Risk Assessment Tool: the 8Ps
Utilizing the Risk Assessment Tool: the 8Ps
Numerous risk factors have been identified in the literature as being associated with increased risk of rehospitalization, emergency department visits, or other adverse event. Researchers have developed a 20-item tool that predicts readmission to the hospital(Coleman, Min et al. 2004). There are, however, no externally validated, easily replicated tools to risk-stratify older patients transitioning out of the hospital. In light of this deficit, Project BOOST has compiled and refined the dominant patient-specific risk factors and created a user-friendly tool called the 8P scale (view the TARGET Screen which encompasses the 8P Scale). This risk assessment tool is completed at admission highlighting the need to identify patients at increased risk of adverse events post-hospitalization, and utilizing the duration of the hospitalization to mitigate these risks as much as possible. Of course, all risks identified and efforts put forth should be communicated with the patient’s post-hospitalization providers.
View the TARGET Assessment 8P Scale
The 8Ps are:
a. Problem medications (Forster, Clark et al. 2004; Forster, Murff et al. 2005; Budnitz, Pollock et al. 2006; Budnitz, Shehab et al. 2007; van Walraven and Forster 2007): Some medications increase the likelihood of adverse events after discharge. Although the list of these medications is quite long, the most risky appear to be: warfarin, insulin, digoxin, and aspirin when used in combination with clopidogrel. It is not clear yet from research whether this risk is only associated with new or changed prescriptions for these medications or if it is associated with any prescription. As such, we recommend including all patients with prescriptions for these medications and perhaps focusing extra attention on patients newly started on them.
b. Psychological (Marcantonio, McKean et al. 1999; Bula, Wietlisbach et al. 2001; Kartha, Anthony et al. 2007; Ng, Niti et al. 2007; Strunin, Stone et al. 2007): Depression in older patients is common and frequently underdiagnosed. The presence of depression, either in screening evaluations or by history, has been associated with increased risk of rehospitalization. The status of depressive symptoms has not been studied. Therefore, we recommend you include any patient with a history of depression (i.e., formally diagnosed) as well as patients who screen positive for depressive symptoms (using the PHQ-2, developed by the Common Wealthfund with information from Information from Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care 2003; 41:1284-92.), which is highly suggestive of this diagnosis.
c. Principal diagnosis: If patients have any of the following main reasons for hospitalization (i.e., their principal diagnosis), they are at increased risk of adverse events after discharge including rehospitalization: cancer (Coleman, Wagner et al. 1998), stroke (Bravata, Ho et al. 2007)), diabetes or glycemic complication (Coleman, Wagner et al. 1998; Billings, Dixon et al. 2006), COPD, (Coleman, Wagner et al. 1998; Smith, Giobbie-Hurder et al. 2000; Westert, Lagoe et al. 2002; Billings, Dixon et al. 2006) and heart failure (Coleman, Wagner et al. 1998; Westert, Lagoe et al. 2002; Gwadry-Sridhar, Flintoft et al. 2004; Phillips, Wright et al. 2004; Billings, Dixon et al. 2006).
d. Polypharmacy (Coleman, Smith et al. 2005): It appears that patients on 5 or more medications (scheduled, not as needed) are at increased risk of adverse event after discharge. It is also clear that with an increasing number of medications, adherence also decreases.
e. Poor health literacy (Williams, Parker et al. 1995; Gazmararian, Baker et al. 1999; Baker, Gazmararian et al. 2002; Gazmararian, Williams et al. 2003): Many validated tools evaluating general and health literacy have been published in the literature. However, most are cumbersome. Given that adherence and adverse events are increased among patients with poor health literacy, a simple screening tool is useful to clinicians to assess this risk factor for adverse events. We suggest clinicians use the teach-back method as their predominant method of patient preparation and education. It is patient centered, easy, and magnifies areas of poor understanding by patients, allowing you to correct misunderstandings while not taking excessive time (Schillinger, Piette et al. 2003). View the Teach-Back Process
f. Patient support (Boult, Dowd et al. 1993; Mistry, Rosansky et al. 2001; Rodriguez-Artalejo, Guallar-Castillon et al. 2006; Strunin, Stone et al. 2007): Social support is critical to many older patients transitioning from the hospital. The absence of a formal or informal care giver has been associated with higher rehospitalization rates.
g. Prior hospitalizations in the last 6 months (Soeken, Prescott et al. 1991; Smith, Katz et al. 1996; Coleman, Wagner et al. 1998; Comette, D'Hoore et al. 2005; Billings, Dixon et al. 2006; Forsythe, Chetty et al. 2006): Prior hospitalizations have been shown in multiple studies to be the single most predictive risk factor for future hospitalizations. A patient should thus be viewed automatically as high risk if an unplanned hospitalization has been identified in the six months (some authors studied up to twelve months) prior to the current admission.
h. Palliative care. (Davis MP, Walsh D, Nelson K, Konrad D, LeGrand SB. The business of palliative medicine: management metrics for an acute-care inpatient unit. Am J Hospice & Palliative Care 2001;18(1);26-29. Axelsson B, Christensen SB. Evaluation of a hospital-based palliative support service with particular regard to financial outcome measures. Palliat Med 1998;12:41-49.): Only the minority of patients qualifying for palliative care services receive them. Engaging these services actively has been shown to improve symptom management, patient satisfaction and limit resources, including rehospitalizations for patients nearing end of life.
The admission 8P score should be generated at the time of admission and may be completed by a multidisciplinary team; however, the role of one specifically identified team member should be to ensure that the assessment is completed. Once risk factors are identified, the Risk Specific Interventions should be reviewed and addressed and the risk factors should be identified specifically to healthcare professionals assuming the patient’s care after discharge. Additional risk specific resources are provided in the Clinical Tools section and should be coordinated with those your organization may already have in place or may need to consider developing.
View the TARGET Assessment 8P Scale