Introduction
Welcome to decision4transition - A database comprising 29 assessment tools, which will support your decision-making on avoidability of care transitions among older adults.
How to navigate?
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Please type your search words in the search field.
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Please choose whether you are a care professional or a patient/caregiver.
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If you are a care professional, you can use further 6 filter options to find what suits you best.
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Please see below a complete list of all assessment tools. Click on the assessment tool´s name to view further information on the tool.
In case you already chose some filter criteria, please ensure to reset all filter criteria to see a complete list of assessment tools (simply click “Reset filters”).
Further guidance
To assist you even further in your decision-making, we would also like to introduce our new consensus-based definition for “avoidable care transitions” that provides overall guiding principles on avoidability of care transitions:
Avoidable care transitions
1) are without significant patient-relevant benefits or with a risk of harm outweighing patient-relevant benefits and/or
2) are when a comparable health outcome could be achieved in lower resource settings using the resources
available in that place/health care system and/or
3) violate a patient’s/informal caregiver´s preference or an agreed care plan.
II. Filter criteria
Care transition
Conditions
Language
Settings
Types
What measures /
what a tool does
The TRST
General information
What measures / what a tool does
Identifies emergency department (ED) patients at risk for ED revisits, hospitalization, or nursing home (NH) placement within 30 and 120 days following ED discharge.
Concepts / items covered
The TRST is a five-item clinical prediction: History of cognitive impairment, Difficulty walking/transferring or recent falls, Taking five or more medications, ED use in previous 30 days or hospitalisation in previous 90 days, RN (registered nurse) professional recommendation.
Structure / format
Table/list.
Target population
Patients hospitalized to medical and surgical departments, Emergency department patients.
Care transition
→Emergency department readmissions within 30 and 120 days after emergency department discharge, →Hospitalizations within 30 and 120 days after emergency department discharge, →Nursing home admissions within 30 and 120 days after emergency department discharge
Objectivity
Process
Self-explaining.
Evaluation
One element may involve subjective judgement. For example, the element “RN professional recommendation” is explained in the study as: “Emergency department (ED) nurse (RN) concern for elder abuse/neglect, substance abuse, medication noncompliance, problems meeting instrumental activities of daily living, or other.” This element of a tool is based on nurse´s recommendation, which may involve subjective judgement.
Interpretation
5 item tool. Risk factors were assessed categorically (yes/no for the items cognitive impairment, difficulty walking/transferring, and professional recommendation; and yes/no/unable to determine for the remaining items: polypharmacy, and recent ED use or hospitalization). The number of risk factors present were summed.Subjects were considered to be a high-risk cohort, a priori, if they had cognitive impairment alone, or the presence of two or more TRST risk factors.
Reliability
Inter-rater
For the purpose of studying reliability, TRST surveys were completed for 37 patients by two different surveyors. There was one discrepancy out of 222 questions (37 screens). Kappa was 1.0 for all items except for a single discrepancy regarding professional recommendation (kappa = 0.94).
Intra-rater
No Information.
Validity
Convergent
Discrimination: AUC = 0.589. Calibration (Hosmer-Lemeshow χ2 test.) χ2 = 3.44, degrees of freedom = 4, p-value = 0.49.Sensitivity (cut-off > 2) = 0.37.Specificity (cut-off > 2) = 0.74.PPV (cut-off > 2) = 0.59.NPV (cut-off > 2) = 0.54.
Costs
Specific input data required
No. TRST items were designed to be quickly and easily assessed.
Language
- English
The 80+ score
General information
What measures / what a tool does
Prediction of risk of rehospitalisation and mortality in hospital patients
Concepts / items covered
The 80+ score is a point score system used for risk estimation: Estimated glomerular filtration rate (eGFR), Level of social support, Pulmonary disease (asthma or chronic ob- struction pulmonary disease), Malignant disease, Prescription of a drug for peptic ulcer or gastro-oesophageal reflux disease, Prescription of an opioid drug, Prescription of an antidepressant drug (ex- cept tricyclic antidepressant).
Structure / format
Table.
Target population
Patients hospitalized to medical and surgical departments.
Care transition
→Rehospitalizations (Emergency department admissions or readmissions)
Objectivity
Process
Self-explaining.
Evaluation
Does not include subjective elements. Clinical and drug variables are included.
Interpretation
Scoring system, ranges from -2 to 10 point total. Table 4 provides estimate of risk for each point total.
Reliability
Inter-rater
No Information.
Intra-rater
No Information.
