The Charlson Comorbidity and Barthel Index predict length of hospital stay, mortality, cardiovascular mortality and rehospitalization in unselected older patients admitted to the emergency department

The association of demographics, frailty and multiple health conditions with outcomes from acute medical admissions to hospitals in England: exploratory analysis of an administrative dataset

Emergency and acute hospital services in England are under increasing pressure. The aim of this study was to investigate the association between key case-mix indicators and outcomes for adults admitted to hospital with an acute medical condition in England. All patients aged ≥16 years admitted to hospital in England as an acute unselected medical admission and who survived to discharge during the financial year 2021-2022 were included. Length of hospital stay was the primary outcome of interest. Data were available for 1,586,168 unique patients. A case-mix index was developed with a score that ranged from 0 to 12. Frailty was the most important variable in the index, followed by multiple health conditions and patient age. The mean case-mix score across hospital trusts in England ranged from 5.3 to 7.8. The case-mix index will support initiatives to better understand factors contributing to outcomes from acute medical admissions to hospital.

Predictive Strategies to Reduce the Risk of Rehospitalization with a Focus on Frail Older Adults: A Narrative Review

Frailty is a geriatric syndrome that has physical, cognitive, psychological, social, and environmental components and is characterized by a decrease in physiological reserves. Frailty is associated with several adverse health outcomes such as an increase in rehospitalization rates, falls, delirium, incontinence, dependency on daily living activities, morbidity, and mortality. Older adults may become frailer with each hospitalization; thus, it is beneficial to develop and implement preventive strategies. The present review aims to highlight the epidemiological importance of frailty in rehospitalization and to compile predictive strategies and related interventions to prevent hospitalizations. Firstly, it is important to identify pre-frail and frail older adults using an instrument with high validity and reliability, which can be a practically applicable screening tool. Comprehensive geriatric assessment-based care is an important strategy known to reduce morbidity, mortality, and rehospitalization in older adults and aims to meet the needs of frail patients with a multidisciplinary approach and intervention that includes physiological, psychological, and social domains. Moreover, effective multimorbidity management, physical activity, nutritional support, preventing cognitive frailty, avoiding polypharmacy and anticholinergic drug burden, immunization, social support, and reducing the caregiver burden are other recommended predictive strategies to prevent post-discharge rehospitalization in frail older adults.

Outcomes of redo for failed colorectal or coloanal anastomoses: a systematic review and meta-analysis

PURPOSE

This study aimed to review the outcomes of redo procedures for failed colorectal or coloanal anastomoses.

METHODS

A systematic review was performed using the PubMed, Embase, Cochrane, and LILACS databases. The inclusion criteria were adult patients undergoing colectomy with primary colorectal or coloanal anastomosis and studies that assessed the postoperative results. The protocol is registered in PROSPERO (No. CRD42021267715).

RESULTS

Eleven articles met the eligibility criteria and were selected. The studied population size ranged from 7 to 78 patients. The overall mortality rate was 0% (95% confidence interval [CI], 0%-0.01%). The postoperative complication rate was 40% (95% CI, 40%-50%). The length of hospital stay was 13.68 days (95% CI, 11.3-16.06 days). After redo surgery, 82% of the patients were free of stoma (95% CI, 75%-90%), and 24% of patients (95% CI, 0%-39%) had fecal incontinence. Neoadjuvant chemoradiotherapy (P=0.002) was associated with a lower probability of being free of stoma in meta-regression.

CONCLUSION

Redo colorectal and coloanal anastomoses are strategies to restore colonic continuity. The decision to perform a redo operation should be based on a proper evaluation of the morbidity and mortality risks, the probability of remaining free of stoma, the quality of life, and a functional assessment.

Hospital length of stay prediction tools for all hospital admissions and general medicine populations: systematic review and meta-analysis

Background

Unwarranted extended length of stay (LOS) increases the risk of hospital-acquired complications, morbidity, and all-cause mortality and needs to be recognized and addressed proactively.

Objective

This systematic review aimed to identify validated prediction variables and methods used in tools that predict the risk of prolonged LOS in all hospital admissions and specifically General Medicine (GenMed) admissions.

Method

LOS prediction tools published since 2010 were identified in five major research databases. The main outcomes were model performance metrics, prediction variables, and level of validation. Meta-analysis was completed for validated models. The risk of bias was assessed using the PROBAST checklist.

