Use Of Risk Stratification Tools Research Articles

Implementation of the Caprini risk assessment model (RAM) in surgical patients to decrease postsurgical venous thromboembolism and enoxaparin prescription at hospital discharge

Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), has been an increasingly common post-surgical complication for surgical patients. In the United States, VTE has become a leading cause of preventable hospital death with more than half occurring after discharge and are directly linked to a recent (within 30 days) hospitalization or surgery [1]. In large, hospital-associated/acquired VTE (HA-VTE) are preventable through measures such as the use of risk stratification tools and chemoprophylaxis. The project institution, a community, academic, medical center, for multiple years has consistently remained a high outlier for postoperative VTE. Also, the choice of VTE chemoprophylaxis in surgical patients at the time of discharge depended on, and varied between, the individual prescribing physician. The goal was to implement and determine the efficacy of a standardized intervention tool, the Caprini risk assessment model (RAM), for reducing postoperative VTE complications and its influence on the physician's prescription of enoxaparin at discharge. Results: Risk assessment scoring pre-operatively increased from 0% baseline to 26.3% at Plan-Do-Study-Act (PDSA) cycle 1 and demonstrated a statistically significant change (p-value = 0.006). Risk assessment scoring pre-operatively was 42.9% by PDSA cycle 2 but was not statistically significantly different from PDSA cycle 1. Risk assessment scoring post-operatively (for eligible patients) remained the same throughout all three cycles at 0%. Appropriate prescription of anticoagulation declined from baseline (12.5%) to PDSA cycle 1 (0%), and improved at PDSA cycle 2 (33.3%), however no differences were significant (p-value 0.302). The National Surgical Quality Improvement Project (NSQIP) database showed a decline in VTE occurrences at the projects institution from baseline (1.02%, 6 occurrences, 2021) to PDSA cycle 2 (0.92%, 4 occurrences, 2022) when compared to the national benchmark (1.0%) for the first time since 2018. Given the significant national problem HA-VTE pose to the public, and the rise in occurrences, this quality improvement (QI) project is clinically relevant.

Comparison of Patient and Provider Practices between Bone Marrow and Solid Organ Transplantation Programs for Patient Education on Increased Risk of Skin Cancer

Patients receiving immunosuppressive therapy following transplantation are at risk for skin cancer owing to dampened tumor surveillance. As long-term immunotherapy is necessary to prevent graft rejection, transplantation providers and recipients are expected to perform regular surveillance for the development of suspicious lesions, and recipients are encouraged to practice preventative sun safe behaviors. No consensus exists regarding the timing of full body skin exams, and despite the well-established risk, patient education is not always prioritized. We investigated whether differences exist between bone marrow transplant (BMT) and organ transplant (OT) recipients and their providers regarding prevention and screening. We distributed surveys to adult and pediatric BMT and OT recipients, as well as their providers, at a single academic institution. Results were evaluated using the chi-square test. The survey results show that most BMT recipients (69%) and OT recipients (77%) were aware of their increased risk for skin cancer, but despite this knowledge, only 13% of patients overall reported using sunscreen, 29% reported reapplying sunscreen, and 48% reported wearing sun protective clothing. Most OT recipients (63%) reported never having a total body skin exam, whereas only 34% BMT recipients reported having a total body skin exam every 6 months (P=.006). BMT providers recommended a total body skin exam every 6 or 12 months (44.4% each), and OT providers recommended a total body skin exam every 12 months (58.3%). Only 11.1% of BMT providers and 8.3% of OT providers reported performing a total body skin exam at each visit. Despite results indicating widespread patient knowledge of skin cancer risk, most patients do not practice adequate prevention. Inclusion of a transplantation dermatologist in the care team or use of risk stratification tools by providers may help streamline timely referrals to Dermatology.

Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline.

