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Sato N, Akazawa K, Mitadera Y, Suzuki T, Ibe N, Hirose Y. Clarifying Problems with Emergency Healthcare Systems in Japanese Long-Term Care Facilities for Older People. Health (London) 2017. [DOI: 10.4236/health.2017.98084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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102
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Kang YS, Ryoo SR, Byun SJ, Jeong YJ, Oh JY, Yoon YS. Antimicrobial Resistance and Clinical Outcomes in Nursing Home-Acquired Pneumonia, Compared to Community-Acquired Pneumonia. Yonsei Med J 2017; 58:180-186. [PMID: 27873512 PMCID: PMC5122635 DOI: 10.3349/ymj.2017.58.1.180] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 07/15/2016] [Accepted: 07/22/2016] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Patients with nursing home-acquired pneumonia (NHAP) should be treated as hospital-acquired pneumonia (HAP) according to guidelines published in 2005. However, controversy still exists on whether the high mortality of NHAP results from multidrug resistant pathogens or underlying disease. We aimed to outline differences and factors contributing to mortality between NHAP and community-acquired pneumonia (CAP) patients. MATERIALS AND METHODS We retrospectively evaluated patients aged 65 years or older with either CAP or NHAP from 2008 to 2014. Patients with healthcare-associated pneumonia other than NHAP or HAP were excluded. RESULTS Among 317 patients, 212 patients had CAP and 105 had NHAP. Patients with NHAP had higher mortality, more frequently used a ventilator, and had disease of higher severity than CAP. The incidences of aspiration, tube feeding, and poor functional status were higher in NHAP. Twenty three out of 54 NHAP patients and three out of 62 CAP patients had multidrug resistant pathogens (p<0.001). Eleven patients with NHAP died at discharge, compared to 7 patients with CAP (p=0.009). However, there was no association between mortality rate and presence of multidrug-resistant pathogens. The number of involved lobes on chest X-ray [odds ratio (OR)=1.708; 95% confidence interval (CI), 1.120 to 2.605] and use of mechanical ventilation (OR=9.537; 95% CI, 1.635 to 55.632) were significantly associated with in-hospital mortality. CONCLUSION Patients with NHAP had higher mortality than patients with CAP. The excess mortality among patients with NHAP and CAP was related to disease severity but not to the presence of multidrug resistant pathogens.
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Affiliation(s)
- Yun Seong Kang
- Division of Pulmonary and Critical Care Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Soo Ryeong Ryoo
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Seung Joo Byun
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Yun Jeong Jeong
- Division of Pulmonary and Critical Care Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Jin Young Oh
- Division of Pulmonary and Critical Care Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Young Soon Yoon
- Division of Pulmonary and Critical Care Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea.
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103
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Managing Heart Failure in Long-Term Care: Recommendations from an Interprofessional Stakeholder Consultation. Can J Aging 2016; 35:447-464. [DOI: 10.1017/s071498081600043x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
RÉSUMÉInsuffisance cardiaque (IC) affecte autant que 20 pour cent des résidents en soins de longue durée (SLD), et est associée à la morbidité substantielle, la mortalité et l’utilisation des services de santé. L’objectif de notre étude était de formuler des recommandations sur la mise en œuvre de processus pour prendre soin de l’insuffisance cardiaque dans SLD. Un processus de consultation itérative triphasé avec les parties prenantes a été guidé par la participation d’un panel d’experts et a servi à élaborer des recommandations. Dix-sept recommandations ont été faites. Éléments clés des celles-ci se concentrent sur l’amélioration de la communication interprofessionnelle et accroître les connaissances relatives à l’insuffisance cardiaque entre tous les intervenants dans SLD. Des recommandations systématiques incluent améliorer la communication entre les foyers de SLD et soins aigus et autres prestataires de santé externes, et développer des interventions dans l’ensemble des installations afin de réduire les apports de sodium alimentaire et d’augmenter l’activité physique.
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104
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Fisher K, Griffith L, Gruneir A, Panjwani D, Gandhi S, Sheng LL, Gafni A, Chris P, Markle-Reid M, Ploeg J. Comorbidity and its relationship with health service use and cost in community-living older adults with diabetes: A population-based study in Ontario, Canada. Diabetes Res Clin Pract 2016; 122:113-123. [PMID: 27833049 DOI: 10.1016/j.diabres.2016.10.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 07/29/2016] [Accepted: 10/11/2016] [Indexed: 11/25/2022]
Abstract
AIMS This study describes the comorbid conditions in Canadian, community-dwelling older adults with diabetes and the association between the number of comorbidities and health service use and costs. METHODS This retrospective cohort study used multiple linked administrative data to determine 5-year health service utilization in a population-based cohort of community-living individuals aged 66 and over with a diabetes diagnosis as of April 1, 2008 (baseline). Utilization included physician visits, emergency department visits, hospitalizations, and home care services. RESULTS There were 376,421 cohort members at baseline, almost all (95%) of which had at least one comorbidity and half (46%) had 3 or more. The most common comorbidities were hypertension (83%) and arthritis (61%). Service use and associated costs consistently increased as the number of comorbidities increased across all services and follow-up years. Conditions generally regarded as nondiabetes-related were the main driver of service use. Over time, use of most services declined for people with the highest level of comorbidity (3+). Hospitalizations and emergency department visits represented the largest share of costs for those with the highest level of comorbidity (3+), whereas physician visits were the main costs for those with fewer comorbidities. CONCLUSIONS Comorbidities in community-living older adults with diabetes are common and associated with a high level of health service use and costs. Accordingly, it is important to use a multiple chronic conditions (not single-disease) framework to develop coordinated, comprehensive and patient-centred programs for older adults with diabetes so that all their needs are incorporated into care planning.
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Affiliation(s)
- Kathryn Fisher
- School of Nursing, McMaster University, 1280 Main Street West, Health Sciences Centre Room, Hamilton, Ontario L8S 4K1, Canada.
| | - Lauren Griffith
- Department of Clinical Epidemiology and Biostatistics, McMaster University, McMaster Innovation Park, 175 Longwood Road South, Hamilton, ON L8P 0A1, Canada.
| | - Andrea Gruneir
- Department of Family Medicine, 6-40 University of Alberta, 6-10 University Terrace, Edmonton, AB T6G 2T4, Canada.
| | - Dilzayn Panjwani
- Women's College Research Institute, Women's College Hospital, 790 Bay Street, 7th Floor, Toronto, ON M5G 1N8, Canada.
| | - Sima Gandhi
- Institute for Clinical Evaluative Sciences (ICES), 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada.
| | - Li Lisa Sheng
- Institute for Clinical Evaluative Sciences (ICES), 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada.
| | - Amiram Gafni
- Centre for Health Economics and Policy Analysis, Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Room CRL-208, Hamilton, Ontario L8S 4K1, Canada,.
| | - Patterson Chris
- Department of Medicine, McMaster University, 1280 Main Street West, Health Sciences Centre, Room 3N25B, Hamilton, Ontario L8S 4K, Canada.
| | - Maureen Markle-Reid
- School of Nursing, McMaster University, 1280 Main Street West, Health Sciences Centre Room, Hamilton, Ontario L8S 4K1, Canada.
| | - Jenny Ploeg
- School of Nursing, McMaster University, 1280 Main Street West, Health Sciences Centre Room, Hamilton, Ontario L8S 4K1, Canada.
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105
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Decisions to Transfer Nursing Home Residents to Emergency Departments: A Scoping Review of Contributing Factors and Staff Perspectives. J Am Med Dir Assoc 2016; 17:994-1005. [DOI: 10.1016/j.jamda.2016.05.012] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 05/07/2016] [Accepted: 05/10/2016] [Indexed: 11/22/2022]
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106
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Tsai HH, Tsai YF, Liu CY. Repeated Hospital Transfers and Associated Outcomes by Residency Time Among Nursing Home Residents in Taiwan. J Am Med Dir Assoc 2016; 17:1020-1024. [DOI: 10.1016/j.jamda.2016.06.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 06/19/2016] [Accepted: 06/20/2016] [Indexed: 11/30/2022]
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107
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Griffith LE, Gruneir A, Fisher K, Panjwani D, Gandhi S, Sheng L, Gafni A, Patterson C, Markle-Reid M, Ploeg J. Patterns of health service use in community living older adults with dementia and comorbid conditions: a population-based retrospective cohort study in Ontario, Canada. BMC Geriatr 2016; 16:177. [PMID: 27784289 PMCID: PMC5080690 DOI: 10.1186/s12877-016-0351-x] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 10/17/2016] [Indexed: 11/20/2022] Open
Abstract
Background Patients with dementia have increased healthcare utilization and often have comorbid chronic conditions. It is not clear if the increase in utilization is driven by dementia, the comorbidities or both. The objective of this study was to describe the number and types of comorbid conditions in a population-based cohort of older adults with dementia and how the level of comorbidity impacts dementia-related and non-dementia-related health service utilization. Methods This study is a retrospective cohort study using multiple linked administrative databases to examine health service utilization and costs of 100,630 community-living older adults living with pre-existing dementia in Ontario, Canada. Comorbid conditions and health service utilization were measured using administrative data (physician visits, emergency department visits, hospitalizations, and homecare contacts). Results Nearly all, 96.3 %, had at least one comorbid condition, while 18.4 % had five or more comorbid conditions. The most common comorbid conditions were hypertension (77.8 %), and arthritis (66.2 %). All types of utilization increased consistently with the number of comorbid conditions. The average number of dementia-related services tended to be similar across all levels of comorbidity while the average number of non-dementia related visits tended to increase with the level of comorbidity. Conclusions Comorbidities in community-living older adults with dementia are common and account for a substantial proportion of health service use and costs in this population. Our results suggest that comprehensive programs that take a holistic view to identify the needs of patients in the context of other comorbidities are required for persons with dementia living in the community. Electronic supplementary material The online version of this article (doi:10.1186/s12877-016-0351-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lauren E Griffith
- Department of Clinical Epidemiology and Biostatistics, McMaster University, McMaster Innovation Park, 175 Longwood Road South, Hamilton, ON, L8P 0A1, Canada.