Results

Overall, 25 all admission studies and 14 GenMed studies were identified. Statistical and machine learning methods were used almost equally in both groups. Calibration metrics were reported infrequently, with only 2 of 39 studies performing external validation. Meta-analysis of all admissions validation studies revealed a 95% prediction interval for theta of 0.596 to 0.798 for the area under the curve. Important predictor categories were co-morbidity diagnoses and illness severity risk scores, demographics, and admission characteristics. Overall study quality was deemed low due to poor data processing and analysis reporting.

Conclusion

To the best of our knowledge, this is the first systematic review assessing the quality of risk prediction models for hospital LOS in GenMed and all admissions groups. Notably, both machine learning and statistical modeling demonstrated good predictive performance, but models were infrequently externally validated and had poor overall study quality. Moving forward, a focus on quality methods by the adoption of existing guidelines and external validation is needed before clinical application.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42021272198.

A Higher Postoperative Barthel Index at Discharge is Associated with a Lower One-Year Mortality After Hip Fracture Surgery for Geriatric Patients: A Retrospective Case‒Control Study

Purpose

To evaluate the relationship between the postoperative Barthel index assessing activities of daily living at discharge and the one-year mortality after hip fracture surgery.

Methods

Patients with hip fracture admitted to Peking University First Hospital from January 2015 to January 2020 were enrolled retrospectively according to the inclusion and exclusion criteria. The Barthel index and other related confounding variables were collected. Logistic regression and Kaplan‒Meier survival curves were constructed to explore the relationship between the postoperative Barthel index at discharge and the one-year mortality of geriatric patients after hip fracture surgery.

Results

A total of 444 patients with a mean age of 81.61±6.14 years were included. A significant difference was not observed in the preoperative Barthel index at admission between the deceased group and the surviving group (38.90±15.83 vs 36.96±10.74, p=0.446). However, the difference in the postoperative Barthel index at discharge between these two groups was statistically significant (43.08±14.40 vs 53.18±13.43, P<0.001). The multivariable logistic regression analysis revealed that the postoperative Barthel index at discharge was an independent risk factor for one-year mortality after adjustment for confounding variables (adjusted OR 0.73, 95% CI 0.55-0.98, p˂0.05). The Kaplan‒Meier survival curve showed that patients who had a high Barthel index (≥50) at discharge had a significantly lower mortality in the long term than patients with a low Barthel index (<50) at discharge (P< 0.001).

Conclusion

The postoperative Barthel index at discharge was independently associated with the one-year mortality of geriatric patients after hip fracture surgery. A higher postoperative Barthel index at discharge indicated a lower mortality after hip fracture surgery. The Barthel index at discharge has the potential to provide essential prognostic information for early risk stratification and directing future care.

Clinical Acuity in the Emergency Department and Injury Severity Determine Hospital Admission of Older Patients with Low Energy Falls: Outcomes from a Prospective Feasibility Study

BACKGROUND

Low energy falls (LEF) in older adults constitute a relevant cause for emergency department (ED) visits, hospital admission and in-hospital mortality. Patient-reported outcome measures containing information about patients' medical, mental and social health problems might support disposition and therapy decisions. We investigated the value of a tablet-based (self-)assessment in predicting hospital admission and in-hospital mortality.

METHODS

Patients 65 years or older, consecutively presenting with LEF to our level I trauma center ED (from November 2020 to March 2021), were eligible for inclusion in this prospective observational study. The primary endpoint was hospital admission; secondary endpoints were in-hospital mortality and the use of the tablet for self-reported assessment. Multivariate logistic regression models were calculated to measure the association between clinical findings and endpoints.

RESULTS

Of 618 eligible patients, 201 patients were included. The median age was 82 years (62.7% women). The hospital admission rate was 45.3% (110/201), with an in-hospital mortality rate of 3.6% (4/110). Polypharmacy (odds ratio (OR): 8.48; 95% confidence interval (95%CI) 1.21-59.37, p = 0.03), lower emergency severity index (ESI) scores (OR: 0.33; 95%CI 0.17-0.64, p = 0.001) and increasing injury severity score (ISS) (OR: 1.54; 95%CI 1.32-1.79, p < 0.001) were associated with hospital admission. The Charlson comorbidity index (CCI) was significantly associated with in-hospital mortality (OR: 2.60; 95%CI: 1.17-5.81, p = 0.03). Increasing age (OR: 0.94; 95%CI: 0.89-0.99, p = 0.03) and frailty (OR: 0.71; 95%CI: 0.51-0.99, p = 0.04) were associated with the incapability of tablet use.

