title: Derivation and validation of the detection of indicators and vulnerabilities for emergency room trips scale for classifying the risk of emergency department use in frail community-dwelling older adults.
abstract: OBJECTIVE
  To develop and validate a prognostic case finding tool that classifies the risk of emergency department (ED) use in an older home care population.
  
  
  METHODS
  Population-based retrospective cohort study using routinely collected data from home care clinical assessments linked prospectively to ED records.
  
  
  METHODS
  Ontario and the Winnipeg Regional Health Authority, Canada.
  
  
  METHODS
  Older adults living at home and expected to receive in-home services for at least 60 days (N = 361,942).
  
  
  METHODS
  One or more ED visits within 6 months after an in-home clinical assessment was used as the main dependent measure. Ninety-five person-level risk measures from a clinical assessment instrument were selected as potential independent variables. The Detection of Indicators and Vulnerabilities for Emergency Room Trips (DIVERT) Scale was derived using recursive partitioning analyses informed by a multinational clinical panel.
  
  
  RESULTS
  Overall, 41.2% had one or more ED visits within 6 months of their in-home assessment. Previous ED use and cardiorespiratory symptoms, cardiac conditions, and specific geriatric syndromes were predictors within the six-level DIVERT Scale. The scale provided adequate risk differentiation for case finding, with an area under the receiver operating characteristic curve of 0.62 (95% confidence interval = 0.61-0.62) and distinct risk gradients between risk scores. The multilevel validation demonstrated consistent performance across geographic and participant clusters.
  
  
  CONCLUSIONS
  The DIVERT Scale is a valid case-finding tool for ED use in older home care clients. It may be suitable for preemptively and systematically risk-stratifying individuals or groups for additional assessment, case management, and preventative interventions. It may also be suitable for the stratification and adjustment of performance metrics.
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada; Department ofMedicine, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Andrew P
authors.initials: AP
authors.lastname: Costa
authors.forename: John P
authors.initials: JP
authors.lastname: Hirdes
authors.forename: Chaim M
authors.initials: CM
authors.lastname: Bell
authors.forename: Susan E
authors.initials: SE
authors.lastname: Bronskill
authors.forename: George A
authors.initials: GA
authors.lastname: Heckman
authors.forename: Lori
authors.initials: L
authors.lastname: Mitchell
authors.forename: Jeffery W
authors.initials: JW
authors.lastname: Poss
authors.forename: Samir K
authors.initials: SK
authors.lastname: Sinha
authors.forename: Paul
authors.initials: P
authors.lastname: Stolee
mesh_terms: D000368:Aged; D003661:Decision Support Techniques; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D016330:Frail Elderly; D006801:Humans; D057187:Independent Living; D008297:Male; D015233:Models, Statistical; D009864:Ontario; D015203:Reproducibility of Results
keywords: case finding; community care; emergency department; home care; risk assessment