Risk Instrument For Screening In The Community Research Articles

Validation of the Risk Instrument for Screening in the Community (RISC) among Older Adults in the Emergency Department

Although several short-risk-prediction instruments are used in the emergency department (ED), there remains insufficient evidence to guide healthcare professionals on their use. The Risk Instrument for Screening in the Community (RISC) is an established screen comprising three Likert scales examining the risk of three adverse outcomes among community-dwelling older adults at one-year: institutionalisation, hospitalisation, and death, which are scored from one (rare/minimal) to five (certain/extreme) and combined into an Overall RISC score. In the present study, the RISC was externally validated by comparing it with different frailty screens to predict risk of hospitalisation (30-day readmission), prolonged length of stay (LOS), one-year mortality, and institutionalisation among 193 consecutive patients aged ≥70 attending a large university hospital ED in Western Ireland, assessed for frailty, determined by comprehensive geriatric assessment. The median LOS was 8 ± 9 days; 20% were re-admitted <30 days; 13.5% were institutionalised; 17% had died; and 60% (116/193) were frail. Based on the area under the ROC curve scores (AUC), the Overall RISC score had the greatest diagnostic accuracy for predicting one-year mortality and institutionalisation: AUC 0.77 (95% CI: 0.68-0.87) and 0.73 (95% CI: 0.64-0.82), respectively. None of the instruments were accurate in predicting 30-day readmission (AUC all <0.70). The Overall RISC score had good accuracy for identifying frailty (AUC 0.84). These results indicate that the RISC is an accurate risk-prediction instrument and frailty measure in the ED.

Multidimensional Short Tools to assess frailty: a narrative review.

The population of the European Union is progressively ageing, therefore frailty is becoming a crucial public health issue. In recent years there is a growing interest in a multidimensional concept of frailty, that is not only physical but also psychological and social, in line with a person-centered care. To measure frailty represents a fundamental step to evaluate the needs for care at both population and individual levels. Of course, to assess frailty in a large population is essential to find short and quick tools able to give reliable results in terms of risk of occurrence of negative events, to stratify older adults according to their frailty level. In this way the most appropriate strategies can be chosen and applied, to delay the functional decline associated to frailty and its consequences, such as hospitalization, institutionalization, low quality of life, and death. In this review we searched on PubMed for articles about scales assessing frailty with peculiar characteristics: published for the first time in 2010, available in English, with a short length and duration of administration, composed by multidimensional domains. Seven scales were found and analyzed: The Zulfiqar Frailty Scale (ZFS), The Pictorial Fit-Frail Scale (PFFS), The Tilburg Frailty Indicator (TFI), The SUNFRAIL Tool, The (fr)AGILE, The Risk Instrument for Screening in the Community (RISC) and The Short Functional Geriatric Evaluation (SFGE). We compared their main features as the number of questions, the time for administration, the domains used and the psychometric properties as validity and reliability, with the aim of providing a set of useful information to health professionals in their everyday work. The use of these tools provides important information to help plan community health and social care and meet individuals' needs for care, but this approach is not common for community care in the EU yet.

Validation of an electronic frailty index with electronic health records: eFRAGICAP index