| | - Andrea Gruneir
- Department of Family Medicine, 6-40 University of Alberta, 6-10 University Terrace, Edmonton, AB, T6G 2T4, Canada
| | - Kathryn Fisher
- School of Nursing, McMaster University, Health Sciences Centre, 1280 Main Street West, Room 3N25B, Hamilton, ON, L8S 4K1, Canada
| | - Dilzayn Panjwani
- Women's College Research Institute, Women's College Hospital, 790 Bay St., 7th floor, Toronto, ON, M5G 1N8, Canada
| | - Sima Gandhi
- Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Li Sheng
- Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Amiram Gafni
- Centre for Health Economics and Policy Analysis; Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Room CRL-208, Hamilton, ON, L8S 4K1, Canada
| | - Christopher Patterson
- Department of Medicine, McMaster University, Health Sciences Centre, 1280 Main Street West, Room 3N25B, Hamilton, ON, L8S 4K1, Canada
| | - Maureen Markle-Reid
- School of Nursing, McMaster University, Health Sciences Centre, 1280 Main Street West, Room 3N25B, Hamilton, ON, L8S 4K1, Canada
| | - Jenny Ploeg
- School of Nursing, McMaster University, Health Sciences Centre, 1280 Main Street West, Room 3N25B, Hamilton, ON, L8S 4K1, Canada
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108
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Lukin B, Fan LJ, Zhao JZ, Sun JD, Dingle K, Purtill R, Tapp S, Hou XY. Emergency department use among patients from residential aged care facilities under a Hospital in the Nursing Home scheme in public hospitals in Queensland Australia. World J Emerg Med 2016; 7:183-90. [PMID: 27547277 DOI: 10.5847/wjem.j.1920-8642.2016.03.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hospital emergency department (ED) use by patients from residential aged care facilities (RACFs) is not always appropriate, and this calls for interventions to avoid some unnecessary uses. This study aims to compare patterns of ED use by RACF patients with and without a Hospital in the Nursing Home (HiNH) program. METHODS RACF patients presenting to EDs of a hospital with and a hospital without this program during pre- and post-intervention periods were included. Data on patient demographics and ED presentation characteristics were obtained from the Emergency Department Information System database, and were analysed by descriptive and comparative statistics. RESULTS In both hospitals, most RACF residents presenting to EDs were aged between 75-94 years, female, triaged at scale 3 to 5, and transferred on weekdays and during working hours. Almost half of them were subsequently admitted to hospitals. In accordance with the ICD-10-AM diagnostic coding system, diagnoses that consistently ranked among the top three reasons for visiting the two hospitals before and after intervention included Chapter XIX: injury and poisoning and Chapter X: respiratory diseases. Associated with the intervention, significant decreases in the numbers of presentations per 1 000 RACF beds were identified among patients diagnosed with Chapter XI: digestive diseases [rate ratio (95%CI): 0.09 (0.04, 0.22); P<0.0001] and Chapter XXI: factors influencing health status and contact with health services [rate ratio (95%CI): 0.22 (0.07, 0.66); P=0.007]. CONCLUSION The HiNH program may reduce the incidence of RACF residents visiting EDs for diagnoses of Chapter XI and Chapter XXI.
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Affiliation(s)
- Bill Lukin
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland 4006, Australia
| | - Li-Jun Fan
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland 4059, Australia
| | - Jing-Zhou Zhao
- Bureau of Investment Promotion, Wuwei City 733000, Gansu Province, China
| | - Jian-Dong Sun
- Queensland Health, Brisbane, Queensland 4029, Australia
| | - Kaeleen Dingle
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland 4059, Australia
| | - Rhonda Purtill
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland 4006, Australia
| | - Sam Tapp
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland 4006, Australia
| | - Xiang-Yu Hou
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland 4059, Australia
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109
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Kahn JH, Magauran BG, Olshaker JS, Shankar KN. Current Trends in Geriatric Emergency Medicine. Emerg Med Clin North Am 2016; 34:435-52. [DOI: 10.1016/j.emc.2016.04.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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110
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Lacny S, Zarrabi M, Martin-Misener R, Donald F, Sketris I, Murphy AL, DiCenso A, Marshall DA. Cost-effectiveness of a nurse practitioner-family physician model of care in a nursing home: controlled before and after study. J Adv Nurs 2016; 72:2138-52. [PMID: 27119440 DOI: 10.1111/jan.12989] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2016] [Indexed: 11/30/2022]
Abstract
AIMS To examine the cost-effectiveness of a nurse practitioner-family physician model of care compared with family physician-only care in a Canadian nursing home. BACKGROUND As demand for long-term care increases, alternative care models including nurse practitioners are being explored. DESIGN Cost-effectiveness analysis using a controlled before-after design. METHODS The study included an 18-month 'before' period (2005-2006) and a 21-month 'after' time period (2007-2009). Data were abstracted from charts from 2008-2010. We calculated incremental cost-effectiveness ratios comparing the intervention (nurse practitioner-family physician model; n = 45) to internal (n = 65), external (n = 70) and combined internal/external family physician-only control groups, measured as the change in healthcare costs divided by the change in emergency department transfers/person-month. We assessed joint uncertainty around costs and effects using non-parametric bootstrapping and cost-effectiveness acceptability curves. RESULTS Point estimates of the incremental cost-effectiveness ratio demonstrated the nurse practitioner-family physician model dominated the internal and combined control groups (i.e. was associated with smaller increases in costs and emergency department transfers/person-month). Compared with the external control, the intervention resulted in a smaller increase in costs and larger increase in emergency department transfers. Using a willingness-to-pay threshold of $1000 CAD/emergency department transfer, the probability the intervention was cost-effective compared with the internal, external and combined control groups was 26%, 21% and 25%. CONCLUSION Due to uncertainty around the distribution of costs and effects, we were unable to make a definitive conclusion regarding the cost-effectiveness of the nurse practitioner-family physician model; however, these results suggest benefits that could be confirmed in a larger study.
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Affiliation(s)
- Sarah Lacny
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Mahmood Zarrabi
- Health Technology Assessment and Innovation Department, Alberta Health Services, Alberta, Canada
| | | | - Faith Donald
- Daphne Cockwell School of Nursing, Ryerson University, Ontario, Canada
| | - Ingrid Sketris
- College of Pharmacy, Dalhousie University, Nova Scotia, Canada
| | - Andrea L Murphy
- College of Pharmacy, Dalhousie University, Nova Scotia, Canada
| | - Alba DiCenso
- School of Nursing and Department of Clinical Epidemiology and Biostatistics, McMaster University, Ontario, Canada
| | - Deborah A Marshall
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
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111
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Petrou P. Failed Attempts to Reduce Inappropriate Laboratory Utilization in an Emergency Department Setting in Cyprus: Lessons Learned. J Emerg Med 2016; 50:510-7. [DOI: 10.1016/j.jemermed.2015.07.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Revised: 07/03/2015] [Accepted: 07/25/2015] [Indexed: 11/30/2022]
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112
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Osman O, Sherifali D, Stolee P, Heckman G. Diabetes Management in Long-Term Care: An Exploratory Study of the Current Practices and Processes to Managing Frail Elderly Persons with Type 2 Diabetes. Can J Diabetes 2016; 40:17-30. [DOI: 10.1016/j.jcjd.2015.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 10/20/2015] [Indexed: 11/30/2022]
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113
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Putot A, Tetu J, Perrin S, Bailly H, Piroth L, Besancenot JF, Bonnotte B, Chavanet P, d'Athis P, Charles PE, Sordet-Guépet H, Manckoundia P. Impact of microbiological samples in the hospital management of community-acquired, nursing home-acquired and hospital-acquired pneumonia in older patients. Eur J Clin Microbiol Infect Dis 2016; 35:489-95. [PMID: 26753994 DOI: 10.1007/s10096-015-2565-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 12/21/2015] [Indexed: 01/07/2023]
Abstract
We investigated the positivity rate, the detection rates for non-covered pathogens and the therapeutic impact of microbiological samples (MS) in community-acquired pneumonia (CAP), nursing home-acquired pneumonia (NHAP) and hospital-acquired pneumonia (HAP) in elderly hospitalised patients. Patients aged 75 years and over with pneumonia and hospitalised between 1/1/2013 and 30/6/2013 in the departments of medicine (5) and intensive care (1) of our university hospital were included. Microbiological findings, intra-hospital mortality and one-year mortality were recorded. Among the 217 patients included, there were 138 CAP, 56 NHAP and 23 HAP. MS were performed in 89.9, 91.1 and 95.6 % of CAP, NHAP and HAP, respectively. Microbiological diagnosis was made for 29, 11.8 and 27.3 % of patients for CAP, NHAP and HAP, respectively (p = 0.05). Non-covered pathogens were detected for 8 % of CAP, 2 % of NHAP and 13.6 % of HAP (p = 0.1). The antimicrobial spectrum was significantly more frequently reduced when the MS were positive (46.7 % vs. 10.8 % when MS were negative, p = 10(-7)). The MS positivity rate was significantly lower in NHAP than in CAP and HAP. MS revealed non-covered pathogens in only 2 % of NHAP. These results show the poor efficiency and weak clinical impact of MS in the management of pneumonia in hospitalised older patients and suggest that their use should be rationalised.
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Affiliation(s)
- A Putot
- Department of Geriatrics and Internal Medicine, Hospital of Champmaillot, University Hospital, Dijon, France
| | - J Tetu
- Department of Microbiology, University Hospital, Dijon, France
| | - S Perrin
- Department of Geriatrics and Internal Medicine, Hospital of Champmaillot, University Hospital, Dijon, France
| | - H Bailly
- Department of Geriatrics and Internal Medicine, Hospital of Champmaillot, University Hospital, Dijon, France
| | - L Piroth
- Department of Infectious Diseases, University Hospital, Dijon, France
| | - J-F Besancenot
- Department of Internal Medicine 2, University Hospital, Dijon, France
| | - B Bonnotte
- Department of Internal Medicine 1, University Hospital, Dijon, France
| | - P Chavanet
- Department of Infectious Diseases, University Hospital, Dijon, France
| | - P d'Athis
- Department of Biostatistics and Medical Computing, University Hospital, Dijon, France
| | - P-E Charles
- Medical Intensive Care Unit, University Hospital, Dijon, France
| | - H Sordet-Guépet
- Department of Geriatrics and Internal Medicine, Hospital of Champmaillot, University Hospital, Dijon, France
| | - P Manckoundia
- Department of Geriatrics and Internal Medicine, Hospital of Champmaillot, University Hospital, Dijon, France. .,Inserm/U1093 Motricity-Plasticity, University of Burgundy and Franche Comté, Dijon, France.
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Bainbridge D, Seow H, Sussman J, Pond G. Factors associated with acute care use among nursing home residents dying of cancer: a population-based study. Int J Palliat Nurs 2015. [PMID: 26203955 DOI: 10.12968/ijpn.2015.21.7.349] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Little is known about residents of long-term care (LTC) facilities who die of cancer. The authors examined factors among this cohort prognostic of greater acute care use to identify areas for improving support in LTC. METHODS The authors used administrative data representing all cancer decedents in Ontario, Canada, who had been living in LTC. Binary logistic regression was used to examine the contribution of covariates to having an emergency department (ED) visit in the last 6 months of life or to death in hospital. RESULTS Among the 1196 LTC residents in the study cohort, 61% had visited an ED in the last 6 months of life and 20% had died in hospital. Cancer type, income, gender, time in LTC and rural location were not strong predictors of the acute care outcomes. However, certain comorbidities, being younger and region of residence significantly increased the odds of an ED visit and/or hospital death (all P<0.05). CONCLUSIONS Determining the characteristics of LTC patients more likely to access acute care services can help to inform interventions that avoid costly and potentially adverse transfers to hospital. The study of cancer patients in LTC represents a starting point for clarifying the potential of specialised palliative care nursing and other support that is often lacking in these facilities.