CONCLUSIONS

The severity of fall-related injuries and the clinical acuity are easily accessible, relevant predictors for hospital admission. Tablet-based (self-)assessment may be feasible and acceptable during ED visits and might help facilitate comprehensive geriatric assessments during ED stay.

Age-adjusted Charlson Comorbidity Index as effective predictor for in-hospital mortality of patients with cardiac arrest: a retrospective study

BACKGROUND

Cardiac arrest is currently one of the leading causes of mortality in clinical practice, and the Charlson Comorbidity Index (CCI) is widely utilized to assess the severity of comorbidities. We aimed to evaluate the relationship between the age-adjusted CCI score and in-hospital mortality in intensive care unit (ICU) patients with the diagnosis of cardiac arrest, which is important but less explored previously.

METHODS

This was a retrospective study including patients aged over 18 years from the MIMIC-IV database. We calculated the age-adjusted CCI using age information and ICD codes. The univariate analysis for varied predictors' differences between the survival and the non-survival groups was performed. In addition, a multiple factor analysis was conducted based on logistic regression analysis with the primary result set as hospitalization death. An additional multivariate regression analysis was conducted to estimate the influence of hospital and ICU stay.

RESULTS

A total of 1772 patients were included in our study, with median age of 66, among which 705 (39.8%) were female. Amongst these patients, 963 (54.3%) died during the hospitalization period. Patients with higher age-adjusted CCI scores had a higher likelihood of dying during hospitalization (P < 0.001; OR: 1.109; 95% CI: 1.068-1.151). With the age-adjusted CCI incorporated into the predictive model, the area under the receiver operating characteristic curve was 0.794 (CI: 0.773-0.814), showing that the prediction model is effective. Additionally, patients with higher age-adjusted CCI scores stayed longer in the hospital (P = 0.026, 95% CI: 0.056-0.896), but there was no significant difference between patients with varied age-adjusted CCI scores on the days of ICU stay.

CONCLUSION

The age-adjusted CCI is a valid indicator to predict death in ICU patients with cardiac arrest, which can offer enlightenment for both theory literatures and clinical practice.

The importance of SNOMED CT concept specificity in healthcare analytics

BACKGROUND

Healthcare data frequently lack the specificity level needed to achieve clinical and operational objectives such as optimising bed management. Pneumonia is a disease of importance as it accounts for more bed days than any other lung disease and has a varied aetiology. The condition has a range of SNOMED CT concepts with different levels of specificity.

OBJECTIVE

This study aimed to quantify the importance of the specificity of an SNOMED CT concept, against well-established predictors, for forecasting length of stay for pneumonia patients.

METHOD

A retrospective data analysis was conducted of pneumonia admissions to a tertiary hospital between 2011 and 2021. For inclusion, the primary diagnosis was a subtype of bacterial or viral pneumonia, as identified by SNOMED CT concepts. Three linear mixed models were constructed. Model One included known predictors of length of stay. Model Two included the predictors in Model One and SNOMED CT concepts of lower specificity. Model Three included the Model Two predictors and the concepts with higher specificity. Model performances were compared.

RESULTS

Sex, ethnicity, deprivation rank and Charlson Comorbidity Index scores (age-adjusted) were meaningful predictors of length of stay in all models. Inclusion of lower specificity SNOMED CT concepts did not significantly improve performance (ΔR2 = 0.41%, p = .058). SNOMED CT concepts with higher specificity explained more variance than each of the individual predictors (ΔR2 = 4.31%, p < .001).

CONCLUSION

SNOMED CT concepts with higher specificity explained more variance in length of stay than a range of well-studied predictors.

IMPLICATIONS

Accurate and specific clinical documentation using SNOMED CT can improve predictive modelling and the generation of actionable insights. Resources should be dedicated to optimising and assuring clinical documentation quality at the point of recording.

Impact of functional impairment and cognitive status on perioperative outcomes and costs after radical cystectomy: The role of Barthel Index

OBJECTIVES

To investigate the association between Barthel Index (BI), which measures level of patients independence during daily living activities (ADL), and perioperative outcomes in a large cohort of consecutive bladder cancer (BCa) patients, who underwent radical cystectomy (RC) at a tertiary referral center.