ObjectiveTo create an electronic frailty index (eFRAGICAP) using electronic health records (EHR) in Catalunya (Spain) and assess its predictive validity with a two-year follow-up of the outcomes: homecare need, institutionalization and mortality in the elderly. Additionally, to assess its concurrent validity compared to other standardized measures: the Clinical Frailty Scale (CFS) and the Risk Instrument for Screening in the Community (RISC).MethodsThe eFRAGICAP was based on the electronic frailty index (eFI) developed in United Kingdom, and includes 36 deficits identified through clinical diagnoses, prescriptions, physical examinations, and questionnaires registered in the EHR of primary health care centres (PHC). All subjects > 65 assigned to a PHC in Barcelona on 1st January, 2016 were included. Subjects were classified according to their eFRAGICAP index as: fit, mild, moderate or severe frailty. Predictive validity was assessed comparing results with the following outcomes: institutionalization, homecare need, and mortality at 24 months. Concurrent validation of the eFRAGICAP was performed with a sample of subjects (n = 333) drawn from the global cohort and the CFS and RISC. Discrimination and calibration measures for the outcomes of institutionalization, homecare need, and mortality and frailty scales were calculated.Results253,684 subjects had their eFRAGICAP index calculated. Mean age was 76.3 years (59.5% women). Of these, 41.1% were classified as fit, and 32.2% as presenting mild, 18.7% moderate, and 7.9% severe frailty. The mean age of the subjects included in the validation subsample (n = 333) was 79.9 years (57.7% women). Of these, 12.6% were classified as fit, and 31.5% presented mild, 39.6% moderate, and 16.2% severe frailty. Regarding the outcome analyses, the eFRAGICAP was good in the detection of subjects who were institutionalized, required homecare assistance, or died at 24 months (c-statistic of 0.841, 0.853, and 0.803, respectively). eFRAGICAP was also good in the detection of frail subjects compared to the CFS (AUC 0.821) and the RISC (AUC 0.848).ConclusionThe eFRAGICAP has a good discriminative capacity to identify frail subjects compared to other frailty scales and predictive outcomes.

Validation of the Portuguese Version of the Risk Instrument for Screening in the Community (RISC) Among Older Patients in Primary Care in Northern Portugal.

Background: Aging is associated with an increase in adverse health outcomes for older people. Short screening instruments that easily and quickly identify those at highest risk can enable decision-makers to anticipate future needs, allocate scarce resources and act to minimize risk. The Risk Instrument for Screening in the Community (RISC) is a brief (2–5 min) Likert scale that scores one-year risk of institutionalization, hospitalization and death from low (1/5) to severe (5/5).Objectives: To externally validate the RISC, scored by general practitioners (GP's), in primary care in Northern Portugal.Methods: The RISC was translated and culturally adapted to Portuguese. A cohort of 457 older adults (aged ≥65) under active follow-up with their GP's were screened. Outcomes at one-year were recorded. Accuracy was determined from the area under the curve (AUC) of receiver operating curve analysis.Results: The mean age of participants was 75.2 years; 57% were female. The proportion identified as being at maximum risk (RISC scores of 3-5/5) of institutionalization, hospitalization and death, were 14.9, 52.4 and 38.4%, respectively. At follow-up 2% (10/431) were institutionalized, 18.6% (84/451) were hospitalized and 3% (14/456) died. Those who were institutionalized (p = 0.021), hospitalized (p = 0.012) or dead (p < 0.001) at one-year were significantly older. Those living alone were more likely to be institutionalized (p = 0.007). The RISC showed fair accuracy in predicting hospitalization (AUC of 0.62 [95% CI: 0.55–0.69]) and good accuracy for Institutionalization (AUC of 0.79 [95% CI: 0.62–0.96]) and death (AUC of 0.77 [95% CI: 0.65–0.88]).Conclusions: The Portuguese version of the RISC accurately predicted institutionalization and death at one-year but like most short screens was less able to predict hospitalization. Given its brevity, the RISC is useful for quickly identifying and stratifying those at increased risk in primary care.

Perceived risk of institutionalization, hospitalization, and death in oldest old primary care patients