Acute lower gastrointestinal bleeding (LGIB) is a common reason for hospitalization in the United States and is associated with significant utilization of hospital resources, as well as considerable morbidity and mortality. These revised guidelines implement the Grading of Recommendations, Assessment, Development, and Evaluation methodology to propose recommendations for the use of risk stratification tools, thresholds for red blood cell transfusion, reversal agents for patients on anticoagulants, diagnostic testing including colonoscopy and computed tomography angiography (CTA), endoscopic therapeutic options, and management of antithrombotic medications after hospital discharge. Important changes since the previous iteration of this guideline include recommendations for the use of risk stratification tools to identify patients with LGIB at low risk of a hospital-based intervention, the role for reversal agents in patients with life-threatening LGIB on vitamin K antagonists and direct oral anticoagulants, the increasing role for CTA in patients with severe LGIB, and the management of patients who have a positive CTA. We recommend that most patients requiring inpatient colonoscopy undergo a nonurgent colonoscopy because performing an urgent colonoscopy within 24 hours of presentation has not been shown to improve important clinical outcomes such as rebleeding. Finally, we provide updated recommendations regarding resumption of antiplatelet and anticoagulant medications after cessation of LGIB.

Gender Differences in Cardiogenic Shock Patients: Clinical Features, Risk Prediction, and Outcomes in a Hub Center.

IntroductionThere is scarce knowledge about gender differences in clinical presentation, management, use of risk stratification tools and prognosis in cardiogenic shock (CS) patients.PurposeThe primary endpoint was to investigate the differences in characteristics, management, and in-hospital mortality according to gender in a cohort of CS patients admitted to a tertiary hub center. The secondary endpoint was to evaluate the prognostic performance of the Society of Cardiovascular Angiography and Interventions (SCAI) classification in predicting in-hospital mortality according to sex.MethodsThis is a retrospective single-Center cohort study of CS patients treated by a multidisciplinary shock team between September 2014 and December 2020. Baseline characteristics and clinical outcomes according to gender were registered. Discrimination of SCAI classification was assessed using the area under the receiver operating characteristic curve (AUC).ResultsOverall, 163 patients were included, 39 of them female (24%). Mean age of the overall cohort was 55 years (44–62), similar between groups. Compared with men, women were less likely to be smokers and the prevalence of COPD and diabetes mellitus was significantly lower in this group (p < 0.05). Postcardiotomy (44 vs. 31%) and fulminant myocarditis (13 vs. 2%) were more frequent etiologies in females than in males (p = 0.01), whereas acute myocardial infarction was less common among females (13 vs. 33%). Regarding management, the use of temporary mechanical circulatory support, mechanical ventilation, or renal replacement therapy was frequent and no different between the groups (88, 87, and 49%, respectively, in females vs. 42, 91, and 41% in males, p > 0.05). In-hospital survival in the overall cohort was 53%, without differences between groups (52% in females vs. 55% in males, p = 0.76). Most of the patients (60.7%) were in SCAIE at presentation without differences between sexes. The SCAI classification showed a moderate ability for predicting in-hospital mortality (overall, AUC: 0.653, 95% CI 0.582–0.725). The AUC was 0.636 for women (95% CI 0.491–0.780) and 0.658 for men (95% CI 0.575–0.740).ConclusionsOnly one in four of patients treated at a dedicated CS team were female. This may reflect differences in prevalence of severe heart disease at young (<65) ages, although a patient-selection bias cannot be ruled out. In this very high-risk CS population of multiple etiologies, overall, in-hospital survival was slightly above 50% and showed no differences between sexes. Treatment approaches, procedures, and SCAI risk stratification performance did not show gender disparities among treated patients.

Addressing beta‐lactam allergy: A time for action

Addressing beta‐lactam allergy: A time for action

The timing of use of risk stratification tools affects their ability to predict mortality from sepsis. A meta-regression analysis.

Background: Risk stratification tools (RSTs) are used in healthcare settings to identify patients at risk of sepsis and subsequent adverse outcomes. In practice RSTs are used on admission and thereafter as ‘trigger’ tools prompting sepsis management. However, studies investigating their performance report scores at a single timepoint which varies in relation to admission. The aim of this meta-analysis was to determine if the predictive performance of RSTs is altered by the timing of their use. Methods: We conducted a systematic review and meta-regression analysis of studies published from inception to 31 October 2018, using EMBASE and PubMed databases. Any cohort studies investigating the ability of an RST to predict mortality in adult sepsis patients admitted to hospital, from which a 2x2 table was available or could be constructed, were included. The diagnostic performance of RSTs in predicting mortality was the primary outcome. Sensitivity, specificity, positive predictive value, negative predictive value and area under the receiver-operating curve (AUROC) were the primary measures, enabling further meta-regression analysis. Results: 47 studies were included, comprising 430,427 patients. Results of bivariate meta-regression analysis found tools using a first-recorded score were less sensitive than those using worst-recorded score (REML regression coefficient 0.57, 95% CI 0.07-1.08). Using worst-recorded score led to a large increase in sensitivity (summary sensitivity 0.76, 95% CI 0.67-0.83, for worst-recorded scores vs. 0.64 (0.57-0.71) for first-recorded scores). Scoring system type did not have a significant relationship with studies’ predictive ability. The most analysed RSTs were qSOFA (n=37) and EWS (n=14). Further analysis of these RSTs also found timing of their use to be associated with predictive performance. Conclusion: The timing of any RST is paramount to their predictive performance. This must be reflected in their use in practice, and lead to prospective studies in future.