METHODS

We retrospectively evaluated data from clinically nonmetastatic BCa patients treated with RC between 2015 and 2022. For each patient, BI was assessed preoperatively. According to BI score, patients were divided into three groups: ≤60 (total/severe dependency) vs. 65-90 (moderate dependency) vs. 95-100 (slight dependency/independency). Regression analyses tested the association between BI score and major postoperative complications (Clavien-Dindo >2), length of in-hospital stay (LOHS), 90-days readmission, and total costs.

RESULTS

Overall, 288 patients were included. According to BI score, the patient cohort was distributed as follows: 4% (n = 11) BI ≤60 vs. 15% (n = 42) BI 65-90 vs. 81% (n = 235) BI 95-100. Patients with BI ≤60 had more frequent ureterocutaneostomy performed, shorter operative time, higher rates of postoperative complications, longer LOHS, higher rates of readmission, and were associated with higher total costs, compared to patients with BI 65-90 and 95-100. In multivariable regression models, BI ≤60 remained an independent predictor of increased risk of major postoperative complications (odds ratio: 6.62, p = 0.006), longer LOHS (rate ratio: 1.25, p < 0.001), and higher costs (β: 2.617, p = 0.038).

CONCLUSIONS

Total/severe dependency in ADL assessed by BI was associated with higher rates of major postoperative complications, longer hospitalization, and higher costs in BCa patients treated with RC. BI assessment should be considered during patients selection process and counseling before surgery.

Development and validation of predictive model for long-term hospitalization, readmission, and in-hospital death of patients over 60 years old

Objective

To develop and validate a high-risk predictive model that identifies, at least, one common adverse event in older population: early readmission (up to 30 days after discharge), long hospital stays (10 days or more) or in-hospital deaths.

Methods

This was a retrospective cohort study including patients aged 60 years or older (n=340) admitted at a 630-beds tertiary hospital, located in the city of São Paulo, Brazil. A predictive model of high-risk indication was developed by analyzing logistical regression models. This model prognostic capacity was assessed by measuring accuracy, sensitivity, specificity, and positive and negative predictive values. Areas under the receiver operating characteristic curve with 95% confidence intervals were also obtained to assess the discriminatory power of the model. Internal validation of the prognostic model was performed in a separate sample (n=168).

Results

Statistically significant predictors were identified, such as current Barthel Index, number of medications in use, presence of diabetes mellitus, difficulty chewing or swallowing, extensive surgery, and dementia. The study observed discrimination model acceptance in the construction sample 0.77 (95% confidence interval: 0.71-0.83) and good calibration. The characteristics of the validation samples were similar, and the receiver operating characteristic curve area was 0.687 (95% confidence interval: 0.598-0.776). We could assess an older patient’s adverse health events during hospitalization after admission.

Conclusion

A predictive model with acceptable discrimination was obtained, with satisfactory results for early readmission (30 days), long hospital stays (10 days), or in-hospital death.

Charlson Comorbidity Index as a predictor of repeated hospital admission and mortality among older women diagnosed with cardiovascular disease

BACKGROUND

Comorbidity can complicate cardiovascular diseases (CVDs), increasing the risk of adverse events including hospitalisation and death. This study aimed to assess the Charlson Comorbidity Index (CCI) as a predictor of repeated hospital admission and mortality in older CVD patients.

METHODS

This study linked data from the Australian longitudinal study on women's health (ALSWH) with hospital and National Death Index datasets to identify dates for hospital admission, discharge, and death for women born 1921-26. CCI was calculated using the International Statistical Classification of Diseases, Australia Modification (ICD-10-AM) diagnostic codes.

RESULTS

Women with a higher CCI on index admission had increased risk of repeated hospital admission (AHR = 1.29, 95% CI 1.06, 1.58) and mortality (AHR = 3.05, 95% CI 2.15, 4.31). Older age and hypertension were also significantly associated with a higher risk of repeated hospital admission and mortality. Living in a remote area was associated with a higher risk of mortality.

CONCLUSIONS

The Charlson Comorbidity Index predicts repeated hospital admission and mortality incidences among older women with CVD. Improving management of comorbidities for older CVD patients should be considered as part of a strategy to mitigate subsequent repeated hospitalisation and delay mortality.

