普通医学在老年人虚弱评估中的作用:定义正确的虚弱框架的标准化工具,并与现有的临床风险分层工具进行比较

F. Robusto, Giovanni Colucci, M. Zamparella, Enrico Maria Pellegrini, Brigida Martucci, P. Iacovazzo, Enza Colucci, M. Minardi, C. Giliberti, V. Bossone, V. Lepore, Stefano Ivis
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引用次数: 0

摘要

虚弱是一种慢性疾病,它增加了对应激因子的易感性,并阻止患者恢复到先前的稳态状态。这增加了负面结果的风险,并逐渐使患者致残,从而导致医疗资源的更高使用率。从医疗保健系统的角度来看,临床风险分层系统通常有助于识别虚弱患者,尽管全科医生在定义和正确诊断虚弱方面发挥着关键和不可替代的作用。这项研究开发了一种标准化工具(称为SVaFra),用于在普通医学环境中定义老年人群的虚弱,并将其与一些已经验证并广泛使用的临床风险分层工具进行了比较。此外,还评估了SVaFra应用对医疗保健结果的影响。一个由经验丰富的全科医生、生物医学工程师和其他医疗保健专业人员组成的科学委员会,参与虚弱患者的管理,通过创建四个主要组成部分(临床复杂性、残疾、家庭环境和管理复杂性),开发了一个以问卷形式评估虚弱的框架。随后进行了一项观察性研究,涉及来自意大利四个地区的98名全科医生,他们填写了问卷。医生被要求对四个虚弱成分和整体虚弱做出判断。此外,通过将Charlson合并症指数(CCI)和药物衍生复杂性指数(DDCI)应用于管理数据库,对一组患者进行分层。将该人群服用SVaFra框架后一年的医疗资源利用率与具有相似临床或人口统计学特征的对照组进行比较。共确定1305名体弱老年患者(男性36.0%;平均年龄83.1±8.52岁)。关于全科医生用于制定虚弱判断的四个主要领域,临床分类“中重度”最常见(57.0%)。全科医生随后指定了以下最常见的病理:动脉高压(76.4%)、充血性心力衰竭(31.5%)、痴呆症(30.7%)、糖尿病(29.9%)、心律失常(27.6%)、严重抑郁症(25.2%),中风(22.0%)、呼吸功能不全(22.0%,慢性肾功能不全)、管理复杂性(48.3%)、残疾(43.2%)和家庭环境(23.8%)。对于165名受试者(12.6%),全科医生根据管理复杂性和残疾表达了“严重”的总体虚弱判断。在102起案件中,有可能与行政数据库建立记录联系。只有20名(15.3%)被全科医生确定为虚弱的患者的CCI评分>0,而88名(86.3%)患者的DDCI评分较高。关于医疗资源的利用,与具有类似临床或人口特征的对照组相比,全科医生认为身体虚弱的人群的医疗成本,特别是与紧急服务相关的医疗成本净下降。SVaFra仪器应用简单,可在不同的医疗现实中对虚弱患者进行个性化和表征。然而,CCI有助于对临床风险状况进行分层,它将大多数被全科医生确定为虚弱的患者归类为低风险患者。另一方面,DDCI为大多数体弱患者确定了高分。全科医生通过SVaFra框架的管理简单地关注虚弱问题,从而降低了急诊室治疗带来的医疗成本。因此,基于SVaFra的使用,开发关于医疗保健系统的适当诊断和治疗途径,可能会在未来对虚弱患者进行更仔细和准确的管理。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
The Role of General Medicine in the Evaluation of Frailty in the Elderly Population: Definition of a Standardized Instrument for the Correct Framing of Frailty and Comparison with Currently Existing Instruments for Stratification of Clinical Risk
Frailty is a chronic condition that increases the vulnerability to stressogenic factors and prevents the patient from returning to the preceding condition of homeostasis. This increases the risk of negative outcomes and progressively brings the patient toward disability, leading to higher use of healthcare resources. Clinical risk stratification systems can generally be useful for identifying frail patients from the standpoint of a healthcare system, though General Practitioners (GPs) assume a key and irreplaceable role in the definition and correct diagnosis of frailty. This study developed a standardized instrument (called SVaFra) for the definition of frailty in the elderly population in a general medicine setting and compared it with a few clinical risk stratification tools that have already been validated and are in wide use. In addition, the impact of the application of SVaFra on healthcare outcomes was evaluated. A scientific board composed of experienced GPs, biomedical engineers, and other healthcare professionals, involved in the management of patients suffering from frailty, developed a framework in the form of a questionnaire for the evaluation of frailty by creating four principal groupings of the components that characterize it (clinical complexity, disability, family environment, and management complexity). An observational study, involving 98 GPs from four Italian regions who filled out the questionnaire, was then developed. The doctors were asked to provide a judgment for the four frailty components and the overall frailty. Additionally, a cohort of patients was stratified by applying Charlson Comorbidity Index (CCI) and Drug Derived Complexity Index (DDCI) to administrative databases. The utilization of healthcare resources in the year following the administration of the SVaFra framework with this population was compared with a control group with similar clinical or demographic characteristics. A total of 1,305 frail geriatric patients were identified (males 36.0%; mean age 83.1 ±8.52 years). Regarding the four principal areas used by the GPs to formulate a frailty judgment, the clinical categorization “moderate-severe” was most frequently noted (57.0%). The GPs then specified the following most frequent pathologies: arterial hypertension (76.4%), congestive heart failure (31.5%), dementia (30.7%), diabetes (29.9%), cardiac arrhythmia (27.6%), major depression (25.2%), stroke (22.0%), respiratory insufficiency (22.0%), chronic renal insufficiency (12.6%), management complexity (48.3%), disability (43.2%), and family environment (23.8%). For 165 subjects (12.6%), the GPs expressed an overall frailty judgment of “severe” based on management complexity and disability. Record linkage with administrative databases was possible in 102 cases. The presence of a CCI score of >0 was recorded in only 20 (15.3%) patients identified as frail by GPs, while high DDCI scores were recorded for 88 (86.3%) patients. As for the utilization of healthcare resources, a net reduction of healthcare costs, especially those associated with emergency services, was observed for the population characterized as frail by GPs as compared with the control group with similar clinical or demographic characteristics. The SVaFra instrument was simple to apply, with transferability for the individualization and characterization of frail patients in diverse healthcare realities. However, CCI, which was useful for the stratification of clinical risk profiles, classified the majority of patients who were identified as frail by GPs as low risk. On the other hand, high scores were identified by DDCI for the majority of frail patients. The simple focus of GPs on the problem of frailty obtained by the administration of the SVaFra framework led to a reduction of healthcare costs due to emergency room treatments. Thus, the development of adequate diagnostic and therapeutic pathways to be developed about healthcare systems based on the use of SVaFra may result in more careful and accurate management of frail patients in the future.
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