Validity
Convergent
Discrimination: AUC (C-statistic) = 0.715. Calibration: (Hosmer-Lemeshow χ2 test) X2 = 7.89, degree of freedom = 8, p-value = 0.44.
Costs
Specific input data required
For example, renal function (estimated glomerular filtration rate (eGFR)).
Language
- English
Modified Early Warning Score (MEWS)
General information
What measures / what a tool does
Early identification of patients deterioration. Helps anasthesists to select the correct level of care to avoid innapropriate admission to the Intensive Care Unit (ICU) and to enhance the use of the High Dependency Unit (HDU) after emergency surgical procedures.
Concepts / items covered
MEWS components are: blood pressure heart rate respiratory rate temperature neurological status.
Structure / format
Table.
Target population
Emergency surgical patients.
Care transition
Emergency department→Intensive Care Unit (ICU), Emergency department→High Dependency Unit (HDU)
Objectivity
Process
Self-explaining.
Evaluation
Does not include subjective elements. Assessment is made based on blood pressure, heart rate, respiratory rate, temperature, neurological status (alert, reacting to voice, reacting to pain, unresponsive).
Interpretation
Scoring system. Total score of 4 or more was considered as a ward alert by nurses. Patients with a MEWS of 3 or 4 in the preoperative evaluation or at operating room discharge were transferred to HDU, whereas a MEWS score of 5 or more was considered a criteria for ICU admission. In case of a total MEWS of 3 calculated only on neurological status (subscore = 3) the patient was admitted to the ICU, as well as in case of a patient with a total MEWS of 2 (made by subscore of 2 in heart rate or by subscore of 2 in respiratory rate) in which the HDU was chosen instead of the surgical ward.
Reliability
Inter-rater
No Information.
Intra-rater
No Information.
Validity
Convergent
No Information.
Costs
Specific input data required
No. The tool is for bedside evaluation based on 5 physiological parameters.
Language
- English
Tool by Ong et al.
General information
What measures / what a tool does
Indicates appropriateness of hospitalizations based on time to death
Concepts / items covered
Assessment based on time to death.
Structure / format
List.
Target population
Nursing home residents.
Care transition
Nursing home→Hospital
Objectivity
Process
Self-explaining.
Evaluation
Some elements may involve subjective judgement. Assessment is based on time to death, and judgement on time to death may be subjective.
Interpretation
Depending on time to death, a patient could be managed either in a care home or in an acute medical setting. Deaths were categorized as incurable or likely to be manageable in the care home (deaths occurring within 3 days of index admission), potentially predictable (within 4–7 days of admission) and likely to be appropriate for acute medical intervention (death after 7 days).
Reliability
Inter-rater
No Information.
Intra-rater
No Information.
Validity
Convergent
No Information.
Costs
Specific input data required
No. Specific data is not required by the instrument. However, access to some data may be required to make necessary judgements.
Language
- English
Tool by Gozalo et al.
General information
What measures / what a tool does
Classifies transitions as being potentially burdensome
Concepts / items covered
Three types of transitions were classified as being potentially burdensome. These types relate to end-of-life transitions, lack of continuity of nursing home facilities, multiple hospitalizations.
Structure / format
List.
Target population
Nursing home residents with cognitive and functional impairment.
Care transition
Nursing home→Hospital
Objectivity
Process
Self-explaining.
Evaluation
One element may involve subjective judgement. For example, “any transfer in the last 3 days of life” may involve subjective judgement (i.e. time to death).
Interpretation
3 types of transitions classified as potentially burdensome: 1. any transfer in the last 3 days of life, 2. a lack of continuity of nursing home facilities before and after a hospitalization in the last 90 days of life (i.e., going from nursing home A to the hospital and then to nursing home B), 3. and multiple hospitalizations in the last 90 days of life.
Reliability
Inter-rater
No Information.
Intra-rater
No Information.
Validity
Convergent
No Information.
Costs
Specific input data required
No. Specific data is not required by the tool. However, access to some data (for example data on ADLs, cognitive impairment) may be needed to make necessary judgements.
Language
- English
A prediction rule to identify low-risk patients with community-acquired pneumonia
General information
What measures / what a tool does
Identifies low-risk patients with community-acquired pneumonia (CAP)
Concepts / items covered
A tool has 2 steps which are administred to assign a patient to one of risk classes out of 5 in total.
Structure / format
Table/flow-chart.
Target population
Patients with community acquired pneumonia (CAP).
Care transition
→Hospitalizations
Objectivity
Process
Self-explaining.