Does geriatric follow-up visits reduce hospital readmission among older patients discharged to temporary care at a skilled nursing facility: a before-and-after cohort study

INTRODUCTION

Hospital readmission is a burden to patients, relatives and society. Older patients with frailty are at highest risk of readmission and its negative outcomes.

OBJECTIVE

We aimed at examining whether follow-up visits by an outgoing multidisciplinary geriatric team (OGT) reduces unplanned hospital readmission in patients discharged to a skilled nursing facility (SNF).

DESIGN

A retrospective single-centre before-and-after cohort study.

SETTING AND PARTICIPANTS

Study population included all hospitalised patients discharged from a Danish geriatric department to an SNF during 1 January 2016-25 February 2020. To address potential changes in discharge and readmission patterns during the study period, patients discharged from the same geriatric department to own home were also assessed.

INTERVENTION

OGT visits at SNF within 7 days following discharge. Patients discharged to SNF before 12 March 2018 did not receive OGT (-OGT). Patients discharged to SNF on or after 12 March 2018 received the intervention (+OGT).

MAIN OUTCOME MEASURES

Unplanned hospital readmission between 4 hours and 30 days following initial discharge.

RESULTS

Totally 847 patients were included (440 -OGT; 407 +OGT). No differences were seen between the two groups regarding age, sex, activities of daily living (ADLs), Charlson Comorbidity Index (CCI) or 30-day mortality. The cumulative incidence of readmission was 39.8% (95% CI 35.2% to 44.8%, n=162) in -OGT and 30.2% (95% CI 25.8% to 35.2%, n=113) in +OGT. The unadjusted risk (HR (95% CI)) of readmission was 0.68 (0.54 to 0.87, p=0.002) in +OGT compared with -OGT, and remained significantly lower (0.72 (0.57 to 0.93, p=0.011)) adjusting for age, length of stay, sex, ADL and CCI. For patients discharged to own home the risk of readmission remained unchanged during the study period.

CONCLUSION

Follow-up visits by OGT to patients discharged to temporary care at an SNF significantly reduced 30-day readmission in older patients.

Utilidad del índice de comorbilidad de Charlson en personas ancianas. Concordancia con otros índices de comorbilidad

Objetivo. El objetivo principal de nuestro estudio fue evaluar la utilidad actual del índice de comorbilidad de Charlson (CCI) para predecir la mortalidad en personas mayores y la concordancia entre varios índices. Diseño. Estudio observacional, cohorte concurrente. Emplazamiento. Servicio de Medicina Interna de un hospital terciario, pacientes ambulatorios de un centro de salud y residentes de cuatro hogares de ancianos. Participantes. 375 individuos ≥ 65 años, con supervivencia esperada ≥ 6 meses, sin deterioro cognitivo. Mediciones principales. Se realizaron tres índices: CCI, el índice geriátrico de comorbilidad (GIC) y el índice de Kaplan-Feinstein (KF). A los 12 meses, se registró mortalidad. Los datos se analizaron con IBM SPSS Statistics® versión 23.0. Resultados. Edad media: 81,4 años. El CCI mostró comorbilidad baja-media en el grupo ambulatorio de 65-75 años (43 [75,4%]); moderada-alta más común en hospitalizados (19 [61,3%]) y en hogares de ancianos (5 [62,5%]). Al año fallecieron 59 (16,1%) individuos: con CCI: 10 (6,4%) comorbilidad baja-media y 49 (23,3%) moderada-alta, odds ratio (OR) 3,63 (intervalo de confianza [IC] 95% 1,76-7,51); con KF: 27 (13,3%) baja-media y 32 (19,5%) moderada-alta, OR 1,38 (IC 95% 0,78-2,44), y con GIC: 45 (14,1%) baja-media y 14 (29,2%) moderada-alta, OR 2,47 (IC 95% 1,21-5,06). La concordancia entre CCI-KF fue: 65-75 años: K = 0,62, 76-85 años: K = 0,396, y ≥ 86 años: K = 0,255. La concordancia entre CCI-GIC: 65-75 años: K = 0,202, 76-85 años: K = 0,069, y ≥ 86 años: K = 0,118. Conclusión. El CCI es el mejor predictor de mortalidad después de 1 año de seguimiento. Concordancia considerable entre CCI y KF en los individuos de 65-75 años, en el resto de las franjas etarias la correlación con GIC fue insignificante. Palabras clave: comorbilidad, mortalidad, anciano frágil.