Does Pancreatic Fistula Affect Long-Term Survival after Resection for Pancreatic Cancer? A Systematic Review and Meta-Analysis.

Simple SummaryThe real influence of postoperative pancreatic fistula (POPF) on long-term survival after pancreatic cancer resection is unclear. The purpose of the present study was therefore to conduct a systematic review and meta-analysis of the impact of POPF on the disease-free and overall survival of patients with pancreatic cancer. Our results highlighted that clinically relevant POPF after surgery for PDAC seems to be significantly associated with shorter DFS and OS. Confirmation, with future studies, of a negative impact of POPF on survival may encourage the widespread use of risk-stratification tools for assessing fistula, centralization of patients, and probably a closer oncological follow-up.Background: The impact of postoperative pancreatic fistula (POPF) on survival after resection for pancreatic ductal adenocarcinoma (PDAC) remains unclear. Methods: The MEDLINE, Scopus, Embase, Web of Science, and Cochrane Library databases were searched for studies reporting on survival in patients with and without POPF. A meta-analysis was performed to investigate the impact of POPF on disease-free survival (DFS) and overall survival (OS). Results: Sixteen retrospective cohort studies concerning a total of 5019 patients with an overall clinically relevant POPF (CR-POPF) rate of 12.63% (n = 634 patients) were considered. Five of eleven studies including DFS data reported higher recurrence rates in patients with POPF, and one study showed a higher recurrence rate in the peritoneal cavity. Six of sixteen studies reported worse OS rates in patients with POPF. Sufficient data for a meta-analysis were available in 11 studies for DFS, and in 16 studies for OS. The meta-analysis identified a shorter DFS in patients with CR-POPF (HR 1.59, p = 0.0025), and a worse OS in patients with POPF, CR-POPF (HR 1.15, p = 0.0043), grade-C POPF (HR 2.21, p = 0.0007), or CR-POPF after neoadjuvant therapy. Conclusions: CR-POPF after resection for PDAC is significantly associated with worse overall and disease-free survival.

Remote home monitoring (virtual wards) for confirmed or suspected COVID-19 patients: a rapid systematic review.

Backgroundthe aim of this review was to analyze the implementation and impact of remote home monitoring models (virtual wards) for confirmed or suspected COVID-19 patients, identifying their main components, processes of implementation, target patient populations, impact on outcomes, costs and lessons learnt.Methodswe carried out a rapid systematic review on models led by primary and secondary care across seven countries (US, Australia, Canada, The Netherlands, Ireland, China, UK). The main outcomes included in the review were: impact of remote home monitoring on virtual length of stay, escalation, emergency department attendance/reattendance, admission/readmission and mortality. The search was updated on February 2021. We used the PRISMA statement and the review was registered on PROSPERO (CRD: 42020202888).Findingsthe review included 27 articles. The aim of the models was to maintain patients safe in the appropriate setting. Most models were led by secondary care and confirmation of COVID-19 was not required (in most cases). Monitoring was carried via online platforms, paper-based systems with telephone calls or (less frequently) through wearable sensors. Models based on phone calls were considered more inclusive. Patient/career training was identified as a determining factor of success. We could not reach substantive conclusions regarding patient safety and the identification of early deterioration due to lack of standardized reporting and missing data. Economic analysis was not reported for most of the models and did not go beyond reporting resources used and the amount spent per patient monitored.Interpretationfuture research should focus on staff and patient experiences of care and inequalities in patients’ access to care. Attention needs to be paid to the cost-effectiveness of the models and their sustainability, evaluation of their impact on patient outcomes by using comparators, and the use of risk-stratification tools.