Evaluation
Does not include subjective elements.
Interpretation
A tool has 2 steps which are administered to assign a patient to one of risk classes out of 5 in total: 1. step 1 is a flow chart form, used to identify whether a patient can be assigned to risk class I. Figure 1. 2. step 2 is a table form, a point based system to identify whether a patient can be assigned to risk classes from II to V. Table 2. Points calculated from table 2 are then classified into classes from II to V according to table 3. Transformation of points into risk classes according to table 3: II (<=70) III (71-90) IV (91-130) V (>130).
Reliability
Inter-rater
No Information.
Intra-rater
No Information.
Validity
Convergent
There was no significant difference (P = 0.15) in the area under the receiver-operating-characteristic curves between the derivation cohort (0.84) and the validation cohort (0.83).
Costs
Specific input data required
For example, laboratory and radiographic data.
Language
- English
Tool by Codde et al.
General information
What measures / what a tool does
Provides list of exclusion criteria and potentially avoidable reasons for emergency department (ED) presentation
Concepts / items covered
1. Exclusion criteria (11) for potentially avoidable ED presentations. Criteria justifying ED presentation. 2. Criteria (11) for potentially avoidable ED presentations. Criteria NOT justifying ED presentation (I.e. criteria indicating potentially avoidable ED presentations).
Structure / format
Table/list.
Target population
Nursing home residents.
Care transition
Nursing home→Emergency department
Objectivity
Process
Self-explaining.
Evaluation
Some elements may involve subjective judgement. For example, assessing for “significant neurological changes” or “increasing confusion with no signs of UTI”.
Interpretation
11 criteria justifying ED presentation and 11 criteria indicating potentially avoidable ED presentations.
Reliability
Inter-rater
Analysis of the interrater reliability of a subset of 54 cases demonstrated moderate agreement (intraclass correlation coefficient 0.414, 95% CI 0.277–0.560) between the four raters.
Intra-rater
No Information.
Validity
Convergent
No Information.
Costs
Specific input data required
No. Data can be acquired from medical records.
Language
- English
Tool on appropriate referrals by Bermejo Higuera et al
General information
What measures / what a tool does
Identifies appropriate or relevant referrals
Concepts / items covered
Tool has 3 criteria relating to duration of observation in a hospital, whether a patient needed to see a specialist and/or needed special diagnostic tests, whether a patient needed special treatment.
Structure / format
List.
Target population
Nursing home residents.
Care transition
Nursing home→Emergency department
Objectivity
Process
Self-explaining.
Evaluation
Does not include subjective elements.
Interpretation
Referrals are considered appropriate or relevant to be those that meet one of the following criteria: 1. the patient was admitted to hospital or stayed in observation for more than 24 hours. 2. the patient had to be seen by a specialist and/or required diagnostic tests not available in the nursing home. 3. the patient required treatment not available in the nursing home.
Reliability
Inter-rater
No Information.
Intra-rater
No Information.
Validity
Convergent
No Information.
Costs
Specific input data required
No
Language
- Spanish
The Identification of Seniors at Risk (ISAR) scale
General information
What measures / what a tool does
Predicts high acute care hospital utilization, and adverse health outcomes during the 6 months after the ED visit
Concepts / items covered
Takes into account function (premorbid and post-acute change), polypharmacy, cognitive and visual impairment, and recent hospitalizations.
Structure / format
Table.
Target population
Emergency department patients.
Care transition
Emergency department→Home or usual Nursing home, Emergency department→Acute hospital, Emergency department→Long term nursing care
Objectivity
Process
Self-explaining.
Evaluation
Some elements may involve subjective judgement. First, the tool can be filled by a patient, which may already be subjective. Second, it includes questions which may include subjective judgement, like “in general, do you see well?”, or “in general, do you have serious problems with your memory?”.
Interpretation
6 question tool, max. 6 points. ISAR score of 2 or higher, indicates an increased risk of adverse health outcomes.
Reliability
Inter-rater
No Information.
Intra-rater
No Information.
Validity
Convergent
The AUC: 0.68.
Costs
Specific input data required
No. Questions can also be answered by a patient.
Language
- English
The Ottawa COPD (chronic obstructive pulmonary disease) Risk Scale (OCRS)
General information
What measures / what a tool does
Identifies ED patients with acute COPD who are at high risk for short-term serious outcomes
Concepts / items covered
10 items grouped into 3 sections: initial assessment, investigations, re-assessment after ED treatment.
Structure / format
Table.