ObjectivesThis study aims to analyze the accuracy and predictive ability of the Risk Instrument for Screening in the Community (RISC) scored by general practitioners (GPs) in a sample of primary care patients aged 80+ with perceived mental health concerns. MethodGPs ranked the perceived risk of the three adverse outcomes (hospitalization, institutionalization and death) at 1 year in a five Likert scale (RISC score), where 1 is the lowest risk and 5 is the highest. Follow up contacts were conducted after 1 year of assessment in order to collect data on the three outcomes. ResultsThe 1-year proportion of institutionalization, hospitalization and death were 12.1 %, 25.2 % and 19.0 % respectively. Based upon the sensitivity and specificity from the Receiver Operating Characteristic (ROC) curves, we found an optimal cut-off point of ≥4 for the RISC. The RISC had fair accuracy for 1-year risk of institutionalization (Area Under the ROC curve (AUC) = 0.75, 95% CI 0.43-0.68) and hospitalization (AUC = 0.65, 95% CI 0.52-0.78), but not for death (AUC = 0.55, 95% CI 0.43-0.68). ConclusionsThe RISC as a short global subjective assessment is to be considered a reliable tool for use by GPs. Our results showed that RISC seems to be a good instrument to triage very old people at risk for institutionalization but with poor accuracy at predicting hospitalization and limited predictive ability for death, suggesting further research and caution on this instrument’s use.

296 Risk-prediction in the Emergency Department: Comparing the Accuracy of Short Frailty Screens to Identify Adverse Healthcare Outcomes among Older Adults

Abstract Background Multiple instruments are available to screen for frailty in the Emergency Department (ED). Despite this, few studies have compared their predictive validity among older adults attending ED. This study aimed to investigate the diagnostic accuracy of a variety of different short frailty and risk-prediction instruments to predict 30-day readmission, length of stay (LOS), one-year mortality and institutionalisation. Methods Consecutive patients aged ≥70 attending a university hospital ED were screened and assessed for frailty. Outcomes were obtained from hospital records. The following instruments were compared: the Clinical Frailty Scale (CFS), PRISMA-7, Identification of Seniors at Risk tool, FRAIL scale, Groningen Frailty Indicator (GFI) and Risk Instrument for Screening in the Community (RISC). Results In all, 193 patients were included, median age 79+/-9; 55% were female. Based upon a CGA, 60% (116/193) were classified as frail. Those identified as frail were significantly older (p=0.03) and reported lower quality of life scores (p&lt;0.001). There was no significant difference in co-morbidity using the Charlson Index (p=0.15). The ED conversion rate was 77%, median LOS 8+/-9 days and 20% were re-admitted within 30 days. At one-year, 13.5% were accepted for long-term care and 17% had died. Comparing instruments, the combined RISC was had the highest accuracy based on the area under the ROC curve (AUC) scores for predicting mortality and nursing home admission at one year, AUC 0.77 (95% CI:0.68-0.87) and 0.73 (95% CI:0.64-0.82), respectively. The GFI, CFS and PRISMA-7 had statistically similar, albeit lower scores. No instrument was accurate in predicting 30-day readmission after discharge (AUC &lt;0.70). Conclusion Short frailty screening instruments applied in ED have poor-modest predictive validity for important healthcare outcomes, particularly hospital re-admission. The RISC score had the highest diagnostic accuracy for institutionalisation and death but this was fair at best, suggesting that instrument selection should be pragmatic with the expectation of identifying frailty.

Perception of risk of adverse outcomes of older people: comparison between nursing homes, day centers and home care services

PurposeIn Portugal, the three main kinds of care services available for older people are nursing homes, day centers and home care services. The use of these care services is mostly based on complex socioeconomic and functional criteria; however it is not clear if this placement corresponds to a higher/lower risk of adverse outcomes. The purposes of this paper are: to characterize clients of each type of service; to estimate the proportion of individuals at perceived risk of each adverse outcome according to type of service; to assess the ability of the Risk Instrument for Screening in the Community (RISC) to identify the risk profiles according to type of service.Design/methodology/approachThe sample comprised individuals aged 65+ (n=224), receiving care at home, in day centers or in nursing homes. The identification of individuals at risk for three adverse outcomes (institutionalization, hospitalization and death) was performed using a short pre-screen instrument (RISC).FindingsThe RISC identified mental state issues as the unique factor that differentiated clients according the type of care services (χ2 (6, N=224)=20.96, p=0.002), with day center presenting the lowest percentage of mental health concerns and nursing home presenting the highest percentage (44.44 and 71.91 percent, respectively). Additionally, a gradient was found between perceived risk of adverse outcomes (institutionalization and hospitalization) and care of levels required.Originality/valueThe RISC can be used to discriminate people in different settings of care and can be helpful in the selection of groups at risk that will benefit more from available services.