ПРЕЖДЕВРЕМЕННАЯ ОВАРИАЛЬНАЯ НЕДОСТАТОЧНОСТЬ, ЕЁ ПОСЛЕДСТВИЯ, СМЕРТНОСТЬ И ВЛИЯНИЕ НА СЕРДЕЧНО-СОСУДИСТУЮ СИСТЕМУ

This review focuses on the topic of premature ovarian failure (POF) as highly relevant in modern medicine (up to 2% of women in the population suffer from this disease). However, patients with premature ovarian failure not only are still not receiving any treatment, but even making this diagnosis is very difficult. Even after a correct diagnosis is made, these patients are not followed up, despite the fact they have already developed a hormonal imbalance. These women develop two groups of complications: short-term complications associated with a rapid estrogen deficiency in the body, and much more dangerous long-term complications affecting multiple organs and even systems. But in the meanwhile, women with premature ovarian failure are under increased risk of death from all causes, in particular from coronary heart disease (CHD), respiratory diseases, genitourinary diseases and from external causes. And this is despite the fact that cardio-vascular diseases (CVD) are already the leading cause of death among women worldwide. It is women with POF that are at the highest risk of development of cardiovascular diseases, compared to women with normal menopause. These patients, therefore, constitute one of the most important groups to be targeted by screening and prevention strategies primarily for cardiovascular diseases. These strategies should include the use of risk stratification tools to identify women that need lifestyle modifying and pharmacological therapy to prevent development of such diseases in them. This is the only way to maintain a high quality of life in these women over the long term.

Developing a Simpler Prognosticating Tool: Comparing the Combined Assessment of Risk Encountered in Surgery Score with Deyo-Charlson Comorbidity Index and The American Society of Anesthesiologists Physical Status Score in Predicting 2 years Mortality after Hip Fracture Surgery

Background: The use of risk stratification tools in identifying high-risk hip fracture patients plays an important role during treatment. The aim of this study was to compare our locally derived Combined Assessment of Risk Encountered in Surgery (CARES) score with the the American Society of Anesthesiologists physical status (ASA-PS) score and the Deyo–Charlson Comorbidity Index (D-CCI) in predicting 2-year mortality after hip fracture surgery. Methods and Material: A retrospective study was conducted on surgically treated hip fracture patients in a large tertiary hospital from Jan 2013 through Dec 2015. Age, gender, time to surgery, ASA-PS score, D-CCI, and CARES score were obtained. Univariate and multivariable logistic regression analyses were used to assess statistical significance of scores and risk factors, and area under the receiver operating characteristic (ROC) curve (AUC) was used to compare ASA-PS, D-CCI, and CARES as predictors of mortality at 2 years. Results: 763 surgically treated hip fracture patients were included in this study. The 2-year mortality rate was 13.1% (n = 100), and the mean ± SD CARES score of surviving and demised patients was 21.2 ± 5.98 and 25.9 ± 5.59, respectively. Using AUC, CARES was shown to be a better predictor of 2-year mortality than ASA-PS, but we found no statistical difference between CARES and D-CCI. A CARES score of 23, attributable primarily to pre-surgical morbidities and poor health of the patient, was identified as the statistical threshold for “high” risk of 2-year mortality. Conclusion: The CARES score is a viable risk predictor for 2-year mortality following hip fracture surgery and is comparable to the D-CCI in predictive capability. Our results support the use of a simpler yet clinically relevant CARES in prognosticating mortality following hip fracture surgery, particularly when information on the pre-existing comorbidities of the patient is not immediately available.

Hot Off the Press: Tell Me How To Diagnose a Pulmonary Embolism.

Pulmonary embolism (PE) is common and life-threatening Emergency Department (ED) diagnosis. Multiple validated risk stratification tools exist to help evaluate for PE and reduce unnecessary imaging. Despite these tools, there is still significant over-investigation for PE and low value testing persists. This study asks ED providers what are the barriers and facilitators to uptake of validated risk stratification tools in evaluation of PE.

Provider Perspectives on the Use of Evidence-based Risk Stratification Tools in the Evaluation of Pulmonary Embolism: A Qualitative Study.