Target population
Patients with shortness of breath or respiratory distress caused by COPD.
Care transition
→Emergency department admissions, →Emergency department discharges
Objectivity
Process
Self-explaining.
Evaluation
Does not include subjective elements. The tool comprising 10 items from history, physical examination, and bedside tests.
Interpretation
Scoring system, max. score is 16. Provides a table for conversion of a total score to a %-risk and risk class (low, medium, high, very high).
Reliability
Inter-rater
No Information.
Intra-rater
No Information.
Validity
Convergent
Compared with current practice, an OCRS score threshold of 1 or more would increase sensitivity by 50% but would require 25% more admissions. Alternately, a threshold of 2 or more would improve sensitivity by 38% while leading to only a slight increase in admissions.
Costs
Specific input data required
For example, ECG, Chest X-ray, Haemoglobin, Urea, Serum.
Language
- English
Ottawa Heart Failure Risk Scale (OHFRS)
General information
What measures / what a tool does
Identifies ED patients with acute heart failure at high risk for serious adverse events
Concepts / items covered
10 criteria grouped into 3 sections: initial assessment, investigations, walk test after ED treatment.
Structure / format
Table.
Target population
Patients with shortness of breath due to acute heart failure.
Care transition
→Emergency department admissions, →Emergency department discharges
Objectivity
Process
Self-explaining.
Evaluation
Does not include subjective elements. The tool comprising 10 items from history, clinical examination, and a walk test.
Interpretation
Scoring system, max. score is 15. Provides a table on for conversion of a total score into %-risk or risk class (low, medium, high, very high).
Reliability
Inter-rater
No Information.
Intra-rater
No Information.
Validity
Convergent
Compared to current practice, an OHFRS score threshold of >1 would significantly improve sensitivity but would require more admissions. Alternately, a threshold of>2 would offer similar sensitivity to current practice but reduce admissions.
Costs
Specific input data required
For example, ECG, Urea, Serum, Troponin.
Language
- English
Rectal bleeding admission guide and algorithm
General information
What measures / what a tool does
Identifies patients with acute LGIB (lower gastrointestinal bleeding) who can be safely managed in primary care
Concepts / items covered
1. haemoglobin (Hb) > 13 g/dl; 2. systolic blood pressure (SBP) > 115 mmHg; 3. Patient not on anticoagulant/antiplatelet therapy.
Structure / format
Algorithm/ flowchart.
Target population
Acute LGIB (Acute lower gastrointestinal bleeding) surgical patients.
Care transition
Community→Hospital, Community→Surgical unit, Community→Emergency department
Objectivity
Process
Self-explaining.
Evaluation
Does not include subjective elements.
Interpretation
If ALL 3 criteria are true, patient will not usually require admission.
Reliability
Inter-rater
No Information.
Intra-rater
No Information.
Validity
Convergent
No Information.
Costs
Specific input data required
For example, laboratory testing (haemoglobin).
Language
- English
The Walter indicator
General information
What measures / what a tool does
Predicts 1-year mortality after hospital discharge
Concepts / items covered
Combines demographics, clinical aspects (heart failure, cancer with or without metastases), and laboratory testing (albumin, creatinine).
Structure / format
Table.
Target population
Hospital patients.
Care transition
Emergency department→Home or usual Nursing home, Emergency department→Acute hospital, Emergency department→Long term nursing care
Objectivity
Process
Self-explaining.
Evaluation
Does not include subjective elements. Requires data on demographic characteristics, activities of daily living (ADL) dependency, comorbid conditions, length of hospital stay, and laboratory measurements.
Interpretation
Scoring system. Max. score 20. Lowest-risk group (0-1 point). Group with 2-3 points (intermediate) Group with 4-6 points (intermediate) Highest risk group with more than 6 points. In the validation cohort, 1-year mortality was 4% in the lowest-risk group, 19% in the group with 2 or 3 points, 34% in the group with 4 to 6 points, and 64% in the highest-risk group.
Reliability
Inter-rater
No Information.
Intra-rater
No Information.
Validity
Convergent
Area under the receiver operating characteristic curve for the point system was 0.75 in the derivation cohort and 0.79 in the validation cohort.
Costs
Specific input data required
For example, lab results (creatinine, albumin).
Language
- English
The Silver Code
General information
What measures / what a tool does
Predicts 1-year mortality and hospital admission
Concepts / items covered
Combines demographics, polypharmacy, comorbidities, and previous hospitalizations.
Structure / format
Table.
Target population
Emergency department patients.