PERCEPTION OF RISK OF ADVERSE OUTCOMES OF OLD PEOPLE IN NURSING HOMES, DAY CENTERS AND HOME CARE

Purpose: In Portugal, the three main kinds of services available for older people are nursing homes, day centers and home care services. The admission of old people to these services is mostly based on socioeconomic criteria. However, it is not clear if admission in one of these three types of services corresponds to a higher/lower risk of adverse outcomes (institutionalization, hospitalization and death). The objectives of this work were: i) to characterize customers of each type of service; ii) to estimate the proportion of individuals at perceived risk of each adverse outcome according to each type of service; iii) to assess the ability of RISC to differentiate the types of services for each adverse outcome. Methodology: The sample comprised old people with 65 or plus years, that receiving care at home, in day centers or in a nursing home. The identification of individuals at risk within a year was realized using a short, reliable and valid pre-screen instrument, the RISC (Risk Instrument for Screening in the Community). Findings: The findings of this research suggest that the three types of services differ according to percentage of mental health problems, but do not differ according to functionality and medical problems of customers. Value: The RISC can be used to discriminate people in different settings of care and help selecting the groups at risk that will benefit more from available services

Measuring the Effect of Carers on Patients' Risk of Adverse Healthcare Outcomes Using the Caregiver Network Score.

Although caregivers are important in the management of frail, community-dwelling older adults, the influence of different caregiver network types on the risk of adverse healthcare outcomes is unknown. To examine the association between caregiver type and the caregiver network subtest of The Risk Instrument for Screening in the Community (RISC), a five point Likert scale scored from one ("can manage") to five ("absent/liability"). To measure the association between caregiver network scores and the one-year incidence of institutionalisation, hospitalisation and death. Observational cohort study. Community-dwelling adults, aged >65, attending health centres in Ireland, (n=779). PROCEDURE AND MEASUREMENTS: The caregiver network subtest of the RISC was scored by public health nurses. Caregivers were grouped dichotomously into low-risk (score of one) or high-risk (scores two-five). The majority of patients had a primary caregiver (582/779; 75%), most often their child (200/582; 34%). Caregiver network scores were highest, indicating greatest risk, when patients had no recognised primary caregiver and lowest when only a spouse or child was available. Despite this, patients with a caregiver were significantly more likely to be institutionalised than those where none was required or identified (11.5% versus 6.5%, p=0.047). The highest one-year incidence of adverse outcomes occurred when state provided care was the sole support; the lowest when private care was the sole support. Significantly more patients whose caregiver networks were scored high-risk required institutionalisation than low-risk networks; this association was strongest for perceived difficulty managing medical domain issues, odds ratio (OR) 3.87:(2.22-6.76). Only perceived difficulty managing ADL was significantly associated with death, OR 1.72:(1.06-2.79). There was no association between caregiver network scores and risk of hospitalisation. This study operationalizes a simple method to evaluate caregiver networks. Networks consisting of close family (spouse/children) and those reflecting greater socioeconomic privilege (private supports) were associated with lower incidence of adverse outcomes. Caregiver network scores better predicted institutionalisation than hospitalisation or death.

The Risk Instrument for Screening in the Community (RISC): a new instrument for predicting risk of adverse outcomes in community dwelling older adults.