Providers often pursue imaging in patients at low risk of pulmonary embolism (PE), resulting in imaging yields <10% and false-positive imaging rates of 10% to 25%. Attempts to curb overtesting have had only modest success and no interventions have used implementation science frameworks. The objective of this study was to identify barriers and facilitators to the adoption of evidence-based diagnostic testing for PE. We conducted semistructured interviews with a purposeful sample of providers. An interview guide was developed using the implementation science frameworks, consolidated framework for implementation research, and theoretical domains framework. Interviews were recorded, transcribed, and analyzed in an iterative process. Emergent themes were identified, discussed, and organized. We interviewed 23 providers from four hospital systems, and participants were diverse with regard to years in practice and practice setting. Barriers were predominately at the provider level and included lack of knowledge of the tools, particularly misunderstanding of the validated scoring systems in Wells, as well as risk avoidance and need for certainty. Barriers to prior implementation strategies included the perception of a clinical decision support (CDS) tool for PE as adding steps with little value; most participants reported that they overrode CDS interventions because they had already made the decision. All providers identified institution-level strategies as facilitators to use, including endorsed guidelines, audit feedback with peer comparison about imaging yield, and peer pressure. This exploration of the use of risk stratification tools in the evaluation of PE found that barriers to use primarily exist at the provider level, whereas facilitators to the use of these tools are largely perceived at the level of the institution. Future efforts to promote the evidence-based diagnosis of PE should be informed by these determinants.

Atrial fibrillation is frequent but does not affect risk stratification in pulmonary embolism.

Although prior studies indicate a high prevalence of atrial fibrillation (AF) in patients with pulmonary embolism (PE), the exact prevalence and prognostic impact are unknown. We aimed to investigate the prevalence, risk factors and prognostic impact of AF on risk stratification, in-hospital adverse outcomes and mortality in 528 consecutive PE patients enrolled in a single-centre registry between 09/2008 and 09/2017. Overall, 52 patients (9.8%) had known AF and 57 (10.8%) presented with AF on admission; of those, 34 (59.6%) were newly diagnosed with AF. Compared to patients with no AF, overt hyperthyroidism was associated with newly diagnosed AF (OR 7.89 [2.99-20.86]), whilst cardiovascular risk comorbidities were more frequently observed in patients with known AF. Patients with AF on admission had more comorbidities, presented more frequently with tachycardia and elevated cardiac biomarkers and were hence stratified to higher risk classes. However, AF on admission had no impact on in-hospital adverse outcome (8.3%) and in-hospital mortality (4.5%). In multivariate logistic regression analyses corrected for AF on admission, NT-proBNP and troponin elevation as well as higher risk classes in risk assessment models remained independent predictors of an in-hospital adverse outcome. Atrial fibrillation is a frequent finding in PE, affecting more than 10% of patients. However, AF was not associated with a higher risk of in-hospital adverse outcomes and did not affect the prognostic performance of risk assessment strategies. Thus, our data support the use of risk stratification tools for patients with acute PE irrespective of the heart rhythm on admission.

Risk Stratification in the Evaluation of Pulmonary Embolism in Cancer Patients

The 2015 American College of Physicians (ACP) guideline for the evaluation of pulmonary embolism (PE) included use of risk stratification tools such as

The 6th World Symposium on Pulmonary Hypertension: what's old is new.

In February 2018, the 6th World Symposium on Pulmonary Hypertension (WSPH) brought together experts from various disciplines to review the most relevant clinical and scientific advances in the field of PH over the last 5 years. Based on careful review and discussions by members of the different task forces, major revisions were made on the hemodynamic definition for various forms of PH and new genes were added to the list of genetic markers associated with pulmonary arterial hypertension (PAH) and pulmonary veno-occlusive disease. In addition, the use of risk stratification tools was encouraged as a strategy to reduce one-year mortality risk in PAH patients through early implementation of PAH therapies. While members of the medical community are still debating some of the proposed changes, the new WSPH guidelines advocate early diagnosis and initiation of combination therapy to reduce mortality and improve quality of life in patients with PH.