Care transition
Emergency department→Home or usual Nursing home, Emergency department→Acute hospital, Emergency department→Long term nursing care, →Hospitalizations, →Emergency department readmissions
Objectivity
Process
Self-explaining.
Evaluation
Does not include subjective elements. Requires data on age, sex, marital status, admission to a day hospital, admission to regular ward with corresponding discharge diagnosis, and polypharmacy, 3–6 months prior to the index ED visit.
Interpretation
Scoring system, max. 30 points. 4 classes of increasing risk score (0–3, 4–6, 7–10, and 11+). (score 0 - 30, best - worst).
Reliability
Inter-rater
No Information.
Intra-rater
No Information.
Validity
Convergent
Area under the receiver-operating characteristic curve in predicting hospital admission ( 0.63) and mortality ( 0.70).
Costs
Specific input data required
No. Based on administrative data.
Language
- English
INTERACT tools (with focus on care paths only)
General information
What measures / what a tool does
Determine which residents could be safely managed in the nursing home
Concepts / items covered
Care paths (for Home health care, Assisted living, Skilled nursing) for 10 conditions: Acute mental status change, Change in behaviour: evaluation of medical causes of new or worsening behavioural symptoms, Dehydration, Fever, Gastrointestinal symptoms, Shortness of breath, Symptoms of congestive heart failure, Symptoms of lower respiratory infection, Symptoms of urinary tract infection, Fall.
Structure / format
Check-list, guide/manual.
Target population
Nursing home resdients.
Care transition
Nursing home→Hospital, Nursing home→Emergency department
Objectivity
Process
Self-explaining.
Evaluation
Depending on a care path, includes some elements that may involve subjective judgement. For example, signs of increased confuision, unrelieved pain and more.
Interpretation
Depending on situation/input data, care paths guide on how to act next.
Reliability
Inter-rater
No Information.
Intra-rater
No Information.
Validity
Convergent
No Information.
Costs
Specific input data required
Depending on care path, may require some specific data. For example, X-ray, blood work, EKG, stool specimen for occult blood.
Language
- English
PAR-Risk Score
General information
What measures / what a tool does
Risk of potentially avoidable readmissions (PAR)
Concepts / items covered
The PAR Risk Score assigns points to the following 12 predictors: length of stay longer than four days, admission in previous six months, anaemia, hypertension, hyperkalaemia, opioid prescription during hospital stay, comorbidities such as heart failure, acute myocardial infarction, chronic ischemic heart disease, diabetes with organ damage, cancer, and metastatic carcinoma.
Structure / format
Table.
Target population
Medical patients.
Care transition
Home→30 day Rehospitalizations
Objectivity
Process
Self-explaining.
Evaluation
Does not include subjective elements. Requires data on administrative characteristics, comorbidities, medications and lab results.
Interpretation
Original threshold levels for low, medium, and high risk categories are based on the raw PAR-Risk Score values of <3, 3–10, and>10, respectively. Adapted threshold levels for low, medium, and high risk categories are based on PAR-Risk Score values of <12, 12 to 25, and >25, respectively.
Reliability
Inter-rater
No Information.
Intra-rater
No Information.
Validity
Convergent
The overall PAR-Risk Scores showed rather poor discriminatory power (C statistic 0.605). The Brier score was 0.053, indicating decent accuracy. The calibration plot indicated a lack of fit, which was also supported by the goodness-of-fit test with a p-value of <0.01.
Costs
Specific input data required
For example, lab results on hyperkalaemia.
Language
- English
LACE index
General information
What measures / what a tool does
Expected probability of death or readmission within 30 days of discharge
Concepts / items covered
Lengths of hospitalisation, Acuteness of the admission, Comorbidities of patients, AED admissions.
Structure / format
List/table.
Target population
Medcial and surgical patients discharged to the community.
Care transition
→30-day Rehospitalizations
Objectivity
Process
Self-explaining.
Evaluation
One element may involve subjective judgement. In particular, “acuity of admission”.
Interpretation
Scoring system, ranges from 0 to 19 points. Score of 0 and 19 correspond to 2% and 43.7% expected probability of death or readmission respectively. A patient with a score greater than 10 is considered at high risk for unplanned hospital readmission.
Reliability
Inter-rater
No Information.
Intra-rater
No Information.
Validity
Convergent
Sensitivity (cut-off > 10): 0.61 Specificity (cut-off > 10): 0.44 PPV (cut-off > 10): 0.52 NPV (cut-off > 10): 0.54 Discrimination: AUC (i.e. c-statistic) = 0.534 Calibration (Hosmer-Lemeshow χ2 test): χ2 = 23.58.
