elderly patients, aged 78 ± 8 years. Satisfaction at discharge scored high in all 4-levels graded items of a questionnaire surveying perception of patient improvement, quality of rehabilitative treatment, physicians' and nurses' intervention, personal care, lodging quality, goodness of information got. Mean overall rating (scoring 0 to 10) of the rehabilitative stay was 9.2 ± 2.1, median and mode were 10. Rating correlated with: relative functional gain (r = 0.23, p < .000), absolute Barthel Index total score at discharge (r = 0.18, p < .000), net gain in Barthel Index total score at discharge (r = 0.1, p = 0.021), and improvement in CIRS Severity Index (r = 0.9, p = 0.043). Relative functional gain was the only variable pre- dictive of rating that was retained by stepwise multiple regressions (p < .000).