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. Jensen & 3 others Christian 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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Hospital Emergency Service
Prospective Studies
Mortality
ROC Curve
Calibration
Area Under Curve
Logistic Models
Regression Analysis
Physicians
Sensitivity and Specificity
Health
Neoplasms

Cite this

Cardona, Magnolia ; Lewis, Ebony ; Kristensen, Mette R. ; Skjøt-Arkil, Helene ; Ekmann, Anette A. ; Nygaard, Hanne H. ; Turner, Robin M. ; Garden, Frances ; Alkhouri, Hatem ; Asha, Stephen Edward ; Mackenzie, John ; Perkins, Margaret ; Suri, Sam ; Holdgate, Anna ; Winoto, Luis ; Chang, David C. W. ; Luxan, Blanca Gallego ; McCarthy, Sally ; Petersen, John A. ; Jensen, Birgitte N. ; Mogensen, Christian Backer ; Hillman, Ken ; Brabrand, Mikkel. / Predictive validity of the CriSTAL tool for short-term mortality in older people presenting at Emergency Departments: a prospective study. In: European Geriatric Medicine. 2018 ; Vol. 9, No. 6. pp. 891-901.
@article{6a5d8e2624844851b5386daafc7f4595,
title = "Predictive validity of the CriSTAL tool for short-term mortality in older people presenting at Emergency Departments: a prospective study",
abstract = "PurposeTo 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.MethodsProspective 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.Results2493 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.ConclusionsThe 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.",
author = "Magnolia Cardona and Ebony Lewis and Kristensen, {Mette R.} and Helene Skj{\o}t-Arkil and Ekmann, {Anette A.} and Nygaard, {Hanne H.} and Turner, {Robin M.} and Frances Garden and Hatem Alkhouri and Asha, {Stephen Edward} and John Mackenzie and Margaret Perkins and Sam Suri and Anna Holdgate and Luis Winoto and Chang, {David C. W.} and Luxan, {Blanca Gallego} and Sally McCarthy and Petersen, {John A.} and Jensen, {Birgitte N.} and Mogensen, {Christian Backer} and Ken Hillman and Mikkel Brabrand",
year = "2018",
month = "12",
day = "1",
doi = "10.1007{\%}2Fs41999-018-0123-6",
language = "English",
volume = "9",
pages = "891--901",
journal = "European Geriatric Medicine",
issn = "1878-7649",
publisher = "Elsevier",
number = "6",

}

Cardona, M, Lewis, E, Kristensen, MR, Skjøt-Arkil, H, Ekmann, AA, Nygaard, HH, Turner, RM, Garden, F, Alkhouri, H, Asha, SE, Mackenzie, J, Perkins, M, Suri, S, Holdgate, A, Winoto, L, Chang, DCW, Luxan, BG, McCarthy, S, Petersen, JA, Jensen, BN, Mogensen, CB, Hillman, K & Brabrand, M 2018, 'Predictive validity of the CriSTAL tool for short-term mortality in older people presenting at Emergency Departments: a prospective study' European Geriatric Medicine, vol. 9, no. 6, pp. 891-901. https://doi.org/10.1007%2Fs41999-018-0123-6

Predictive validity of the CriSTAL tool for short-term mortality in older people presenting at Emergency Departments: a prospective study. / Cardona, Magnolia; Lewis, Ebony; Kristensen, Mette R.; Skjøt-Arkil, Helene; Ekmann, Anette A.; Nygaard, Hanne H.; Turner, Robin M.; Garden, Frances; Alkhouri, Hatem; Asha, Stephen Edward; Mackenzie, John; Perkins, Margaret; Suri, Sam; Holdgate, Anna; Winoto, Luis; Chang, David C. W.; Luxan, Blanca Gallego; McCarthy, Sally; Petersen, John A.; Jensen, Birgitte N.; Mogensen, Christian Backer; Hillman, Ken; Brabrand, Mikkel.

In: European Geriatric Medicine, Vol. 9, No. 6, 01.12.2018, p. 891-901.

Research output: Contribution to journalArticleResearchpeer-review

TY - JOUR

T1 - Predictive validity of the CriSTAL tool for short-term mortality in older people presenting at Emergency Departments: a prospective study

AU - Cardona, Magnolia

AU - Lewis, Ebony

AU - Kristensen, Mette R.

AU - Skjøt-Arkil, Helene

AU - Ekmann, Anette A.

AU - Nygaard, Hanne H.

AU - Turner, Robin M.

AU - Garden, Frances

AU - Alkhouri, Hatem

AU - Asha, Stephen Edward

AU - Mackenzie, John

AU - Perkins, Margaret

AU - Suri, Sam

AU - Holdgate, Anna

AU - Winoto, Luis

AU - Chang, David C. W.

AU - Luxan, Blanca Gallego

AU - McCarthy, Sally

AU - Petersen, John A.

AU - Jensen, Birgitte N.

AU - Mogensen, Christian Backer

AU - Hillman, Ken

AU - Brabrand, Mikkel

PY - 2018/12/1

Y1 - 2018/12/1

N2 - PurposeTo 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.MethodsProspective 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.Results2493 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.ConclusionsThe 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.

AB - PurposeTo 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.MethodsProspective 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.Results2493 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.ConclusionsThe 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.

UR - http://www.scopus.com/inward/record.url?scp=85057073457&partnerID=8YFLogxK

U2 - 10.1007%2Fs41999-018-0123-6

DO - 10.1007%2Fs41999-018-0123-6

M3 - Article

VL - 9

SP - 891

EP - 901

JO - European Geriatric Medicine

JF - European Geriatric Medicine

SN - 1878-7649

IS - 6

ER -