Healthcare risk stratification model for emergency departments based on drugs, income and comorbidities: the DICER-score

Background During the last decade, the progressive increase in age and associated chronic comorbidities and polypharmacy. However, assessments of the risk of emergency department (ED) revisiting published to date often neglect patients' pharmacotherapy plans, thus overseeing the Drug-related problems (DRP) risks associated with the therapy burden. The aim of this study is to develop a predictive model for ED revisit, hospital admission, and mortality based on patient's characteristics and pharmacotherapy.MethodsRetrospective cohort study including adult patients visited in the ED (triage 1, 2, or 3) of multiple hospitals in Catalonia (Spain) during 2019. The primary endpoint was a composite of ED visits, hospital admission, or mortality 30 days after ED discharge. The study population was randomly split into a model development (60%) and validation (40%) datasets. The model included age, sex, income level, comorbidity burden, measured with the Adjusted Morbidity Groups (GMA), and number of medications. Forty-four medication groups, associated with medication-related health problems, were assessed using ATC codes. To assess the performance of the different variables, logistic regression was used to build multivariate models for ED revisits. The models were created using a stepwise-forward approach based on the Bayesian Information Criterion (BIC). Area under the curve of the receiving operating characteristics (AUCROC) curve for the primary endpoint was calculated.Results851.649 patients were included; 134.560 (15.8%) revisited the ED within 30 days from discharge, 15.2% were hospitalized and 9.1% died within 30 days from discharge. Four factors (sex, age, GMA, and income level) and 30 ATC groups were identified as risk factors and combined into a final score. The model showed an AUCROC values of 0.720 (95%CI:0.718-0.721) in the development cohort and 0.719 (95%CI.0.717-0.721) in the validation cohort. Three risk categories were generated, with the following scores and estimated risks: low risk: 18.3%; intermediate risk: 40.0%; and high risk: 62.6%.ConclusionThe DICER score allows identifying patients at high risk for ED revisit within 30 days based on sociodemographic, clinical, and pharmacotherapeutic characteristics, being a valuable tool to prioritize interventions on discharge. Risk scores are often used to predict the clinical outcomes of patients in many healthcare settings.To the date, no prediction model of emergency department (ED) visits based on patients' pharmacotherapy, income level, and comorbidities have been developed.We have designed an ED risk score combined four risk factors (sex, age, comorbidity score and income level) and 30 drug categories to identify those patients at high risk of health-care visit

Short-term prognosis of polypharmacy in elderly patients treated in emergency departments: results from the EDEN project

Background: Polypharmacy is a growing phenomenon among elderly individuals. However, there is little information about the frequency of polypharmacy among the elderly population treated in emergency departments (EDs) and its prognostic effect. This study aims to determine the prevalence and short-term prognostic effect of polypharmacy in elderly patients treated in EDs. Methods: A retrospective analysis of the Emergency Department Elderly in Needs (EDEN) project's cohort was performed. This registry included all elderly patients who attended 52 Spanish EDs for any condition. Mild and severe polypharmacy was defined as the use of 5-9 drugs and >10 drugs, respectively. The assessed outcomes were ED revisits, hospital readmissions, and mortality 30 days after discharge. Crude and adjusted logistic regression analyses, including the patient's comorbidities, were performed. Results: A total of 25,557 patients were evaluated [mean age: 78 (IQR: 71-84) years]; 10,534 (41.2%) and 5678 (22.2%) patients presented with mild and severe polypharmacy, respectively. In the adjusted analysis, mild polypharmacy and severe polypharmacy were associated with an increase in ED revisits [odds ratio (OR) 1.13 (95% confidence interval (CI): 1.04-1.23) and 1.38 (95% CI: 1.24-1.51)] and hospital readmissions [OR 1.18 (95% CI: 1.04-1.35) and 1.36 (95% CI: 1.16-1.60)], respectively, compared to non-polypharmacy. Mild and severe polypharmacy were not associated with increased 30-day mortality [OR 1.05 (95% CI: 0.89-2.26) and OR 0.89 (95% CI: 0.72-1.12)], respectively. Conclusion: Polypharmacy was common among the elderly treated in EDs and associated with increased risks of ED revisits and hospital readmissions 10 drugs. In these patients comorbidities were associated with an increase in the number of drugs. In the patients with severe polypharmacy (>10 drugs), diuretics were the most frequently drugs prescribed, followed by antihypertensives and statins. The results obtained indicate that polypharmacy is a frequent phenomenon among the elderly population treated in Emergency departments, being antihypertensives the most frequently used drugs in this population. Those patients who takes >10 drugs have a higher risk of new visits to the emergency room and hospital readmissions in short term period

Ensayo clínico randomizado de un programa de atención farmaceútica en pacientes con insuficiencia cardíaca y/o enfermedad pulmonar obstructiva crónica usuarios del servicio de urgencias del hospital de la Santa Creu i Sant Pau de Barcelona

La morbilidad relacionada con los medicamentos es un problema de salud importante en los países occidentales que tiene un elevado coste sanitario y social, siendo especialmente prevalente en los SUH (4)(5)(6) entre los pacientes pluripatológicos y polimedicados (36)(38)(37)(39)(63). Distintos estudios publicados han demostrado la utilidad de programas de atención farmacéutica en los SUH en relación con la disminución de errores de medicación y PRM (12)(14)(15). Sin embargo, no nos consta que se haya evaluado el impacto que tiene la reducción de PRM/errores de medicación en términos de resultados en salud. En este contexto, pensamos que sería importante disponer de ensayos clínicos aleatorizados que midan la efectividad de estos programas evaluando su impacto en variables clínicas como por ejemplo resultados negativos asociados a la medicación. Sería especialmente relevante conocerlo en pacientes polimedicados, hiperfrecuentadores del sistema de salud y con patologías crónicas que se descompensen con frecuencia, como por ejemplo pacientes con insuficiencia cardiaca (IC) y/o enfermedad pulmonar obstructiva crónica (EPOC).Tesis Univ. Granada. Programa Oficial de Doctorado en Medicina Clínica y Salud Públic

Drug-Related Problems in Elderly Patients Attended to by Emergency Services

The progressive aging and comorbidities of the population have led to an increase in the number of patients with polypharmacy attended to in the emergency department. Drug-related problems (DRPs) have become a major cause of admission to these units, as well as a high rate of short-term readmissions. Anticoagulants, antibiotics, antidiabetics, and opioids have been shown to be the most common drugs involved in this issue. Inappropriate polypharmacy has been pointed out as one of the major causes of these emergency visits. Different ways of conducting chronic medication reviews at discharge, primary care coordination, and phone contact with patients at discharge have been shown to reduce new hospitalizations and new emergency room visits due to DRPs, and they are key elements for improving the quality of care provided by emergency services