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Affiliation(s)
- Daryl Bainbridge
- Senior Research Coordinator, McMaster University, and Juravinski Cancer Centre, Hamilton, Ontario, Canada
| | - Hsien Seow
- Associate Professor, McMaster University, and Juravinski Cancer Centre, Hamilton, Ontario, Canada
| | - Jonathan Sussman
- Associate Professor, McMaster University, and Juravinski Cancer Centre, Hamilton, Ontario, Canada
| | - Gregory Pond
- Associate Professor; all at Department of Oncology, McMaster University, and Juravinski Cancer Centre, Hamilton, Ontario, Canada
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115
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Rojas-Fernandez C, Dadfar F, Wong A, Brown SG. Use of fall risk increasing drugs in residents of retirement villages: a pilot study of long term care and retirement home residents in Ontario, Canada. BMC Res Notes 2015; 8:568. [PMID: 26467915 PMCID: PMC4606840 DOI: 10.1186/s13104-015-1557-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 10/05/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Falls continue to be a problem for older people in long-term care (LTC) and retirement home (RH) settings and are associated with significant morbidity and health care use. Fall-risk increasing drugs (FRIDs) are known to increase fall risk and represent modifiable risk factors. There are limited data regarding the use of FRIDs in contemporary LTC and RH settings, and it has not been well documented to what extent medication regimens are reviewed and modified for those who have sustained falls. The objective of this study is to characterize medication related fall risk factors in LTC and RH residents and on-going use of medications known to increase fall risk. METHODS Retrospective chart review of residents aged >65 who sustained one or more falls living in LTC or RH settings. RESULTS 105 residents who fell one or more times during 2009-2010 were identified with a mean age of 89 years, a mean of nine scheduled medications and seven diagnoses, and 83% were women. Residents in LTC were ostensibly at higher risk for falls relative to those in RH settings as suggested by higher proportion of residents with multiple falls, multiple comorbidities, comorbidities that increase fall risk and visual impairment. Post fall injuries were sustained by 42% of residents, and residents in RH sustained more injuries relative to LTC residents (47 vs 34%). Use of FRIDs such as benzodiazepines, antipsychotic, antidepressant and various antihypertensive drugs was common in the present sample. No medication regimen changes were noted in the 6-month post fall period. CONCLUSIONS The present study documented common use FRIDs by LTC and RH residents with multiple falls. These potentially modifiable falls risk factors are not being adequately addressed in contemporary practice, demonstrating that there is much room for improvement with regards to the safe and appropriate use of medications in LTC and RH residents.
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Affiliation(s)
- Carlos Rojas-Fernandez
- Schlegel Research Chair in Geriatric Pharmacotherapy, Schlegel-UW Research Institute for Ageing, School of Pharmacy, University of Waterloo, 10 Victoria St S, Room 7004, Kitchener, ON, N2G 1C5, Canada. .,, .
| | - Farzan Dadfar
- University of Waterloo School of Pharmacy, Kitchener, ON, Canada.
| | - Andrea Wong
- University of Waterloo School of Pharmacy, Kitchener, ON, Canada.
| | - Susan G Brown
- Schlegel-University of Waterloo Research Institute for Aging, 325 Max Becker Drive, Suite 202, Kitchener, ON, N2E 4H5, Canada.
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Stephens C, Halifax E, Bui N, Lee SJ, Harrington C, Shim J, Ritchie C. Provider Perspectives on the Influence of Family on Nursing Home Resident Transfers to the Emergency Department: Crises at the End of Life. Curr Gerontol Geriatr Res 2015; 2015:893062. [PMID: 26379704 PMCID: PMC4561315 DOI: 10.1155/2015/893062] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 08/16/2015] [Indexed: 11/29/2022] Open
Abstract
Background. Nursing home (NH) residents often experience burdensome and unnecessary care transitions, especially towards the end of life. This paper explores provider perspectives on the role that families play in the decision to transfer NH residents to the emergency department (ED). Methods. Multiple stakeholder focus groups (n = 35 participants) were conducted with NH nurses, NH physicians, nurse practitioners, physician assistants, NH administrators, ED nurses, ED physicians, and a hospitalist. Stakeholders described experiences and challenges with NH resident transfers to the ED. Focus group interviews were recorded and transcribed verbatim. Transcripts and field notes were analyzed using a Grounded Theory approach. Findings. Providers perceive that families often play a significant role in ED transfer decisions as they frequently react to a resident change of condition as a crisis. This sense of crisis is driven by 4 main influences: insecurities with NH care; families being unprepared for end of life; absent/inadequate advance care planning; and lack of communication and agreement within families regarding goals of care. Conclusions. Suboptimal communication and lack of access to appropriate and timely palliative care support and expertise in the NH setting may contribute to frequent ED transfers.
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Affiliation(s)
- Caroline Stephens
- Department of Community Health Systems, School of Nursing, University of California, San Francisco, 2 Koret Way, N531E, UCSF Box 0608, San Francisco, CA 94143-0608, USA
| | - Elizabeth Halifax
- Department of Community Health Systems, School of Nursing, University of California, San Francisco, 2 Koret Way, N531E, UCSF Box 0608, San Francisco, CA 94143-0608, USA
| | - Nhat Bui
- Department of Community Health Systems, School of Nursing, University of California, San Francisco, 2 Koret Way, N531E, UCSF Box 0608, San Francisco, CA 94143-0608, USA
| | - Sei J. Lee
- Department of Geriatrics, Palliative & Extended Care, San Francisco VA Medical Center, Division of Geriatrics, School of Medicine, University of California, San Francisco, 4150 Clement Street, Building 1, Room 220F, San Francisco, CA 94121, USA
| | - Charlene Harrington
- Department of Social & Behavioral Sciences, School of Nursing, University of California, San Francisco, 3333 California Street, Suite 455, UCSF Box 0612, San Francisco, CA 94118, USA
| | - Janet Shim
- Department of Social & Behavioral Sciences, School of Nursing, University of California, San Francisco, 3333 California Street, Suite 455, UCSF Box 0612, San Francisco, CA 94118, USA
| | - Christine Ritchie
- Division of Geriatrics, School of Medicine, University of California, San Francisco, 3333 California Street, Suite 380, San Francisco, CA 94143-1265, USA
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Unplanned Transfer to Emergency Departments for Frail Elderly Residents of Aged Care Facilities: A Review of Patient and Organizational Factors. J Am Med Dir Assoc 2015; 16:551-62. [DOI: 10.1016/j.jamda.2015.03.007] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 02/07/2015] [Accepted: 03/05/2015] [Indexed: 12/20/2022]
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Grabowski DC, O'Malley AJ. Use of telemedicine can reduce hospitalizations of nursing home residents and generate savings for medicare. Health Aff (Millwood) 2015; 33:244-50. [PMID: 24493767 DOI: 10.1377/hlthaff.2013.0922] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Hospitalizations of nursing home residents are frequent and result in complications, morbidity, and Medicare expenditures of more than a billion dollars annually. The lack of a physician presence at many nursing homes during off hours might contribute to inappropriate hospitalizations. Findings from our controlled study of eleven nursing homes provide the first indications that switching from on-call to telemedicine physician coverage during off hours could reduce hospitalizations and therefore generate cost savings to Medicare in excess of the facility's investment in the service. But those savings were evident only at the study nursing homes that used the telemedicine service to a greater extent, compared to the other study facilities. Telemedicine service providers and nursing home leaders might need to take additional steps to encourage buy-in to the use of telemedicine at facilities with such services. At the same time, closer alignment of the stakeholders that bear the costs of telemedicine and those that might realize savings because of its use could offer further incentives for the adoption of telemedicine.
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O’Connell B, Hawkins M, Considine J, Au C. Referrals to hospital emergency departments from residential aged care facilities: Stuck in a time warp. Contemp Nurse 2014; 45:228-33. [DOI: 10.5172/conu.2013.45.2.228] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Changing global demography is resulting in older people presenting to emergency departments (EDs) in greater numbers than ever before. They present with greater urgency and are more likely to be admitted to hospital or re-attend and utilize greater resources. They experience longer waits for care and are less likely to be satisfied with their experiences. Not only that, but older people suffer poorer health outcomes after ED attendance, with higher mortality rates and greater dependence in activities of daily living or rates of admission to nursing homes. Older people's assessment and management in the ED can be complex, time consuming, and require specialist skills. The interplay of multiple comorbidities and functional decline result in the complex state of frailty that can predispose to poor health outcomes and greater care needs. Older people with frailty may present to services in an atypical fashion requiring detailed, multidimensional, and increasingly multidisciplinary care to provide the correct diagnosis and management as well as appropriate placement for ongoing care or admission avoidance. Specific challenges such as delirium, functional decline, or carer strain need to be screened for and managed appropriately. Identifying patients with specific frailty syndromes can be critical to identifying those at highest risk of poor outcomes and most likely to benefit from further specialist interventions. Models of care are evolving that aim to deliver multidimensional assessment and management by multidisciplinary specialist care teams (comprehensive geriatric assessment). Increasingly, these models are demonstrating improved outcomes, including admission avoidance or reduced death and dependence. Delivering this in the ED is an evolving area of practice that adapts the principles of geriatric medicine for the urgent-care environment.
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Affiliation(s)
- Graham Ellis
- Medicine for the Elderly, Monklands Hospital, Airdrie, Scotland, UK
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Dwyer R, Gabbe B, Stoelwinder JU, Lowthian J. A systematic review of outcomes following emergency transfer to hospital for residents of aged care facilities. Age Ageing 2014; 43:759-66. [PMID: 25315230 DOI: 10.1093/ageing/afu117] [Citation(s) in RCA: 201] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND residential aged care facility (RACF) resident numbers are increasing. Residents are frequently frail with substantial co-morbidity, functional and cognitive impairment with high susceptibility to acute illness. Despite living in facilities staffed by health professionals, a considerable proportion of residents are transferred to hospital for management of acute deteriorations in health. This model of emergency care may have unintended consequences for patients and the healthcare system. This review describes available evidence about the consequences of transfers from RACF to hospital. METHODS a comprehensive search of the peer-reviewed literature using four electronic databases. Inclusion criteria were participants lived in nursing homes, care homes or long-term care, aged at least 65 years, and studies reported outcomes of acute ED transfer or hospital admission. Findings were synthesized and key factors identified. RESULTS residents of RACF frequently presented severely unwell with multi-system disease. In-hospital complications included pressure ulcers and delirium, in 19 and 38% of residents, respectively; and up to 80% experienced potentially invasive interventions. Despite specialist emergency care, mortality was high with up to 34% dying in hospital. Furthermore, there was extensive use of healthcare resources with large proportions of residents undergoing emergency ambulance transport (up to 95%), and inpatient admission (up to 81%). CONCLUSIONS acute emergency department (ED) transfer is a considerable burden for residents of RACF. From available evidence, it is not clear if benefits of in-hospital emergency care outweigh potential adverse complications of transfer. Future research is needed to better understand patient-centred outcomes of transfer and to explore alternative models of emergency healthcare.