Costs
Specific input data required
For example, calculation of another index to measure comorbidity (using Charlson comorbidity index).
Language
- English
Simplified HOSPITAL score
General information
What measures / what a tool does
Risk of readmission
Concepts / items covered
The HOSPITAL score is a predictor model using seven clinical variables at discharge. Haemoglobin level at discharge, Cancer diagnosis or discharge from an Oncology unit, Sodium level at discharge, Index admission type, Number of hospital admissions during the previous year, Length of hospitalisation.
Structure / format
List/table.
Target population
All patients aged 18 or more.
Care transition
→30-day Rehospitalizations
Objectivity
Process
Self-explaining.
Evaluation
Does not include subjective elements.
Interpretation
Scoring system, ranges from 0 to 12 points. Unlikely to be readmitted if 0-4 point(s), and likely to be readmitted if 5 points or more. These categories were created for ease of interpretation, roughly corresponding to a risk of potentially avoidable readmission of more than 15% in the “likely” category.
Reliability
Inter-rater
No Information.
Intra-rater
No Information.
Validity
Convergent
1. The overall performance was very good, as reflected by a Brier score of 0.08. 2. Discriminatory power was good also, with a C-statistic of 0.69 (95%CI 0.68-0.69). The negative predictive value of the simplified HOSPITAL score was 94%, and its specificity 73%. 3. The calibration was excellent with predicted rates matching exactly the observed rates.
Costs
Specific input data required
For example, laboratory testing (haemoglobin, sodium level).
Language
- English
HOSPITAL score
General information
What measures / what a tool does
Risk of readmission
Concepts / items covered
The HOSPITAL score is a predictor model using seven clinical variables at discharge. Haemoglobin level at discharge, Discharge from an Oncology unit, Sodium level at discharge, Procedures during hospital stay, Index admission type, Number of hospital admissions during the previous year, Length of hospitalisation.
Structure / format
List/table.
Target population
Discharged acute and non-acute patients (medical and surgical wards), patients with polymedications.
Care transition
→30-day Rehospitalizations
Objectivity
Process
Self-explaining.
Evaluation
Does not include subjective elements. Some elements relate to laboratory testing data, like haemoglobin, sodium level. Other relate to ICD-9 coded procedure, admission type, number of admissions, LOS, discharge from an oncology service.
Interpretation
The scoring system ranges from 0 to 13 points with higher scores connoting higher risk of readmission. These risks were further categorized into 3 groups: low risk (up to 4 points); intermediate risk (5–6 points); and high risk (7 or more points), roughly corresponding to 5%, 10%, and 20% risk of potentially preventable 30-day readmissions, respectively.
Reliability
Inter-rater
No Information.
Intra-rater
No Information.
Validity
Convergent
C statistic: 0.72. The Brier score: 0.08. Calibration: Pearson χ2 test with a P value of 0.89.
Costs
Specific input data required
For example, laboratory testing (haemoglobin, sodium level).
Language
- English
Risk Nomogram
General information
What measures / what a tool does
Probability of having no unplanned revisit during the 28 days after discharge
Concepts / items covered
Prior number attendances, age, gender, polypharmacy, SIS cognition score, malignancy, CCT intervention, depression Hx.
Structure / format
Scoring system/scales.
Target population
Community patients discharged from the emergency department.
Care transition
Community→Emergency department readmissions within 28 days of emergency department discharge
Objectivity
Process
Self-explaining.
Evaluation
One element may involve subjective judgement. In particular, depression (includes patient self-reporting of significant depressive syndromes).
Interpretation
Risk factors are assigned the appropriate number of corresponding points displayed in the nomogram (top line). The points allocated for each risk factor are then summed to obtain total points for that patient, which is used to calculate the probability of having no unplanned revisit during the 28 days after discharge (bottom line). The predicted probability of revisit (1-probability of no attendance).
Reliability
Inter-rater
No Information.
Intra-rater
No Information.
Validity
Convergent
Area under the ROC curve is 0.65.
Costs
Specific input data required
No. Mostly data from medical record verified with patient interview.
Language
- English
CURB-65 score (for Community setting)
General information
What measures / what a tool does
Mortality risk
Concepts / items covered
4 clinical characteristics (confusion, respiratory rate, blood pressure, and age >= 65 years).
Structure / format
List.
Target population
Community acquired pneumonia patients in community.
