title: Paramedics assessing Elders at Risk for Independence Loss (PERIL): Derivation, Reliability and Comparative Effectiveness of a Clinical Prediction Rule.
abstract: OBJECTIVE
  We conducted a program of research to derive and test the reliability of a clinical prediction rule to identify high-risk older adults using paramedics' observations.
  
  
  METHODS
  We developed the Paramedics assessing Elders at Risk of Independence Loss (PERIL) checklist of 43 yes or no questions, including the Identifying Seniors at Risk (ISAR) tool items. We trained 1,185 paramedics from three Ontario services to use this checklist, and assessed inter-observer reliability in a convenience sample. The primary outcome, return to the ED, hospitalization, or death within one month was assessed using provincial databases. We derived a prediction rule using multivariable logistic regression.
  
  
  RESULTS
  We enrolled 1,065 subjects, of which 764 (71.7%) had complete data. Inter-observer reliability was good or excellent for 40/43 questions. We derived a four-item rule: 1) "Problems in the home contributing to adverse outcomes?" (OR 1.43); 2) "Called 911 in the last 30 days?" (OR 1.72); 3) male (OR 1.38) and 4) lacks social support (OR 1.4). The PERIL rule performed better than a proxy measure of clinical judgment (AUC 0.62 vs. 0.56, p=0.02) and adherence was better for PERIL than for ISAR.
  
  
  CONCLUSIONS
  The four-item PERIL rule has good inter-observer reliability and adherence, and had advantages compared to a proxy measure of clinical judgment. The ISAR is an acceptable alternative, but adherence may be lower. If future research validates the PERIL rule, it could be used by emergency physicians and paramedic services to target preventative interventions for seniors identified as high-risk.
authors.affiliation: *Sunnybrook Research Institute,Toronto,ON.
authors.forename: Jacques S
authors.initials: JS
authors.lastname: Lee
authors.affiliation: *Sunnybrook Research Institute,Toronto,ON.
authors.forename: P Richard
authors.initials: PR
authors.lastname: Verbeek
authors.affiliation: *Sunnybrook Research Institute,Toronto,ON.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Schull
authors.affiliation: ‡Department of Emergency Medicine,University of Ottawa,Ottawa,ON.
authors.forename: Lisa
authors.initials: L
authors.lastname: Calder
authors.affiliation: ‡Department of Emergency Medicine,University of Ottawa,Ottawa,ON.
authors.forename: Ian G
authors.initials: IG
authors.lastname: Stiell
authors.affiliation: §The Ottawa Hospital Research Institute,Ottawa,ON.
authors.forename: John
authors.initials: J
authors.lastname: Trickett
authors.affiliation: †Division of Emergency Medicine,Department of Medicine,University of Toronto,Toronto,ON.
authors.forename: Laurie J
authors.initials: LJ
authors.lastname: Morrison
authors.affiliation: ǁCounty of Renfrew Paramedic Services,Pembroke,ON.
authors.forename: Michael
authors.initials: M
authors.lastname: Nolan
authors.affiliation: **Department of Emergency Medicine,University of Alberta,Edmonton,AB.
authors.forename: Brian H
authors.initials: BH
authors.lastname: Rowe
authors.affiliation: **Department of Emergency Medicine,University of Alberta,Edmonton,AB.
authors.forename: Sunil
authors.initials: S
authors.lastname: Sookram
authors.affiliation: ‡‡Regional Geriatric Program of Toronto,Toronto,ON.
authors.forename: David
authors.initials: D
authors.lastname: Ryan
authors.affiliation: *Sunnybrook Research Institute,Toronto,ON.
authors.forename: Alex
authors.initials: A
authors.lastname: Kiss
authors.affiliation: §§Department of Medicine and Rotman Research Institute,Baycrest Health Sciences,Toronto,ON.
authors.forename: Gary
authors.initials: G
authors.lastname: Naglie
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000488:Allied Health Personnel / Q000706:statistics & numerical data*; D003661:Decision Support Techniques; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D016330:Frail Elderly / Q000706:statistics & numerical data*; D015577:Geriatric Assessment / Q000379:methods*; D006801:Humans; D008297:Male; D015203:Reproducibility of Results; D018570:Risk Assessment; D011795:Surveys and Questionnaires
keywords: Clinical Prediction Rule; EMS; Geriatrics; Screening Tool