The Use of Empiric Parenteral Anticoagulation for Acute Pulmonary Embolisms: A Cohort Study

SESSION TITLE: Venous Thromboembolism SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: Timely anticoagulation for patients diagnosed with acute pulmonary embolism (PE) is paramount in reducing morbidity and mortality. In fact, guidelines recommend the administration of empiric anticoagulation when the pretest probability for PE is high, or for moderate risk, when diagnostic testing will be delayed greater than 4 hours. However, the risk-benefit ratio must be carefully considered as empiric anticoagulation increases risk for bleeding. We hypothesize that empiric anticoagulation is inadequately administered in moderate to high-risk probability PE patients. METHODS: We conducted a retrospective cohort study of adult patients, between October-December 2016, who were suspected of having a PE. All patients who underwent a CT chest with PE protocol or ventilation-perfusion (V/Q) scan were enrolled. PE was defined as a positive CT chest or a high probability V/Q scan. Data collected included baseline demographics, risk stratification scores for PE (PERC, Geneva, and Wells), and use of full strength anticoagulants prior to diagnostic testing. Risk stratification scores were dichotomized to those with low vs moderate-high pretest probability for PE. The primary outcome measure was the use of empiric anticoagulation based on risk stratification scoring. Fisher’s exact test and student’s t-test was used when appropriate. A p-value of <0.05 was considered significant with a two-tailed approach. RESULTS: The cohort consisted of 104 patients (mean age: 64.1+/-15.5, male: 51%) with a PE diagnostic rate of 10.6%. In patients diagnosed with PE, 27.3% received empiric anticoagulation compared to 1.1% without a PE diagnosis (p-value: <0.0001). When using PERC, 2.9% of low risk patients received empiric anticoagulation compared to 12.9% in the moderate-high risk group (p-value: 0.108). For Well’s criteria, empiric anticoagulation was lower in the low risk group (1.9% vs 17.6%, p-value: 0.006). Finally, 13.0% of low risk patients for the Geneva score received empiric anticoagulation versus 8.6% of moderate-high risk scores (p-value: 0.527). CONCLUSIONS: Only 12.9-17.6% of patients with a moderate-high pretest probability for PE were given empiric anticoagulation. In contrast, 1.9-13.0% of patients determined to be low risk for PE received anticoagulation. Thus, we are not aggressive enough in providing empiric anticoagulation in moderate-high risk patients, but may be too aggressive in those who are low risk. CLINICAL IMPLICATIONS: The use of empiric anticoagulation must be thoughtfully administered in those suspected of PE. The risk-benefit ratio must be carefully weighed and should be adjusted based on the pretest probability for PE. A protocolized approach that couples the use of risk stratification tools with administration of empiric anticoagulation may decrease the risks for significant morbidity and mortality associated with acute PE, while minimizing the risks of bleeding in those where clinical suspicion is low. DISCLOSURE: The following authors have nothing to disclose: Kimberley Doucette, Bilal ElChaarani, Tanuj Sharma, Chee Chan No Product/Research Disclosure Information

Implementing system-wide risk stratification approaches: A review of critical success and failure factors.

Risk stratification has become a widely used tool for linking people identified at risk of health deterioration to the most appropriate evidence-based care. This article systematically reviews recent literature to determine key factors that have been identified as critical enablers and/or barriers to successful implementation of risk stratification tools at a system level. A systematic search found 23 articles and four promising protocols for inclusion in the review, covering the use to 20 different risk stratification tools. These articles reported on only a small fraction of the risk stratification tools used in health systems; suggesting that while the development and statistical validation of risk stratification algorithms is widely reported, there has been little published evaluation of how they are implemented in real-world settings. Controlled studies provided some evidence that the use of risk stratification tools in combination with a care management plan offer patient benefits and that the use of a risk stratification tool to determine components of a care management plan may contribute to reductions in hospital readmissions, patient satisfaction and improved patient outcomes. Studies with the strongest focus on implementation used qualitative and case study methods. Among these, the literature converged on four key areas of implementation that were found to be critical for overcoming barriers to success: the engagement of clinicians and safeguarding equity, both of which address barriers of acceptance; the health system context to address administrative, political and system design barriers; and data management and integration to address logistical barriers.