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Affiliation(s)
- Rosamond Dwyer
- Monash University, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, The Alfred Centre, Alfred Hospital 99 Commercial Road Melbourne, VIC, Melbourne, Victoria 3004, Australia
| | - Belinda Gabbe
- Monash University, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, The Alfred Centre, Alfred Hospital 99 Commercial Road Melbourne, VIC, Melbourne, Victoria 3004, Australia
| | - Johannes U Stoelwinder
- Monash University, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, The Alfred Centre, Alfred Hospital 99 Commercial Road Melbourne, VIC, Melbourne, Victoria 3004, Australia Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Judy Lowthian
- Monash University, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, The Alfred Centre, Alfred Hospital 99 Commercial Road Melbourne, VIC, Melbourne, Victoria 3004, Australia
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Amador S, Goodman C, King D, Machen I, Elmore N, Mathie E, Iliffe S. Emergency ambulance service involvement with residential care homes in the support of older people with dementia: an observational study. BMC Geriatr 2014; 14:95. [PMID: 25164581 PMCID: PMC4154936 DOI: 10.1186/1471-2318-14-95] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 08/19/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Older people resident in care homes have a limited life expectancy and approximately two-thirds have limited mental capacity. Despite initiatives to reduce unplanned hospital admissions for this population, little is known about the involvement of emergency services in supporting residents in these settings. METHODS This paper reports on a longitudinal study that tracked the involvement of emergency ambulance personnel in the support of older people with dementia, resident in care homes with no on-site nursing providing personal care only. 133 residents with dementia across 6 care homes in the East of England were tracked for a year. The paper examines the frequency and reasons for emergency ambulance call-outs, outcomes and factors associated with emergency ambulance service use. RESULTS 56% of residents used ambulance services. Less than half (43%) of all call-outs resulted in an unscheduled admission to hospital. In addition to trauma following a following a fall in the home, results suggest that at least a reasonable proportion of ambulance contacts are for ambulatory care sensitive conditions. An emergency ambulance is not likely to be called for older rather than younger residents or for women more than men. Length of residence does not influence use of emergency ambulance services among older people with dementia. Contact with primary care services and admission route into the care home were both significantly associated with emergency ambulance service use. The odds of using emergency ambulance services for residents admitted from a relative's home were 90% lower than the odds of using emergency ambulance services for residents admitted from their own home. CONCLUSIONS Emergency service involvement with this vulnerable population merits further examination. Future research on emergency ambulance service use by older people with dementia in care homes, should account for important contextual factors, namely, presence or absence of on-site nursing, GP involvement, and access to residents' family, alongside resident health characteristics.
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Affiliation(s)
- Sarah Amador
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield AL109AB, UK
| | - Claire Goodman
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield AL109AB, UK
| | - Derek King
- Personal Social Services Research Unit, Cowdray House, The London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK
| | - Ina Machen
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield AL109AB, UK
| | - Natasha Elmore
- Primary Care Unit, Institute of Public Health, Forvie Site, University of Cambridge, Robinson Way, Cambridge, CB2 0SR, UK
| | - Elspeth Mathie
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield AL109AB, UK
| | - Steve Iliffe
- Department of Primary Care and Population Sciences, University College London, London, NW32PF, UK
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Campbell RJ, Bell CM, Bronskill SE, Paterson JM, Whitehead M, Campbell EDL, Gill SS. Adverse gastrointestinal events with intravitreal injection of vascular endothelial growth factor inhibitors: nested case-control study. Drug Saf 2014; 37:723-33. [PMID: 25096958 DOI: 10.1007/s40264-014-0211-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intravenous administration of vascular endothelial growth factor (VEGF)-inhibiting drugs is associated with adverse gastrointestinal (GI) events. Clinical trials of VEGF inhibitors used for the treatment of retinal diseases have suggested higher risks of adverse GI events among patients treated with bevacizumab. However, population-based studies have been lacking. OBJECTIVE Our objective was to assess risks for GI adverse events associated with intravitreal injections of VEGF-inhibiting drugs. METHODS We conducted a population-based, nested case-control study of 114,427 older adults in Ontario, Canada, with retinal disease identified between 1 November 2005 and 30 April 2011. Of these, 3,582 cases were admitted to hospital or assessed in an emergency department for GI adverse events. Controls were matched to cases on the basis of age, sex, and outcome history. RESULTS Patients experiencing adverse events were equally as likely as matched controls to have been exposed to bevacizumab or ranibizumab. Adjusted odds ratios for bevacizumab were 1.05 (95 % confidence interval [CI] 0.69-1.61) for upper GI ulceration, 1.29 (95 % CI 0.86-1.96) for diverticular disease, 1.49 (95 % CI 0.84-2.63) for pancreatitis, 0.82 (95 % CI 0.53-1.29) for cholelithiasis, and 1.45 (95 % CI 0.67-3.12) for cholecystitis. For ranibizumab they were 1.25 (95 % CI 0.88-1.77) for upper GI ulceration, 1.12 (95 % CI 0.83-1.52) for diverticular disease, 0.85 (95 % CI 0.51-1.40) for pancreatitis, 0.77 (95 % CI 0.53-1.11) for cholelithiasis, and 0.83 (95 % CI 0.44-1.56) for cholecystitis. Results were similar when the analysis was restricted to patients only exposed to a single type of VEGF inhibitor. CONCLUSIONS In this population-based study, intravitreal injections of bevacizumab and ranibizumab were not associated with increased risks of adverse GI events.
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Affiliation(s)
- Robert J Campbell
- Department of Ophthalmology, Queen's University, Kingston, ON, Canada,
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Abstract
RÉSUMÉL'insuffisance cardiaque (IC) est fréquente chez les résidents en soins de longue durée (SLD), et peut représenter 40 pour cent des transferts aux soins aigus. Des lignes directrices de l’IC de la Société canadienne de cardiologie approuvent les traitements standards, mais les résidents de SLD sont moins susceptibles de recevoir un traitement.* Cette étude qualitative a utilisé des groupes de discussion pour explorer les perceptions, de 18 médécins et infirmières praticiennes dans trois foyers de l’Ontario, des pratiques de soins de l’IC et les défis de SLD. Par exemple, les participants ont rapporté les défis concernant aptitudes diagnostiques et les connaissances procédurales de l’IC. Ils ont également identifié la nécessité de la collaboration interprofessionnelle et la clarification des rôles pour améliorer les soins et les résultats de l’IC. Pour résoudre ces problèmes, les interventions multi-modales et l'enseignement de chevet sont requis. Le leadership a été considéré comme essentielle pour améliorer les soins de l’IC. Plusieurs préoccupations ont surgi concernant les lacunes dans les connaissances et les déficits cliniques chez les fournisseurs de soins primaires qui traitent l'insuffisance cardiaque chez les résidents de SLD. Pour améliorer les soins de l'IC à long terme, des solutions éducatives et interprofessionnelles multi-modales et cliniquement ciblées sont nécessaires.
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Wang H, Robinson RD, Johnson C, Zenarosa NR, Jayswal RD, Keithley J, Delaney KA. Using the LACE index to predict hospital readmissions in congestive heart failure patients. BMC Cardiovasc Disord 2014; 14:97. [PMID: 25099997 PMCID: PMC4128541 DOI: 10.1186/1471-2261-14-97] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 07/30/2014] [Indexed: 12/02/2022] Open
Abstract
Background The LACE index has been used to predict the risk of unplanned readmission within 30 days after hospital discharge in both medical and surgical patients. The aim of this study is to validate the accuracy of using the LACE index in CHF patients. Methods This was a retrospective study. The LACE index score was calculated on each patient who was admitted to hospital due to an acute CHF exacerbation. Operational and clinical variables were collected from patients including basic clinical characteristics, length of hospitalization, comorbidities, number of previous ED visits in the past 6 months before the index admission, and the number of post discharge ED revisits at 30, 60, and 90 days. All variables were analyzed by multivariate logistic regression to determine the association between clinical variables and the hospital unplanned readmissions. C-statistic was used to discriminate those patients with high risk of readmissions. Results Of the 253 patients included in the study, 24.50% (62/253) experienced unplanned readmission to hospital within 30 days after discharge. The LACE index was slightly higher in patients readmitted versus patients not readmitted (12.17 ± 2.22 versus 11.80 ± 1.92, p = 0.199). Adjusted odds ratios based on logistic regression of all clinical variables showed only the number of previous ED visits (OR 1.79, 95% CI 1.30-2.47, p < 0.001), history of myocardial infarction (OR 2.51, 95% CI 1.02-6.21, p = 0.045), and history of peripheral vascular disease (OR 10.75, 95% CI 1.52-75.73, p = 0.017) increased the risk of unplanned readmission within 30 days of hospital discharge. However, patients with high LACE scores (≥10) had a significantly higher rate of ED revisits (15.04% vs 0%) within 30 days from the index discharge than those with low LACE scores (p = 0.030). Conclusion The LACE index may not accurately predict unplanned readmissions within 30 days from hospital discharge in CHF patients. The LACE high risk index may have utility as a screening tool to predict high risk ED revisits after hospital discharge.
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Affiliation(s)
- Hao Wang
- Department of Emergency Medicine, Integrative Emergency Service, John Peter Smith Health Network, 1500 S, Main St, 76104 Fort Worth, TX, USA.
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Heckman GA, Boscart VM, McKelvie RS. Management considerations in the care of elderly heart failure patients in long-term care facilities. Future Cardiol 2014; 10:563-77. [DOI: 10.2217/fca.14.35] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
ABSTRACT: Heart failure, a condition that affects up to 20% of older persons residing in long-term care facilities, is an important cause of morbidity, health service utilization and death. Effective and interprofessional heart failure care processes could potentially improve care, outcomes and quality of life and delay decline or hospital admission. This article reviews the clinical aspects of heart failure, and the challenges to the diagnosis and management of this condition in long-term care residents who are frail and are affected by multiple comorbidities.
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Affiliation(s)
- George A Heckman
- Research Institute on Aging, University of Waterloo, BMH 3734, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada
| | - Veronique M Boscart
- Conestoga College, School for Health & Life Sciences & Community Services, 299 Doon Valley Drive, Kitchener, ON, N2G 4M4, Canada
| | - Robert S McKelvie
- McMaster University & Hamilton Health Sciences, David Braley Cardiac, Vascular & Stroke Research Institute, 237 Barton Street East, Hamilton, ON, L8L 2X2, Canada
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Assessment tools for determining appropriateness of admission to acute care of persons transferred from long-term care facilities: a systematic review. BMC Geriatr 2014; 14:80. [PMID: 24952409 PMCID: PMC4094601 DOI: 10.1186/1471-2318-14-80] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 06/11/2014] [Indexed: 11/10/2022] Open
Abstract
Background Residents of long-term care facilities have a high risk of acute care admission. Estimates of the frequency of inappropriate transfers vary substantially throughout the studies and various assessment tools have been used. The purpose of this study is to systematically review and describe the internationally existing assessment tools used for determining appropriateness of hospital admissions among long-term care residents. Method Systematic review of the literature of two databases (PubMed and CINAHL®). The search covered seven languages and the period between January 2000 and December 2012. All quantitative studies were included if any assessment tool for appropriateness of hospital and/or emergency department admission of long-term care residents was used. Two pairs of independent researchers extracted the data. Results Twenty-nine articles were included, covering study periods between 1991 and 2009. The proportion of admissions considered as inappropriate ranged from 2% to 77%. Throughout the studies, 16 different assessment tools were used; all were based on expert opinion to some extent; six also took into account published literature or interpretation of patient data. Variation between tools depended on the concepts studied, format and application, and aspects evaluated. Overall, the assessment tools covered six aspects: specific medical diagnoses (assessed by n = 8 tools), acuteness/severity of symptoms (n = 7), residents’ characteristics prior to admission (n = 6), residents’ or families’ wishes (n = 3), existence of a care plan (n = 1), and availability or requirement of resources (n = 10). Most tools judged appropriateness based on one fulfilled item; five tools judged appropriateness based on a balance of aspects. Five tools covered only one of these aspects and only six considered four or more aspects. Little information was available on the psychometric properties of the tools. Conclusions Most assessment tools are not comprehensive and do not take into account residents’ individual aspects, such as characteristics of residents prior to admission and wishes of residents or families. The generalizability of the existing tools is unknown. Further research is needed to develop a tool that is evidence-based, comprehensive and generalizable to different regions or countries in order to assess the appropriateness of hospital admissions among long-term care residents.