Care transition
→Hospitalizations
Objectivity
Process
Self-explaining.
Evaluation
One element may involve subjective judgement. In particular, assessment of confusion (measured by a mental test, or new disorientation in person, place or time).
Interpretation
Max. score is 4. Score of 1 is given for every element present. Scores 0, 1-2, 3-4 indicate low, intermediate and high risk for mortality respectively. Treatment options are shown in the tool.
Reliability
Inter-rater
No Information.
Intra-rater
No Information.
Validity
Convergent
The calculated positive predictive value of the CURB-65 score as a sole indicator for inappropriate hospitalization was 52%. The sensitivity and specificity of the CURB-65 score of 2 or more—in the derivation cohort was 92.8% and 49.2%, respectively (with PPV and NPV in %: 16.2 and 98.5). Corresponding values in the validation cohort were 100% and 46.4% (with PPV and NPV in %: 16.1 and 100).
Costs
Specific input data required
No
Language
- English
CURB-65 score (for Hospital setting)
General information
What measures / what a tool does
Mortality risk
Concepts / items covered
5 clinical and laboratory characteristics (confusion, blood urea nitrogen, respiratory rate, blood pressure, and age >= 65 years).
Structure / format
List.
Target population
Community acquired pneumonia patients presenting to hospital.
Care transition
→Hospitalizations
Objectivity
Process
Self-explaining.
Evaluation
One element may involve subjective judgement. In particular, assessment of confusion (measured by a mental test, or new disorientation in person, place or time).
Interpretation
Max. score is 5. Score of 1 is given for every element present. Scores 0-1, 2, 3-5 indicate low, intermediate and high risk for mortality respectively. Treatment options are shown in the tool.
Reliability
Inter-rater
No Information.
Intra-rater
No Information.
Validity
Convergent
The calculated positive predictive value of the CURB-65 score as a sole indicator for inappropriate hospitalization was 52%. The sensitivity and specificity of the CURB-65 score of 2 or more—in the derivation cohort was 92.8% and 49.2%, respectively (with PPV and NPV in %: 16.2 and 98.5). Corresponding values in the validation cohort were 100% and 46.4% (with PPV and NPV in %: 16.1 and 100).
Costs
Specific input data required
For example, blood urea test.
Language
- English
Appropriateness Evaluation Protocol Geriatric adaptation (AEPg)
General information
What measures / what a tool does
Appropriateness of hospital admissions
Concepts / items covered
17 criteria 11 criteria on clinical severity, 6 criteria on delivery of care.
Structure / format
List/table.
Target population
Nursing home residents.
Care transition
Nursing home→Acute geriatric unit
Objectivity
Process
Self-explaining.
Evaluation
Some elements may involve subjective judgement. For example, sudden impairment of essential functions (moving, eating, breathing, urinating, etc.) except for a chronic manifestation with no new facts.
Interpretation
If one of 17 criteria is present, admission is considered appropriate.
Reliability
Inter-rater
No Information.
Intra-rater
No Information.
Validity
Convergent
No Information.
Costs
Specific input data required
For example data on electrolyte (Na, K), ECG.
Language
- French
Appropriateness Evaluation Protocol French version (AEPf)
General information
What measures / what a tool does
Appropriateness of hospital admissions
Concepts / items covered
16 criteria in total 10 criteria on clinical severity 6 criteria on delivery of care.
Structure / format
List/table.
Target population
Nursing home residents, Hospitalized patients via emergency department, Emergency department patients, Patients discharged from acute geriatric unit.
Care transition
→Hospitalizations, →Rehospitalizations, Nursing home→Acute geriatric unit
Objectivity
Process
Self-explaining.
Evaluation
Some elements may involve subjective judgement. For example, sudden impairment of essential functions (moving, eating, breathing, urinating, etc.) except for a chronic manifestation with no new facts.
Interpretation
If one of 16 criteria is present, the admission is considered appropriate.
Reliability
Inter-rater
The degree of agreement between two observers were assessed by the concordance and the Kappa coefficient. The reproducibility of the instrument was high (Kappa: 0.81).
Intra-rater
No Information.
Validity
Convergent
No Information.
Costs
Specific input data required
For example data on electrolyte (Na, K), ECG.
Language
- French
Appropriateness Evaluation Protocol (AEP) (with focus on criteria of appropriateness of admission only)
General information
What measures / what a tool does
Appropriateness of hospital admissions
Concepts / items covered
18 criteria of appropriateness of hospital admission. Of which, 11 are related to severity of illness and patient condition, and 7 are related to health care requirements or intensity of services.