Multi-morbidity as a driver of high cost, high resource utilisation and future risk

Introduction : Key health policy imperatives within the National Health Service (NHS) in England over recent years have seen an increase in the use of risk stratification tools and case finding activities, particularly in relation to identifying individuals at risk of unplanned admission to hospital. A common belief is that those at risk of emergency admission are a homogenous group, generally elderly, frail, multi-morbid and have had a high degree of hospital use in the past. This work illustrates that this is not the case and that there is a need to do more than just use a risk stratification algorithm to identify high risk patients - there is a benefit in using integrated data sets and analytical techniques to gain greater insight into what drives risk and identifying the different types of individuals within the high risk category. Method : An exercise was undertaken within Slough Clinical Commissioning Group (CCG) in Berkshire to profile the whole population (c. 150,000 individuals). A data set combining primary and secondary care records that contained data relating to all diagnoses, degree of morbidity burden, risk of future adverse events (e.g. hospitalisation, high cost) and prior activity and cost was used. The analysis focused on relationships and correlations between variables such as age, multi-morbidity, frailty and presence of specific diseases and prior cost and future risk of adverse outcomes. Results : Results will be shared that have provided the CCG and GPs with a new understanding about the key drivers of cost and how the overlap between different at-risk groups is not as large as the CCG first thought. A key finding is that multi-morbidity rather than age is the key driver of prior cost and future risk. The analysis has also revealed new insights for the CCG including: - Multi-morbidity is the norm – it is more common for people to have multiple chronic conditions than to have just one. - Multi-morbidity is not distributed evenly across a population - case-mix varies quite significantly between GP practices. - Multi-morbidity occurs in the whole of the adult population, not just in the elderly. - Multi-morbidity rather than individual diseases such as diabetes or COPD significantly increase future risk. Discussion : There has been a focus within the NHS on preventing unplanned admissions to hospital and the principle use of risk stratification tools and case finding techniques has been to identify people at risk of this adverse outcome. However, the analysis undertaken in Slough CCG raises a number of interesting issues which include: - 40% of high cost patients do not have an emergency admission. - High cost individuals occur across all of the adult population not just in the elderly. - Frail elderly patients only represent a small proportion of those who are going to be high cost or are at risk on an emergency admission. - People with certain diseases are more expensive to treat than others but cost and risk increase significantly in people with certain co-morbidity combinations. As a result of this, Slough CCG and GPs have begun to focus on patients with multi-morbidity and to think about the management of the totality of patients’ morbidity burden rather than managing individual diseases. They are also using this new intelligence to commissioning new services where there are gaps in provision. One example is a GP led service proactively managing 550 patients with certain disease combinations through a 6-month programme of care. Each patient will have an initial review by their GP and then a series of regular consultations aimed at managing them in a holistic way. Input and support will come from community based services, hospital based specialists and from the voluntary sector. This “Complex Case Management Service” is improving quality and reducing hospital use. Conclusion : Slough CCG will continue to focus on reducing emergency admissions, managing individual diseases and supporting the frail elderly as these will remain key national policy imperatives. However, as a result of this population profiling exercise they have a better appreciation of multi-morbidity as a key driver of cost and are now using this as a locus for their thinking, how services are provided and the case finding techniques to identify cohorts of people who may be amenable to particular care programmes.

The Cost-Effective Evaluation of Syncope.

Syncope is a common clinical problem that carries a high socioeconomic burden. A structured approach in the evaluation of syncope with special emphasis on a detailed history, comprehensive physical examination that includes orthostatic vital signs, and an electrocardiogram, proves to be the most cost-effective approach. The need for additional testing and hospital admission should be based on the results of the initial evaluation and use of risk-stratification tools that help identify those syncope patients at highest risk for poor outcomes.

Use of Risk Stratification Tools to Enhance Antimicrobial Stewardship Practices

Abstract Antimicrobial stewardship is an important strategic initiative to ensure patient safety and antimicrobial efficacy. National guidelines advocate the utilization of guidelines and clinical pathways as effective stewardship strategies to enhance the appropriate selection of antimicrobial treatment regimens. This article reviews 3 algorithms using risk stratification techniques implemented within our organization: treatment of acute bacterial skin and skin structure infections, febrile neutropenia, and Clostridium difficile infection. The relevant literature surrounding the utilization of risk stratification tools and applications to other disease states will also be reviewed. Further studies are warranted to evaluate the impact of risk stratification tools on patient outcomes.