Predictive validity of the CriSTAL tool for short-term mortality in older people presenting at Emergency Departments: a prospective study

Magnolia Cardona, Ebony Lewis, Mette R. Kristensen, Helene Skjøt-Arkil, Anette A. Ekmann, Hanne H. Nygaard, Robin M. Turner, Frances Garden, Hatem Alkhouri, Stephen Edward Asha, John Mackenzie, Margaret Perkins, Sam Suri, Anna Holdgate, Luis Winoto, David C. W. Chang, Blanca Gallego Luxan, Sally McCarthy, John A. Petersen, Birgitte N. JensenChristian Backer Mogensen, Ken Hillman, Mikkel Brabrand

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Abstract

Purpose
To determine the validity of the Australian clinical prediction tool Criteria for Screening and Triaging to Appropriate aLternative care (CRISTAL) based on objective clinical criteria to accurately identify risk of death within 3 months of admission among older patients.

Methods
Prospective study of ≥ 65 year-olds presenting at emergency departments in five Australian (Aus) and four Danish (DK) hospitals. Logistic regression analysis was used to model factors for death prediction; Sensitivity, specificity, area under the ROC curve and calibration with bootstrapping techniques were used to describe predictive accuracy.

Results
2493 patients, with median age 78–80 years (DK–Aus). The deceased had significantly higher mean CriSTAL with Australian mean of 8.1 (95% CI 7.7–8.6 vs. 5.8 95% CI 5.6–5.9) and Danish mean 7.1 (95% CI 6.6–7.5 vs. 5.5 95% CI 5.4–5.6). The model with Fried Frailty score was optimal for the Australian cohort but prediction with the Clinical Frailty Scale (CFS) was also good (AUROC 0.825 and 0.81, respectively). Values for the Danish cohort were AUROC 0.764 with Fried and 0.794 using CFS. The most significant independent predictors of short-term death in both cohorts were advanced malignancy, frailty, male gender and advanced age. CriSTAL’s accuracy was only modest for in-hospital death prediction in either setting.

Conclusions
The modified CriSTAL tool (with CFS instead of Fried’s frailty instrument) has good discriminant power to improve prognostic certainty of short-term mortality for ED physicians in both health systems. This shows promise in enhancing clinician’s confidence in initiating earlier end-of-life discussions.
Original languageEnglish
Pages (from-to)891-901
Number of pages11
JournalEuropean Geriatric Medicine
Volume9
Issue number6
DOIs
Publication statusPublished - 1 Dec 2018

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