Structure / format
List/table.
Target population
Adult patients with acute conditions (reliable for any type of diagnosis). Not suitable for pediatric, obstetric, or psychiatric patients.
Care transition
→Hospitalizations
Objectivity
Process
Self-explaining.
Evaluation
Some elements may involve subjective judgement. For example, acute or progressive sensory, motor, circulatory or respiratory embarrassment sufficient to incapacitate the patient (does not include back pain).
Interpretation
Admission is considered to be appropriate when any of the 18 criteria of the appropriateness of hospital admission is fulfilled. When none of the criteria are fulfilled, hospital admission is considered inappropriate.
Reliability
Inter-rater
Independent application by 2 physicians. Overall agreement rate: 89%. Specific concordance: 40%. Kappa index: 0.5.
Intra-rater
No Information.
Validity
Convergent
No Information.
Costs
Specific input data required
For example data on electrolyte (Na, K) or blood gas (CO2, arterial pH), electrocardiographic data.
Language
- English
Novel Decision Guide “Go to the Hospital or Stay Here?”
General information
What measures / what a tool does
To guide residents, families, friends, caregivers on a decision-making whether to go to a hospital or stay in a nursing home
Concepts / items covered
Change in condition, what to expect in different situations, how to get involved in a decision, pros and cons of being treated in a hospital or in the NH, FAQs, decision tree, what residents family and caregivers say and more.
Structure / format
Booklet and trifold.
Target population
Nursing home residents, families, caregivers, friends.
Care transition
Nursing home→Hospital
Objectivity
Process
Self-explaining.
Evaluation
A decision tree (part of the guide) may involve subjective judgement. For example, assessing how sick a person is with 3 options: mild, moderate, very sick.
Interpretation
Depending on situaion/input data, a decision tree (part of the guide) guides on how to act next.
Reliability
Inter-rater
No Information.
Intra-rater
No Information.
Validity
Convergent
No Information.
Costs
Specific input data required
A decision tree (part of the guide) may require some tests, but specific tests are not mentioned.
Language
- English
- Spanish
- French
- Filipino
- Creole
- Chinese
Reference:
http://www.decisionguide.org/A complex intervention to reduce avoidable hospital admissions in nursing homes (with focus on a care pathway only)
General information
What measures / what a tool does
Determine which residents could be safely managed in the nursing home
Concepts / items covered
Dehydration, deterioration of congestive heart failure, lower respiratory tract infection, urinary tract infection.
Structure / format
Guide/instruction/flowchart.
Target population
Nursing home resdients.
Care transition
→Hospitalizations
Objectivity
Process
Self-explaining.
Evaluation
Some elements of a care pathway may involve subjective judgement. For example, when checking for lower UTI symptoms (i.e. discomfort on passing urine, lower abdominal discomfort/pain).
Interpretation
Depending on situaion/input data, a care pathway guides on how to act next.
Reliability
Inter-rater
No Information.
Intra-rater
No Information.
Validity
Convergent
No Information.
Costs
Specific input data required
May require specific data, for example testing for UTI, lower respiratory tract infection.
Language
- English
ACE model (with focus on evidence-based algorithms only)
General information
What measures / what a tool does
Determine which residents could be safely managed in the nursing home
Concepts / items covered
Over 20 evidence-based algorithms. Some of the algorithms for the following conditions also include further related sub-sections: Allergic Reactions/Anaphylaxis, Assaults, Cardiology, Cellulitis, Dental and Oral Health, Diabetes, Falls, Gastroenterology, Neurology, Nosebleeds (Epistaxis), Pain, Palliative Care and Last Days of Life Care, Polypharmacy and high-risk medications in RACFs, Respiratory, Subcutaneous Fluid Administration, Urology, Wound Care.
Structure / format
Algorithms / flowcharts / tables.
Target population
Nursing home residents.
Care transition
Nursing home→Hospital, Nursing home→Emergency department
Objectivity
Process
Self-explaining.
Evaluation
Depending on an algorithm, includes some elements that may involve subjective judgement. For example, measuring pain level.
Interpretation
Depending on situaion/input data, algorithms guide on how to act next.
Reliability
Inter-rater
No Information.
Intra-rater
No Information.
Validity
Convergent
No Information.
Costs
Specific input data required
Depending on an algorithm, may require specific data. For example test for blood glucose level (BGL), testing of urine for culture and sensitivity, imaging (CT head or MRI).
Language
- English