BackgroundPredicting risk of adverse healthcare outcomes, among community dwelling older adults, is difficult. The Risk Instrument for Screening in the Community (RISC) is a short (2–5 min), global subjective assessment of risk created to identify patients’ 1-year risk of three outcomes:institutionalisation, hospitalisation and death.MethodsWe compared the accuracy and predictive ability of the RISC, scored by Public Health Nurses (PHN), to the Clinical Frailty Scale (CFS) in a prospective cohort study of community dwelling older adults (n = 803), in two Irish PHN sectors. The area under the curve (AUC), from receiver operating characteristic curves and binary logistic regression models, with odds ratios (OR), compared the discriminatory characteristics of the RISC and CFS.ResultsFollow-up data were available for 801 patients. The 1-year incidence of institutionalisation, hospitalisation and death were 10.2, 17.7 and 15.6 % respectively. Patients scored maximum-risk (RISC score 3,4 or 5/5) at baseline had a significantly greater rate of institutionalisation (31.3 and 7.1 %, p < 0.001), hospitalisation (25.4 and 13.2 %, p < 0.001) and death (33.5 and 10.8 %, p < 0.001), than those scored minimum-risk (score 1 or 2/5). The RISC had comparable accuracy for 1-year risk of institutionalisation (AUC of 0.70 versus 0.63), hospitalisation (AUC 0.61 versus 0.55), and death (AUC 0.70 versus 0.67), to the CFS. The RISC significantly added to the predictive accuracy of the regression model for institutionalisation (OR 1.43, p = 0.01), hospitalisation (OR 1.28, p = 0.01), and death (OR 1.58, p = 0.001).ConclusionFollow-up outcomes matched well with baseline risk. The RISC, a short global subjective assessment, demonstrated satisfactory validity compared with the CFS.

Risk Instrument for Screening in the Community (RISC): Cross Cultural Perspectives

Older people are at an increased risk of developing multiple co-morbidities causing subsequent cognitive, functional decline and frailty and increasing the risk of adverse healthcare outcomes. Public Health Nurses (PHNs), geriatricians and researchers developed the Risk Instrument for Screening in the Community (RISC) to record the presence of problems, severity (mild, moderate, severe) of concerns and caregiver networks’ ability to manage the patient across three domains: mental state, activities of daily living and medical state. The aim of this study was to explore the experiences of healthcare professionals who had used the RISC with community-dwelling older adults, between countries. Five focus groups (n = 28) were conducted in five countries (Australia, Northern Ireland, Portugal, Republic of Ireland and Spain). Four main themes were identified from participants’ experiences using the RISC: ‘Tool Usability’; ‘Benefits for Patients and Carers’; ‘Operational Challenges’; and ‘Recommendations for Improvement’. Some cultural differences were found between participants with regards to terminologies such as ‘caregiver network’ and ‘insight’ and expectation in relation to caring. Disciplinary differences were identified related to different conceptualisations of health. The RISC offers an innovative approach to identify and score risk in community dwelling older adults. However, further research is necessary to reflect cultural and disciplinary norms.

COMPONENTS OF THE RISK INSTRUMENT FOR SCREENING IN THE COMMUNITY (RISC) THAT CORRELATE WITH PUBLIC HEALTH NURSES’ PERCEPTION OF RISK

Functional decline and frailty are common in community-dwelling older adults, leading to an increased risk of adverse outcomes. To examine the factors that public health nurses perceive to cause risk of three adverse outcomes: institutionalisation, hospitalisation, and death, in older adults, using the Risk Instrument for Screening in the Community (RISC). A quantitative, correlational, descriptive design was used. A sample of 803 community-dwellers, aged over 65 years receiving regular follow-up by public health nurses. Procedure and Measurements: Public health nurses (n=15) scored the RISC and the Clinical Frailty Scale (CFS) on patients in their caseload. We examined and compared correlations between the severity of concern and ability of the caregiver network to manage these concerns with public health nurses' perception of risk of the three defined adverse outcomes. In total, 782 RISC scores were available. Concern was higher for the medical state domain (686/782,88%) compared with the mental state (306/782,39%) and activities of daily living (595/782,76%) domains. Concern was rated as severe for only a small percentage of patients. Perceived risk of institutionalisation had the strongest correlation with concern over patients mental state,(r=0.53), while risk of hospitalisation,(r=0.53) and death,(r=0.40) correlated most strongly with concern over the medical state. Weaker correlations were found for the other domains and RISC scores. The CFS most strongly correlated with the ADL domain,(r=0.78). Although the prevalence of concern was high, it was mostly rated as mild. Perceived risk of institutionalisation correlated most with concern over the ability of caregiver networks to manage patients' mental state, while risk of hospitalisation and death correlated with patients' medical state. The findings suggest the importance of including an assessment of the caregiver network when examining community-dwelling older adults. Validation of the RISC and public health nurses' ratings are now required.