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Rojas-Fernandez CH, Seymour N, Brown SG. Helping pharmacists to reduce fall risk in long-term care: A clinical tool to facilitate the medication review process. Can Pharm J (Ott) 2014; 147:171-8. [PMID: 24847370 DOI: 10.1177/1715163514529706] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND One-third to one-half of adults older than 65 fall at least once per year. Fall prevention through medication management requires little effort and has consistently been shown to reduce risk of falls. The objective of this study was to further develop and perform preliminary pilot testing of an algorithm designed to assist consultant pharmacists in systematically identifying medications that might be modifiable, in order to reduce the risk of falls in older adults. We hypothesized that algorithm use would increase the number of fall-related medication change recommendations made to physicians. METHODS Four consultant pharmacists were trained to use the algorithm during their routine medication reviews over a 3-week period. An informal survey was administered at the end of the study period to assess the algorithm. RESULTS Overall, 51% of residents of long-term facilities had 1 or more recommendations for medication changes related to reducing fall risk (range 0-3 recommendations per resident), with an average 0.675 recommendations made per resident. There were more recommendations for men compared with women and for residents receiving more medications, but the number of recommendations did not correspond with age. All 4 pharmacists agreed that the algorithm was useful and worthwhile. DISCUSSION The absolute 20% increase in recommendations related to falls supports the study hypothesis. Time was cited as a barrier to using the algorithm, but this should decrease with continued use of this tool. CONCLUSION This preliminary study furthered the development of and confirmed the possible utility and acceptability of a fall risk-reducing algorithm that may be used in practice.
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Affiliation(s)
- Carlos H Rojas-Fernandez
- Schlegel-University of Waterloo Research Institute for Aging (Rojas-Fernandez, Brown), University of Waterloo, Waterloo, Ontario
| | - Nicole Seymour
- Schlegel-University of Waterloo Research Institute for Aging (Rojas-Fernandez, Brown), University of Waterloo, Waterloo, Ontario
| | - Susan G Brown
- Schlegel-University of Waterloo Research Institute for Aging (Rojas-Fernandez, Brown), University of Waterloo, Waterloo, Ontario
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Gardhouse A, Corriveau S, Tyagi NK, O'Shea T, Vegas DB. Reasons and outcomes for long-term care transfers to the hospital: a retrospective review. J Am Geriatr Soc 2014; 62:577-8. [PMID: 24628635 DOI: 10.1111/jgs.12705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Amanda Gardhouse
- Department of Medicine, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
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Emergency department visit rates and patterns in Canada's Vancouver coastal health region. Can J Aging 2014; 33:154-62. [PMID: 24690211 DOI: 10.1017/s0714980814000038] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
This study used administrative health data to describe emergency department (ED) visits by residents from assisted living and nursing home facilities in the Vancouver Coastal Health region, British Columbia. We compared ED visit rates, the distribution of visits per resident, and ED dispositions of the assisted living and nursing home populations over a 3-year period (2005-2008). There were 13,051 individuals in our study population. Visit rates (95% confidence interval) were 124.8 (118.1-131.7) and 64.1 (62.9-65.3) visits per 100 resident years in assisted living and nursing home facilities respectively. A smaller proportion of ED visits by assisted living residents resulted in hospital admission compared to nursing home residents (45% vs. 48%, p < .01). The ED visit rate among assisted living residents is significantly higher compared to that among nursing home residents. Future research is needed into the underlying causes for this finding.
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Stephens CE, Sackett N, Govindarajan P, Lee SJ. Emergency department visits and hospitalizations by tube-fed nursing home residents with varying degrees of cognitive impairment: a national study. BMC Geriatr 2014; 14:35. [PMID: 24650076 PMCID: PMC3994482 DOI: 10.1186/1471-2318-14-35] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 03/07/2014] [Indexed: 11/24/2022] Open
Abstract
Background Numerous studies indicate that the use of feeding tubes (FT) in persons with advanced cognitive impairment (CI) does not improve clinical outcomes or survival, and results in higher rates of hospitalization and emergency department (ED) visits. It is not clear, however, whether such risk varies by resident level of CI and whether these ED visits and hospitalizations are potentially preventable. The objective of this study was to determine the rates of ED visits, hospitalizations and potentially preventable ambulatory care sensitive (ACS) ED visits and ACS hospitalizations for long-stay NH residents with FTs at differing levels of CI. Methods We linked Centers for Medicare and Medicaid Services inpatient & outpatient administrative claims and beneficiary eligibility data with Minimum Data Set (MDS) resident assessment data for nursing home residents with feeding tubes in a 5% random sample of Medicare beneficiaries residing in US nursing facilities in 2006 (n = 3479). Severity of CI was measured using the Cognitive Performance Scale (CPS) and categorized into 4 groups: None/Mild (CPS = 0-1, MMSE = 22-25), Moderate (CPS = 2-3, MMSE = 15-19), Severe (CPS = 4-5, MMSE = 5-7) and Very Severe (CPS = 6, MMSE = 0-4). ED visits, hospitalizations, ACS ED visits and ACS hospitalizations were ascertained from inpatient and outpatient administrative claims. We estimated the risk ratio of each outcome by CI level using over-dispersed Poisson models accounting for potential confounding factors. Results Twenty-nine percent of our cohort was considered “comatose” and “without any discernible consciousness”, suggesting that over 20,000 NH residents in the US with feeding tubes are non-interactive. Approximately 25% of NH residents with FTs required an ED visit or hospitalization, with 44% of hospitalizations and 24% of ED visits being potentially preventable or for an ACS condition. Severity of CI had a significant effect on rates of ACS ED visits, but little effect on ACS hospitalizations. Conclusions ED visits and hospitalizations are common in cognitively impaired tube-fed nursing home residents and a substantial proportion of ED visits and hospitalizations are potentially preventable due to ACS conditions.
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Affiliation(s)
- Caroline E Stephens
- Department of Community Health Systems, University of California San Francisco, 2 Koret Way, #N531E, San Francisco, CA 94143-0608, USA.
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Ugajin M, Yamaki K, Hirasawa N, Kobayashi T, Yagi T. Prognostic value of severity indicators of nursing-home-acquired pneumonia versus community-acquired pneumonia in elderly patients. Clin Interv Aging 2014; 9:267-74. [PMID: 24611004 PMCID: PMC3929165 DOI: 10.2147/cia.s58682] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The credibility of prognostic indicators in nursing-home-acquired pneumonia (NHAP) is not clear. We previously reported a simple prognostic indicator in community-acquired pneumonia (CAP): blood urea nitrogen to serum albumin (B/A) ratio. This retrospective study investigated the prognostic value of severity indicators in NHAP versus CAP in elderly patients. METHODS Patients aged ≥65 years and hospitalized because of NHAP or CAP within the previous 3 years were enrolled. Demographics, coexisting illnesses, laboratory and microbiological findings, and severity scores (confusion, urea, respiratory rate, blood pressure, and age ≥65 [CURB-65] scale; age, dehydration, respiratory failure, orientation disturbance, and pressure [A-DROP] scale; and pneumonia severity index [PSI]) were retrieved from medical records. The primary outcome was mortality within 28 days of admission. RESULTS In total, 138 NHAP and 307 CAP patients were enrolled. Mortality was higher in NHAP (18.1%) than in CAP (4.6%) (P<0.001). Patients with NHAP were older and had lower functional status and a higher rate of do-not-resuscitate orders, heart failure, and cerebrovascular diseases. The NHAP patients more frequently had typical bacterial pathogens. Using the receiver-operating characteristics curve for predicting mortality, the area under the curve in NHAP was 0.70 for the A-DROP scale, 0.69 for the CURB-65 scale, 0.67 for the PSI class, and 0.65 for the B/A ratio. The area under the curve in CAP was 0.73 for the A-DROP scale, 0.76 for the CURB-65 scale, 0.81 for the PSI class, and 0.83 for the B/A ratio. CONCLUSION Patient mortality was greater in NHAP than in CAP. Patient characteristics, coexisting illnesses, and detected pathogens differed greatly between NHAP and CAP. The existing severity indicators had less prognostic value for NHAP than for CAP.
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Affiliation(s)
- Motoi Ugajin
- Department of Respiratory Medicine, Ichinomiya-Nishi Hospital, Ichinomiya City, Japan
| | - Kenichi Yamaki
- Department of Respiratory Medicine, Ichinomiya-Nishi Hospital, Ichinomiya City, Japan
| | - Natsuko Hirasawa
- Department of Respiratory Medicine, Ichinomiya-Nishi Hospital, Ichinomiya City, Japan
| | - Takanori Kobayashi
- Department of Respiratory Medicine, Ichinomiya-Nishi Hospital, Ichinomiya City, Japan
| | - Takeo Yagi
- Department of Respiratory Medicine, Ichinomiya-Nishi Hospital, Ichinomiya City, Japan
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133
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Gruneir A, Kwong JC, Campitelli MA, Newman A, Anderson GM, Rochon PA, Mor V. Influenza and seasonal patterns of hospital use by older adults in long-term care and community settings in Ontario, Canada. Am J Public Health 2014; 104:e141-7. [PMID: 24328631 PMCID: PMC3935705 DOI: 10.2105/ajph.2013.301519] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2013] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We compared seasonal influenza hospital use among older adults in long-term care (LTC) and community settings. METHODS We used provincial administrative data from Ontario to identify all emergency department (ED) visits and hospital admissions for pneumonia and influenza among adults older than 65 years between 2002 and 2008. We used sentinel laboratory reports to define influenza and summer seasons and estimated mean annual event rates and influenza-associated rates. RESULTS Mean annual pneumonia and influenza ED visit rates were higher in LTC than the community (rate ratio [RR] for influenza season = 3.9; 95% confidence interval [CI] = 3.8, 4.0; for summer = 4.9; 95% CI = 4.8, 5.1) but this was attenuated in influenza-associated rates (RR = 2.4; 95% CI = 2.1, 2.8). The proportion of pneumonia and influenza ED visits attributable to seasonal influenza was 17% (15%-20%) in LTC and 28% (27%-29%) in the community. Results for hospital admissions were comparable. CONCLUSIONS We found high rates of hospital use from LTC but evidence of lower impact of circulating influenza in the community. This differential impact of circulating influenza between the 2 environments may result from different influenza control policies.
