The Diagnostic Accuracy and Clinimetric Properties of Screening Instruments to Identify Frail Older Adults Attending Emergency Departments: A Protocol for a Mixed Methods Systematic Review and Meta-Analysis.

BACKGROUND: Prompt and efficient identification and stratification of patients who are frail is important, as this cohort are at high risk of adverse healthcare outcomes. Numerous frailty screening tools have been developed to support their identification across different settings, yet relatively few have emerged for use in emergency departments (EDs). This protocol provides details for a systematic review aiming to synthesize the accumulated evidence regarding the diagnostic accuracy and clinimetric properties of frailty screening instruments to identify frail older adults in EDs. METHODS: Six electronic databases will be searched from January 2000 to March 2021. Eligible studies will include adults aged ≥60 years screened in EDs with any available screening instrument to identify frailty (even if not originally designed for this purpose). Studies, including case-control, longitudinal, and cohort studies, will be included, where instruments are compared to a reference standard to explore diagnostic accuracy. Predictive accuracy for a selection of outcomes, including mortality, institutionalization, and readmission, will be assessed. Clinical and methodological heterogeneity will be examined, and a random effects meta-analysis performed if appropriate. CONCLUSION: Understanding whether frailty screening on presentation to EDs is accurate in identifying frailty, and predicting these outcomes is important for decision-making and targeting appropriate management.

Small-scale spatial distribution of COVID-19-related excess mortality.

Mortality due to massive events like the COVID-19 pandemic is underestimated because of several reasons, among which the impossibility to track all positive cases and the inadequacy of coding systems are presumably the most relevant. Therefore, the most affordable method to estimate COVID-19-related mortality is excess mortality (EM). Very often, though, EM is calculated on large spatial units that may entail different EM patterns and without stratifying deaths by age or sex, while, especially in the case of epidemics, it is important to identify the areas that suffered a higher death toll or that were spared. We developed the Stata COVID19_EM.ado procedure that estimates EM within municipalities in six subgroups defined by sex and age class using official data provided by ISTAT (Italian National Statistics Bureau) on deaths occurred from 2015 to 2020. Using simple linear regression models, we estimated the mortality trend in each age-and-sex subgroup and obtained the expected deaths of 2020 by extrapolating the linear trend. The results are then displayed using choropleth maps. Subsequently, local autocorrelation maps, which allow to appreciate the presence of local clusters of high or low EM, may be obtained using an R procedure that we developed.•We focused on estimating excess mortality in small-scale spatial units (municipalities) and in population strata defined by age and sex.•This method gives a deeper insight on excess mortality than summary figures at regional or national level, enabling to identify the local areas that suffered the most and the high-risk population subgroups within them.•This type of analysis could be replicated on different time frames, which might correspond to successive epidemic waves, as well as to periods in which containment measures were enforced and for different age classes; moreover, it could be applied in every instance of mortality crisis within a region or a country.

Patterns of COVID-19 related excess mortality in the municipalities of Northern Italy during the first wave of the pandemic.

The impact of Coronavirus Disease 2019 (COVID-19) on mortality in Italy has been described at the regional level, while less is known about mortality in municipalities, although the spatial distribution of COVID-19 in its first wave has been uneven. We aimed to describe the excess mortality due to COVID-19 from February 23rd to April 30th, 2020 in the three most affected Italian regions, in age and gender subgroups within each municipality. Excess mortality varied widely among municipalities even within the same region; it was higher among the elderly and higher in males except in the ≥75 age group. Thus, nearby municipalities may show a different mortality burden despite being under common regional health policies, possibly as a result of local reinforcements of regional policies. Identifying the municipalities where mortality was higher and the pathways used by the virus to spread may help to concentrate efforts in understanding the reasons why this happened and to identify the frailest areas in light of recurrences of the epidemic.

What services should be guaranteed in universal health-care systems?

COVID-19 pandemic highlighted the importance of public, universal and equal access health-care, and reminded us that challenges are always incumbent for health-care systems. Because accessible and universal health-care systems will be critical into the future, it will be crucial to earmark adequate resources, fostering the financing of sectors that for many years have been neglected such as primary care and public health, and investments in new models of care and in health-related workforce.