Which Part of a Short, Global Risk Assessment, the Risk Instrument for Screening in the Community, Predicts Adverse Healthcare Outcomes?

The Risk Instrument for Screening in the Community (RISC) is a short, global risk assessment to identify community-dwelling older adults' one-year risk of institutionalisation, hospitalisation, and death. We investigated the contribution that the three components of the RISC (concern, its severity, and the ability of the caregiver network to manage concern) make to the accuracy of the instrument, across its three domains (mental state, activities of daily living (ADL), and medical state), by comparing their accuracy to other assessment instruments in the prospective Community Assessment of Risk and Treatment Strategies study. RISC scores were available for 782 patients. Across all three domains each subtest more accurately predicted institutionalisation compared to hospitalisation or death. The caregiver network's ability to manage ADL more accurately predicted institutionalisation (AUC 0.68) compared to hospitalisation (AUC 0.57, P = 0.01) or death (AUC 0.59, P = 0.046), comparing favourably with the Barthel Index (AUC 0.67). The severity of ADL (AUC 0.63), medical state (AUC 0.62), Clinical Frailty Scale (AUC 0.67), and Charlson Comorbidity Index (AUC 0.66) scores had similar accuracy in predicting mortality. Risk of hospitalisation was difficult to predict. Thus, each component, and particularly the caregiver network, had reasonable accuracy in predicting institutionalisation. No subtest or assessment instrument accurately predicted risk of hospitalisation.

Screening for markers of frailty and perceived risk of adverse outcomes using the Risk Instrument for Screening in the Community (RISC).

BackgroundFunctional decline and frailty are common in community dwelling older adults, increasing the risk of adverse outcomes. Given this, we investigated the prevalence of frailty-associated risk factors and their distribution according to the severity of perceived risk in a cohort of community dwelling older adults, using the Risk Instrument for Screening in the Community (RISC).MethodsA cohort of 803 community dwelling older adults were scored for frailty by their public health nurse (PHN) using the Clinical Frailty Scale (CFS) and for risk of three adverse outcomes: i) institutionalisation, ii) hospitalisation and iii) death, within the next year, from one (lowest) to five (highest) using the RISC. Prior to scoring, PHNs stated whether they regarded patients as frail.ResultsThe median age of patients was 80 years (interquartile range 10), of whom 64% were female and 47.4% were living alone. The median Abbreviated Mental Test Score (AMTS) was 10 (0) and Barthel Index was 18/20 (6). PHNs regarded 42% of patients as frail, while the CFS categorized 54% (scoring ≥5) as frail. Dividing patients into low-risk (score one or two), medium-risk (score three) and high-risk (score four or five) using the RISC showed that 4.3% were considered high risk of institutionalization, 14.5% for hospitalization, and 2.7% for death, within one year of the assessment. There were significant differences in median CFS (4/9 versus 6/9 versus 6/9, p < 0.001), Barthel Index (18/20 versus 11/20 versus 14/20, p < 0.001) and mean AMTS scores (9.51 versus 7.57 versus 7.00, p < 0.001) between those considered low, medium and high risk of institutionalisation respectively. Differences were also statistically significant for hospitalisation and death. Age, gender and living alone were inconsistently associated with perceived risk. Frailty most closely correlated with functional impairment, r = −0.80, p < 0.001.ConclusionThe majority of patients in this community sample were perceived to be low risk for adverse outcomes. Frailty, cognitive impairment and functional status were markers of perceived risk. Age, gender and social isolation were not and may not be useful indicators when triaging community dwellers. The RISC now requires validation against adverse outcomes.