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Affiliation(s)
- Andrea Gruneir
- Andrea Gruneir and Paula A. Rochon are with the Women's College Research Institute, Women's College Hospital, Toronto, ON. Jeff C. Kwong, Michael A. Campitelli, and Alice Newman are with the Institute for Clinical Evaluative Sciences, Toronto. Geoffrey M. Anderson is with the Institute of Health Policy, Management, and Evaluation, University of Toronto. Vincent Mor is with the Department of Health Services, Policy and Practice, Brown University, Providence, RI
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Reducing hospital admissions from nursing homes: a systematic review. BMC Health Serv Res 2014; 14:36. [PMID: 24456561 PMCID: PMC3906881 DOI: 10.1186/1472-6963-14-36] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 01/21/2014] [Indexed: 11/18/2022] Open
Abstract
Background The geriatric nursing home population is vulnerable to acute and deteriorating illness due to advanced age, multiple chronic illnesses and high levels of dependency. Although the detriments of hospitalising the frail and old are widely recognised, hospital admissions from nursing homes remain common. Little is known about what alternatives exist to prevent and reduce hospital admissions from this setting. The objective of this study, therefore, is to summarise the effects of interventions to reduce acute hospitalisations from nursing homes. Methods A systematic literature search was performed in Cochrane Library, PubMed, MEDLINE, EMBASE and ISI Web of Science in April 2013. Studies were eligible if they had a geriatric nursing home study population and were evaluating any type of intervention aiming at reducing acute hospital admission. Systematic reviews, randomised controlled trials, quasi randomised controlled trials, controlled before-after studies and interrupted time series were eligible study designs. The process of selecting studies, assessing them, extracting data and grading the total evidence was done by two researchers individually, with any disagreement solved by a third. We made use of meta-analyses from included systematic reviews, the remaining synthesis is descriptive. Based on the type of intervention, the included studies were categorised in: 1) Interventions to structure and standardise clinical practice, 2) Geriatric specialist services and 3) Influenza vaccination. Results Five systematic reviews and five primary studies were included, evaluating a total of 11 different interventions. Fewer hospital admissions were found in four out of seven evaluations of structuring and standardising clinical practice; in both evaluations of geriatric specialist services, and in influenza vaccination of residents. The quality of the evidence for all comparisons was of low or very low quality, using the GRADE approach. Conclusions Overall, eleven interventions to reduce hospital admissions from nursing homes were identified. None of them were tested more than once and the quality of the evidence was low for every comparison. Still, several interventions had effects on reducing hospital admissions and may represent important aspects of nursing home care to reduce hospital admissions.
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135
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Reid RC, Cummings GE, Cooper SL, Abel SL, Bissell LJ, Estabrooks CA, Rowe BH, Wagg A, Norton PG, Ertel M, Cummings GG. The Older Persons' Transitions in Care (OPTIC) study: pilot testing of the transition tracking tool. BMC Health Serv Res 2013; 13:515. [PMID: 24330805 PMCID: PMC3867622 DOI: 10.1186/1472-6963-13-515] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 12/09/2013] [Indexed: 11/13/2022] Open
Abstract
Background OPTIC is a mixed method Partnership for Health System Improvement (http://www.cihr-irsc.gc.ca/e/34348.html) study focused on improving care for nursing home (NH) residents who are transferred to and from emergency departments (EDs) via emergency medical services (EMS). In the pilot study we tested feasibility of concurrently collecting individual resident data during transitions across settings using the Transition Tracking Tool (T3). Methods The pilot study tracked 54 residents transferred from NHs to one of two EDs in two western Canadian provinces over a three month period. The T3 is an electronic data collection tool developed for this study to record data relevant to describing and determining success of transitions in care. It comprises 800+ data elements including resident characteristics, reasons and precipitating factors for transfer, advance directives, family involvement, healthcare services provided, disposition decisions, and dates/times and timing. Results Residents were elderly (mean age = 87.1 years) and the majority were female (61.8%). Feasibility of collecting data from multiple sources across two research sites was established. We identified resources and requirements to access and retrieve specific data elements in various settings to manage data collection processes and allocate research staff resources. We present preliminary data from NH, EMS, and ED settings. Conclusions While most research in this area has focused on a unidirectional process of patient progression from one care setting to another, this study established feasibility of collecting detailed data from beginning to end of a transition across multiple settings and in multiple directions.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Greta G Cummings
- Faculty of Nursing, University of Alberta, 5-110 Edmonton Clinical Health Academy, 11405 87 Avenue, Edmonton, Alberta T6G 1C9, Canada.
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136
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Vilpert S, Ruedin HJ, Trueb L, Monod-Zorzi S, Yersin B, Büla C. Emergency department use by oldest-old patients from 2005 to 2010 in a Swiss university hospital. BMC Health Serv Res 2013; 13:344. [PMID: 24011089 PMCID: PMC3846121 DOI: 10.1186/1472-6963-13-344] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 08/30/2013] [Indexed: 12/04/2022] Open
Abstract
Background Aging of the population in all western countries will challenge Emergency Departments (ED) as old patients visit these health services more frequently and present with special needs. The aim of this study is to describe the trend in ED visits by patients aged 85 years and over between 2005 and 2010, and to compare their service use to that of patients aged 65–84 years during this period and to investigate the evolution of these comparisons over time. Methods Data considered were all ED visits to the University of Lausanne Medical Center (CHUV), a tertiary Swiss teaching hospital, between 2005 and 2010 by patients aged 65 years and over (65+ years). ED visit characteristics were described according to age group and year. Incidence rates of ED visits and length of ED stay were calculated. Results Between 2005 and 2010, ED visits by patients aged 65 years and over increased by 26% overall, and by 46% among those aged 85 years and over (85+ years). Estimated ED visit incidence rate for persons aged 85+ years old was twice as high as for persons aged 65–84 years. Compared to patients aged 65–84 years, those aged 85+ years were more likely to be hospitalized and have a longer ED stay. This latter difference increased over time between 2005 and 2010. Conclusions Oldest-old patients are increasingly using ED services. These services need to adapt their care delivery processes to meet the needs of a rising number of these complex, multimorbid and vulnerable patients.
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Affiliation(s)
- Sarah Vilpert
- Swiss Health Observatory, Espace de l'Europe 10, CH-2010 Neuchâtel, Switzerland.
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Briggs R, Coughlan T, Collins R, O'Neill D, Kennelly SP. Nursing home residents attending the emergency department: clinical characteristics and outcomes. QJM 2013; 106:803-8. [PMID: 23818688 DOI: 10.1093/qjmed/hct136] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Nursing home (NH) residents represent the frailest group of older people, and providing gerontologically attuned care that addresses these frailties is often a challenge within the emergency department (ED). This study sought to prospectively profile acutely unwell NH residents in order to clarify some of the challenges of providing emergency care to this group. Over an 18-week period, we prospectively reviewed all NH residents presenting to the ED of an urban university teaching hospital. Relevant data were retrieved by direct physician review (as part of a comprehensive geriatric assessment in the ED), collateral history from NH staff and primary carers, and review of electronic records. There were 155 ED visits by 116 NH residents. Their mean age was 80.3 (±9.6) years. High pre-morbid levels of dependency were reflected by a mean Barthel Index of 34.1 (±20) and almost two-thirds had a pre-existing diagnosis of dementia. One-third of visits were during 'normal' working hours. Patients were reviewed by their regular NH doctor pre-transfer for 36% of visits. Using accepted international criteria, over half of the visits were deemed 'potentially preventable'. Unwell NH residents have complex medical needs. The decision to refer these patients to the ED is often made by 'out of hours' general practitioners and their initial care in the ED is directed by physicians with limited experience in geriatric medicine. Most referrals to the ED are potentially preventable but this would require enhancements to the package of care available in NHs.
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Affiliation(s)
- R Briggs
- Age-Related Health Care, Tallaght Hospital, Dublin, Ireland.
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138
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Vigod SN, Taylor VH, Fung K, Kurdyak PA. Within-hospital readmission: an indicator of readmission after discharge from psychiatric hospitalization. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2013; 58:476-81. [PMID: 23972109 DOI: 10.1177/070674371305800806] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Readmission after psychiatric hospitalization is widely used as a quality of care indicator by government funding agencies, policy-makers, and hospitals deciding on clinical priorities. Readmission rates are calculated accurately to allow these varied groups to correctly translate the knowledge into appropriate, tangible outcomes. We aimed to assess how well hospital readmission rates, calculated using only readmissions to the discharging institution, can approximate actual readmission rates. METHOD We used administrative data sources to identify patients with a mental health discharge in the province of Ontario (2008-2011). We identified mental health readmissions within 30 and 90 days of discharge occurring to the hospital from which the patient was discharged (within-hospital readmissions), and compared readmission rates using only within-hospital admissions with actual readmission rates. RESULTS The percentage of readmissions occurring to the discharging institution ranged from 39% to 89% (median 73%) and from 37% to 86% (median 70%) for 30- and 90-day readmissions, respectively. Using only within-hospital readmissions to rank hospitals by their readmission rates, only 56% of hospitals for 30-day readmissions and 50% for 90-day readmissions were ranked in the same quartile as when actual readmission rates were used. CONCLUSIONS These findings highlight the importance of measuring psychiatric readmissions at the system level, particularly for hospitals with lower discharge volumes. As well, the high likelihood that multiple hospitals are involved in the hospital-based care of people who require readmission requires consideration at clinical and policy levels.
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Affiliation(s)
- Simone N Vigod
- Staff Psychiatrist, Women's College Hospital, Toronto, Ontario, Canada
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139
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Gray LC, Peel NM, Costa AP, Burkett E, Dey AB, Jonsson PV, Lakhan P, Ljunggren G, Sjostrand F, Swoboda W, Wellens NIH, Hirdes J. Profiles of older patients in the emergency department: findings from the interRAI Multinational Emergency Department Study. Ann Emerg Med 2013; 62:467-474. [PMID: 23809229 DOI: 10.1016/j.annemergmed.2013.05.008] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Revised: 05/07/2013] [Accepted: 05/14/2013] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE We examine functional profiles and presence of geriatric syndromes among older patients attending 13 emergency departments (EDs) in 7 nations. METHODS This was a prospective observational study of a convenience sample of patients, aged 75 years and older, recruited sequentially and mainly during normal working hours. Clinical observations were drawn from the interRAI Emergency Department Screener, with assessments performed by trained nurses. RESULTS A sample of 2,282 patients (range 98 to 549 patients across nations) was recruited. Before becoming unwell, 46% were dependent on others in one or more aspects of personal activities of daily living. This proportion increased to 67% at presentation to the ED. In the ED, 26% exhibited evidence of cognitive impairment, and 49% could not walk without supervision. Recent falls were common (37%). Overall, at least 48% had a geriatric syndrome before becoming unwell, increasing to 78% at presentation to the ED. This pattern was consistent across nations. CONCLUSION Functional problems and geriatric syndromes affect the majority of older patients attending the ED, which may have important implications for clinical protocols and design of EDs.
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Affiliation(s)
- Leonard C Gray
- Centre for Research in Geriatric Medicine, the University of Queensland, Brisbane, Queensland, Australia
| | - Nancye M Peel
- Centre for Research in Geriatric Medicine, the University of Queensland, Brisbane, Queensland, Australia.
| | - Andrew P Costa
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada; Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Ellen Burkett
- Princess Alexandra Hospital Emergency Department, Brisbane, Queensland, Australia
| | - Aparajit B Dey
- Department of Geriatric Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Palmi V Jonsson
- Department of Geriatrics, Landspitali University Hospital and Faculty of Medicine, University of Iceland, Reykjavic, Iceland
| | - Prabha Lakhan
- Centre for Research in Geriatric Medicine, the University of Queensland, Brisbane, Queensland, Australia
| | - Gunnar Ljunggren
- Public Healthcare Services Committee Administration, Stockholm County Council, Stockholm, Sweden; Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Stockholm, Sweden; Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Sjostrand
- Karolinska Institutet, Stockholm, Sweden; Department of Clinical Science and Education, Södersjukhuset and Section of Emergency Medicine, Södersjukhuset AB, Stockholm, Sweden
| | - Walter Swoboda
- Institute for Biomedicine of Aging, University of Erlangen Nuremberg, Klinikum Nuremberg, Germany
| | - Nathalie I H Wellens
- Department of Public Health, Centre for Health Services and Nursing Research, KU Leuven, Belgium
| | - John Hirdes
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
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Gender differences in home care clients and admission to long-term care in Ontario, Canada: a population-based retrospective cohort study. BMC Geriatr 2013; 13:48. [PMID: 23678949 PMCID: PMC3679828 DOI: 10.1186/1471-2318-13-48] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 04/23/2013] [Indexed: 11/27/2022] Open
Abstract
Background Home care is integral to enabling older adults to delay or avoid long-term care (LTC) admission. To date, there is little population-based data about gender differences in home care users and their subsequent outcomes. Our objectives were to quantify differences between women and men who used home care in Ontario, Canada and to determine if there were subsequent differences in LTC admission. Methods This is a population-based retrospective cohort study. We identified all adults aged 76+ years living in Ontario and receiving home care on April 1, 2007 (baseline). Using the Resident Assessment Instrument – Home Care (RAI-HC) linked to other databases, we characterized the cohort by living condition, health and functioning, and identified all acute care and LTC use in the year following baseline. Results The cohort consisted of 51,201 women and 20,102 men. Women were older, more likely to live alone, and more likely to rely on a child or child-in-law for caregiver support. Men most frequently identified a spouse as caregiver and their caregivers reported distress twice as often as women’s caregivers. Men had higher rates of most chronic conditions and were more likely to experience impairment. Men were more likely to be admitted to hospital, to have longer stays in hospital, and to be admitted to LTC. Conclusions Understanding who uses home care and why is critical to ensuring that these programs effectively reduce LTC use. We found that women outnumbered men but that men presented with higher levels of need. This detailed gender analysis highlights how needs differ between older women, men, and their respective caregivers.
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141
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Vossius CE, Ydstebø AE, Testad I, Lurås H. Referrals from nursing home to hospital: reasons, appropriateness and costs. Scand J Public Health 2013; 41:366-73. [PMID: 23585367 DOI: 10.1177/1403494813484398] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Nursing home residents represent a frail and multimorbid group of patients. The rationality of the hospitalisation of nursing home patients has therefore been questioned. OBJECTIVE To investigate hospital referrals of nursing home patients in the municipality of Stavanger, Norway and identify the number of inappropriate referrals and costs. METHODS The number of referrals was retrospectively identified by the emergency dispatch centre in the 18 municipalities of South Rogaland in 2011. For the municipality of Stavanger, referring instance, reason for referral, purpose of referral, the existence of an advance care plan, and appropriateness were assessed. Total costs and costs for inappropriate referrals were estimated. RESULTS In Stavanger there were 0.38 hospital referrals per nursing home bed per year as compared to 0.60 in the surrounding municipalities. Of 359 referrals, 78.6% resulted in an in-hospital stay, in-hospital mortality rate was 7.8%, and 7% were assessed as being inappropriate. The costs per referral were estimated to be €6198. CONCLUSION Stavanger had a lower referral rate than the surrounding municipalities. The results also show that the in-hospital mortality rate and the share of inappropriate referrals were low compared to other studies in the field. Further research is needed in order to evaluate which interventions are effective in improving medical care at nursing homes and thus reduce referral rates.
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142
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Graverholt B, Riise T, Jamtvedt G, Husebo BS, Nortvedt MW. Acute hospital admissions from nursing homes: predictors of unwarranted variation? Scand J Public Health 2013; 41:359-65. [PMID: 23554388 DOI: 10.1177/1403494813482200] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND The geriatric nursing home population is frail and vulnerable to sudden changes in their health condition. Very often, these incidents lead to hospitalization, in which many cases represent an unfavourable discontinuity of care. Analysis of variation in hospitalization rates among nursing homes where similar rates are expected may identify factors associated with unwarranted variation. OBJECTIVES To 1) quantify the overall and diagnosis specific variation in hospitalization rates among nursing homes in a well-defined area over a two-year period, and 2) estimate the associations between the hospitalization rates and characteristics of the nursing homes. METHOD The acute hospital admissions from 38 nursing homes to two hospitals were identified through ambulance records and linked to hospital patient journals (n = 2451). Overall variation in hospitalization rates for 2 consecutive years was tested using chi-square and diagnosis-specific variation using Systematic Component of Variation. Associations between rates and nursing home characteristics were tested using multiple regression and ANOVA. RESULTS Annual hospitalization rates varied significantly between 0.16 and 1.49 per nursing home. Diagnoses at discharge varied significantly between the nursing homes. The annual hospitalization rates correlated significantly with size (r = -0.38) and percentage short-term beds (r = 0.41), explaining 32% of the variation observed (R (2) = 0.319). No association was found for ownership status (r = 0.05) or location of the nursing home (p = 0.52). CONCLUSION A more than nine-fold variation in annual hospitalization rates among the nursing homes in one municipality suggests the presence of unwarranted variation. This finding demands for political action to improve the premises for a more uniform practice in nursing homes.
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Affiliation(s)
- Birgitte Graverholt
- Centre for Evidence-Based Practice, Bergen University College, Bergen, Norway.
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143
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Yu WY, Hwang HF, Hu MH, Chen CY, Lin MR. Effects of fall injury type and discharge placement on mortality, hospitalization, falls, and ADL changes among older people in Taiwan. ACCIDENT; ANALYSIS AND PREVENTION 2013; 50:887-894. [PMID: 22878142 DOI: 10.1016/j.aap.2012.07.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 06/28/2012] [Accepted: 07/16/2012] [Indexed: 06/01/2023]
Abstract
A longitudinal study was conducted to investigate the effects of injury type and discharge placement on mortality, falls, hospital admissions, and changes in activities of daily living (ADLs) over a 12-month period among older fallers. Of 762 community-dwelling people aged 65 years or older who visited an emergency department (ED) of a general hospital in Taiwan due to a fall, 273 sustained a hip fracture, 157 had a vertebral fracture, 47 had a distal forearm fracture, 102 had a traumatic brain injury, and 183 had soft-tissue injuries. Results showed that, compared to patients with a soft-tissue injury, those with TBI had significantly higher risks of dying (rate ratio (RR)=3.59) and hospital admissions (RR=3.23) and better improvement in ADLs (1.93 points) at 6 months post-injury, and those who sustained a hip fracture (4.26 and 4.41 points), a vertebral fracture (3.81 and 3.83 points), or a distal-forearm fracture (2.80 and 2.80 points) had significantly better improvement in ADLs at 6 and 12 months post-injury. Patients discharged to a nursing home had a significantly increased risk of death (RR=2.08) and hospital admission (RR=2.05) than those returning to their usual residence during the first year post-injury. No significant differences in the occurrence of falls during the first post-injury year were found among patients with different injury types or between those with different discharge placements. In conclusion, among the five major fall injury types in older people, TBIs result in the highest risk of death and hospital admissions, while hip and vertebral fractures exhibited the largest improvement during the first year after injury. Additionally, nursing home care may be associated with increased risks of death and hospital admissions than home care. In addition to primary prevention of falls, further research to investigate mechanisms leading to TBIs during a fall is needed to facilitate effective secondary fall-prevention programs for older people.
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Affiliation(s)
- Wen-Yu Yu
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan, ROC
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Cummings GG, Reid RC, Estabrooks CA, Norton PG, Cummings GE, Rowe BH, Abel SL, Bissell L, Bottorff JL, Robinson CA, Wagg A, Lee JS, Lynch SL, Masaoud E. Older Persons' Transitions in Care (OPTIC): a study protocol. BMC Geriatr 2012; 12:75. [PMID: 23241360 PMCID: PMC3570479 DOI: 10.1186/1471-2318-12-75] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Accepted: 11/30/2012] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Changes in health status, triggered by events such as infections, falls, and geriatric syndromes, are common among nursing home (NH) residents and necessitate transitions between NHs and Emergency Departments (EDs). During transitions, residents frequently experience care that is delayed, unnecessary, not evidence-based, potentially unsafe, and fragmented. Furthermore, a high proportion of residents and their family caregivers report substantial unmet needs during transitions. This study is part of a program of research whose overall aim is to improve quality of care for frail older adults who reside in NHs. The purpose of this study is to identify successful transitions from multiple perspectives and to identify organizational and individual factors related to transition success, in order to inform improvements in care for frail elderly NH residents during transitions to and from acute care. Specific objectives are to: 1. define successful and unsuccessful elements of transitions from multiple perspectives; 2. develop and test a practical tool to assess transition success; 3. assess transition processes in a discrete set of transfers in two study sites over a one year period; 4. assess the influence of organizational factors in key practice locations, e.g., NHs, emergency medical services (EMS), and EDs, on transition success; and 5. identify opportunities for evidence-informed management and quality improvement decisions related to the management of NH - ED transitions. METHODS/DESIGN This is a mixed-methods observational study incorporating an integrated knowledge translation (IKT) approach. It uses data from multiple levels (facility, care unit, individual) and sources (healthcare providers, residents, health records, and administrative databases). DISCUSSION Key to study success is operationalizing the IKT approach by using a partnership model in which the OPTIC governance structure provides for team decision-makers and researchers to participate equally in developing study goals, design, data collection, analysis and implications of findings. As preliminary and ongoing study findings are developed, their implications for practice and policy in study settings will be discussed by the research team and shared with study site administrators and staff. The study is designed to investigate the complexities of transitions and to enhance the potential for successful and sustained improvement of these transitions.
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Affiliation(s)
- Greta G Cummings
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
- Faculty of Nursing, Edmonton Clinic Health Academy, University of Alberta, 11405-87 Ave, Edmonton, AB, T6G 0C1, Canada
| | - R Colin Reid
- School of Health and Exercise Sciences, University of British Columbia’s Okanagan campus, Kelowna, BC, Canada
| | | | - Peter G Norton
- Department of Family Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Garnet E Cummings
- Department of Emergency Medicine, Faculty of Medicine and Dentistry and School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, Faculty of Medicine and Dentistry and School of Public Health, University of Alberta, Edmonton, AB, Canada
| | | | - Laura Bissell
- School of Health and Exercise Sciences, University of British Columbia’s Okanagan campus, Kelowna, BC, Canada
| | - Joan L Bottorff
- School of Nursing, University of British Columbia’s Okanagan campus, Kelowna, BC, Canada
| | - Carole A Robinson
- School of Nursing, University of British Columbia’s Okanagan campus, Kelowna, BC, Canada
| | - Adrian Wagg
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Jacques S Lee
- Department of Emergency Services, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - Susan L Lynch
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
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145
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Is the emergency department an appropriate substitute for primary care for persons with traumatic spinal cord injury? Spinal Cord 2012; 51:202-8. [DOI: 10.1038/sc.2012.123] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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146
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Serious events in older Ontario residents receiving bowel preparations for outpatient colonoscopy with various comorbidity profiles: a descriptive, population-based study. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2012; 26:436-40. [PMID: 22803018 DOI: 10.1155/2012/238387] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Polyethylene glycol-based bowel preparations (PEGBPs) and sodium picosulfate (NaPS) are commonly used for bowel cleansing before colonoscopy. Little is known about adverse events associated with these preparations, particularly in older patients or patients with medical comorbidities. OBJECTIVE To characterize the incidence of serious events following outpatient colonoscopy in patients using PEGBPs or NaPS. METHODS The present population-based retrospective cohort study examined data from Ontario health care databases between April 1, 2005 and December 31, 2007, including patients >=66 years of age who received either PEGBP or NaPS for an outpatient colonoscopy. Patients with cardiac or renal disease, long-term care residents or patients receiving concurrent diuretic therapy were identified as high risk for adverse events. The primary outcome was a serious event (SE) defined as a composite of nonelective hospitalization, emergency department visit or death within seven days of the colonoscopy. RESULTS Of the 50,660 outpatients >=66 years of age who underwent a colonoscopy, SEs were observed in 675 (2.4%) and 543 (2.4%) patients in the PEGBP and NaPS groups, respectively. Among high-risk patients (n=30,168), SEs occurred in 481 (2.8%) and 367 (2.8%) of patients receiving PEGBP and NaPS, respectively. CONCLUSIONS The SE rate within seven days of outpatient colonoscopy was 24 per 1000 procedures, and among high-risk patients was 28 per 1000 procedures. The rates were similar for PEGBP and NaPS. Clinicians should be aware of the risks associated with colonoscopy in older patients with comorbidities.
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147
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Aged Residential Care Health Utilisation Study (ARCHUS): a randomised controlled trial to reduce acute hospitalisations from residential aged care. BMC Geriatr 2012; 12:54. [PMID: 22974314 PMCID: PMC3489701 DOI: 10.1186/1471-2318-12-54] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 09/05/2012] [Indexed: 11/17/2022] Open
Abstract
Background For residents of long term care, hospitalisations can cause distress and disruption, and often result in further medical complications. Multi-disciplinary team interventions have been shown to improve the health of Residential Aged Care (RAC) residents, decreasing the need for acute hospitalisation, yet there are few randomised controlled trials of these complex interventions. This paper describes a randomised controlled trial of a structured multi-disciplinary team and gerontology nurse specialist (GNS) intervention aiming to reduce residents’ avoidable hospitalisations. Methods/Design This Aged Residential Care Healthcare Utilisation Study (ARCHUS) is a cluster- randomised controlled trial (n = 1700 residents) of a complex multi-disciplinary team intervention in long-term care facilities. Eligible facilities certified for residential care were selected from those identified as at moderate or higher risk of resident potentially avoidable hospitalisations by statistical modelling. The facilities were all located in the Auckland region, New Zealand and were stratified by District Health Board (DHB). Intervention The intervention provided a structured GNS intervention including a baseline facility needs assessment, quality indicator benchmarking, a staff education programme and care coordination. Alongside this, three multi-disciplinary team (MDT) meetings were held involving a geriatrician, facility GP, pharmacist, GNS and senior nursing staff. Outcomes Hospitalisations are recorded from routinely-collected acute admissions during the 9-month intervention period followed by a 5-month follow-up period. ICD diagnosis codes are used in a pre-specified definition of potentially reducible admissions. Discussion This randomised-controlled trial will evaluate a complex intervention to increase early identification and intervention to improve the health of residents of long term care. The results of this trial are expected in early 2013. Trial registration Australian New Zealand Clinical Trials Registry: ACTRN 12611000187943
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148
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Yanamadala M, Heflin MT, White HK, Buhr GT. Ensuring vitamin D supplementation in nursing home patients--a quality improvement project. J Nutr Gerontol Geriatr 2012; 31:158-71. [PMID: 22607104 DOI: 10.1080/21551197.2012.678240] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Randomized controlled trials have shown that adequate vitamin D supplementation in nursing home (NH) residents reduces the rates of falls and fractures. In our NH, review of medication administration records of all patients (n = 101) revealed that only 34.6% of the patients were currently prescribed adequate doses of vitamin D, revealing a need for intervention. We designed a Quality Improvement (QI) project with the objective of improving the vitamin D prescription rate in our NH. We used the Plan-Do-Study-Act (PDSA) approach to implement this QI project. Patients not currently prescribed an adequate dose of vitamin D were identified and started on a daily dose of 800 IU of vitamin D. Additionally, patients who were experiencing falls while on an adequate dose of vitamin D for 3 months were examined for the possibility of vitamin D deficiency and were started on 50,000 IU of vitamin D per week for 12 weeks if they were found to be vitamin D-deficient based on blood levels of 25-hydroxy-vitamin D below 30 ng/mL. We found that with several PDSA cycles over a period of 5 months, the prescription rate for vitamin D was increased to 86%, surpassing our initial goal of 80%. In conclusion, we found that a multidisciplinary QI program utilizing multiple PDSA cycles was effective in reaching target prescription rates for vitamin D supplementation in a population of NH patients.
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149
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Stephenson A, Seitz DP, Fischer HD, Gruneir A, Bell CM, Gershon AS, Fu L, Anderson GM, Austin PC, Rochon PA, Gill SS. Cholinesterase inhibitors and adverse pulmonary events in older people with chronic obstructive pulmonary disease and concomitant dementia: a population-based, cohort study. Drugs Aging 2012; 29:213-223. [PMID: 22332932 DOI: 10.2165/11599480-000000000-00000] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Cholinesterase inhibitors (ChEIs) are a mainstay treatment for individuals with dementia. ChEIs may worsen airflow obstruction because of their pro-cholinergic properties. OBJECTIVE The objective of this study was to evaluate the risk of serious pulmonary complications in the elderly with concomitant chronic obstructive pulmonary disease (COPD) and dementia who were receiving ChEIs. METHODS This was a population-based, cohort study conducted between 2003 and 2010 in residents of Ontario, Canada. Subjects were over the age of 66 years and had concomitant dementia and COPD, identified using linked administrative databases. Exposure to ChEIs was determined using a drug benefits database. The primary outcome was an emergency room (ER) visit or hospitalization for COPD. The risk difference at 60 days and the relative risk (RR) for study outcomes were estimated in the propensity score-matched sample. RESULTS Of 266,840 individuals with COPD, 45,503 had a concomitant diagnosis of dementia. A total of 7166 unexposed subjects were matched to subjects newly exposed to ChEIs. New users of ChEIs were not at significantly higher risk of ER visits or hospitalizations for COPD (RR 0.90; 95% CI 0.76, 1.07) or COPD exacerbations (RR 1.02; 95% CI 0.91, 1.15). Furthermore, ER visits for any respiratory diagnoses were not increased among new users of ChEIs (RR 1.02; 95% CI 0.87, 1.19) when compared with non-users. Sub-group analyses were consistent with the main analysis. CONCLUSIONS In a large cohort of elderly individuals with COPD and dementia, new users of ChEIs had a similar risk for adverse pulmonary outcomes as those who were not receiving ChEIs.
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Affiliation(s)
- Anne Stephenson
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada. .,St Michael's Hospital, 30 Bond Street, 6th Floor, Toronto, Ontario, Canada, M5B 1W8.
| | - Dallas P Seitz
- Department of Psychiatry, Queen's University, Kingston, ON, Canada
| | - Hadas D Fischer
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Andrea Gruneir
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Chaim M Bell
- St Michael's Hospital, 30 Bond Street, 6th Floor, Toronto, Ontario, Canada, M5B 1W8.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Andrea S Gershon
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Longdi Fu
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Geoff M Anderson
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Peter C Austin
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Paula A Rochon
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sudeep S Gill
- St Mary's of the Lake Hospital, Queen's University, Kingston, ON, Canada
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150
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Campbell RJ, Gill SS, Bronskill SE, Paterson JM, Whitehead M, Bell CM. Adverse events with intravitreal injection of vascular endothelial growth factor inhibitors: nested case-control study. BMJ 2012; 345:e4203. [PMID: 22763393 PMCID: PMC3389519 DOI: 10.1136/bmj.e4203] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2012] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To assess the risk of systemic adverse events associated with intravitreal injections of vascular endothelial growth factor inhibiting drugs. DESIGN Population based nested case-control study. SETTING Ontario, Canada. PARTICIPANTS 91,378 older adults with a history of physician diagnosed retinal disease identified between 1 April 2006 and 31 March 2011. Cases were 1477 patients admitted to hospital for ischaemic stroke, 2229 admitted for an acute myocardial infarction, 1059 admitted or assessed in an emergency department for venous thromboembolism, and 2623 admitted for congestive heart failure. Event-free controls (at a ratio of 5:1) were matched to cases on the basis of year of birth, sex, history of the outcome in the previous 5 years, and diabetes. MAIN EXPOSURE MEASURE Exposure to vascular endothelial growth factor inhibiting drugs identified within 180 days before the index date. RESULTS After adjustment for potential confounders, participants who had ischaemic stroke, acute myocardial infarction, congestive heart failure, or venous thromboembolism were not more likely than control participants to have been exposed to either bevacizumab (adjusted odds ratios of 0.95 (95% confidence interval 0.68 to 1.34) for ischaemic stroke, 1.04 (0.77 to 1.39) for acute myocardial infarction, 0.81 (0.49 to 1.34) for venous thromboembolism, and 1.21 (0.91 to 1.62) for congestive heart failure) or ranibizumab (adjusted odds ratios 0.87 (0.68 to 1.10) for ischaemic stroke, 0.90 (0.72 to 1.11) for acute myocardial infarction, 0.88 (0.67 to 1.16) for venous thromboembolism, and 0.87 (0.70 to 1.07) for congestive heart failure). Similarly, a secondary analysis of exclusive users of bevacizumab or ranibizumab showed no differences in risk between the two drugs (adjusted odds ratios for bevacizumab relative to ranibizumab of 1.03 (0.67 to 1.60) for ischaemic stroke, 1.23 (0.85 to 1.77) for acute myocardial infarction, 0.92 (0.51 to 1.69) for venous thromboembolism, and 1.35 (0.93 to 1.95) for congestive heart failure). These findings were consistent for all but one outcome in subgroup analyses. CONCLUSIONS Intravitreal injections of bevacizumab and ranibizumab were not associated with significant risks of ischaemic stroke, acute myocardial infarction, congestive heart failure, or venous thromboembolism.
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Affiliation(s)
- Robert J Campbell
- Department of Ophthalmology, Queen's University, Kingston, ON, Canada
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