Nutrition in the Actual COVID-19 Pandemic. A Narrative Review

The pandemic of Coronavirus Disease 2019 (COVID-19) has shocked world health authorities generating a global health crisis. The present study discusses the main finding in nutrition sciences associated with COVID-19 in the literature. We conducted a consensus critical review using primary sources, scientific articles, and secondary bibliographic indexes, databases, and web pages. The method was a narrative literature review of the available literature regarding nutrition interventions and nutrition-related factors during the COVID-19 pandemic. The main search engines used in the present research were PubMed, SciELO, and Google Scholar. We found how the COVID-19 lockdown promoted unhealthy dietary changes and increases in body weight of the population, showing obesity and low physical activity levels as increased risk factors of COVID-19 affection and physiopathology. In addition, hospitalized COVID-19 patients presented malnutrition and deficiencies in vitamin C, D, B12 selenium, iron, omega-3, and medium and long-chain fatty acids highlighting the potential health effect of vitamin C and D interventions. Further investigations are needed to show the complete role and implications of nutrition both in the prevention and in the treatment of patients with COVID-19.

Geriatric emergency department revisits after discharge with Potentially Inappropriate Medications: A retrospective cohort study

OBJECTIVE

To determine whether Potentially Inappropriate Medications (PIMs) prescribed in an academic emergency department (ED) are associated with increased ED revisits in older adults.

METHODS

A retrospective chart review of Medicare beneficiaries 65 years and older, discharged from an academic ED (January 2012 - November 2015) with any PIMs versus no PIMs. PIMs were defined using Category 1 of the 2015 Updated Beers criteria. Primary outcomes, obtained from a Medicare database linked to hospital ED subjects, were ED revisits 3 and 30 days from index ED discharge. Adjusted multiple logistic regression was used with entropy balance weighted covariates: Age in years, Gender, Race, Number of discharge medications, Charlson Comorbidity Index (CCI) score, Emergency Severity Index scores (ESI), Chief Complaint, Medicaid status, and prior 90 Day ED visits.

RESULTS

Over the study period, there were a total of 7,591 Medicare beneficiaries 65+ discharged from the ED with a prescription; 1,383 (18%) received one or more PIMs. ED revisits in 30 days were fewer for the PIMs cohort (12% PIMs vs 16% no PIMs, OR 0.79, 95% CI 0.65 - 0.95, P value <0.005). Hospital admissions in 30 days were fewer for the PIMs cohort (4 PIMs vs 7% no PIMs, OR 0.75, 95% CI 0.56 - 1.00, P value <0.005). In addition to PIMs, covariate risk factors associated with ED revisits in 30 days included comorbidity severity, history of prior ED revisits, chief complaint, and Medicaid status. Risk factors associated with hospitalization in 30 days included those plus age and emergency severity index, but not race nor ethnicity.

CONCLUSIONS

Patients discharged from the ED receiving potentially inappropriate medications as defined by Category 1 of the 2015 updated Beers criteria had lower odds of revisiting the ED within 30 days of index visit. Sociodemographic factors such as gender and race did not predict ED revisits or hospital admissions. Clinical characteristics predicted ED revisits and hospital admissions, the strongest risk being increasing Charlson Comorbidity Index score followed by triage acuity and chief complaint. Future studies are needed to delineate the implications of our findings.

Cognitive Impairment and Length of Stay in Acute Care Hospitals: A Scoping Review of the Literature

Older persons experiencing a longer length of stay (LOS) or delayed discharge (DD) may see a decline in their health and well-being, generating significant costs. This review aimed to identify evidence on the impact of cognitive impairment (CI) on acute care hospital LOS/DD. A scoping review of studies examining the association between CI and LOS/DD was performed. We searched six databases; two reviewers independently screened references until November 2019. A narrative synthesis was used to answer the research question; 58 studies were included of which 33 found a positive association between CI and LOS or DD, 8 studies had mixed results, 3 found an inverse relationship, and 14 showed an indirect link between CI-related syndromes and LOS/DD. Thus, cognitive impairment seemed to be frequently associated with increased LOS/DD. Future research should consider CI together with other risks for LOS/DD and also focus on explaining the association between the two.

Socioeconomic and Clinical Predictors of Mortality in Patients with Acute Dyspnea

Background

Factors predicting long-term prognosis in patients with acute dyspnea may guide both acute management and follow-up. The aim of this study was to identify socioeconomic and clinical risk factors for all-cause mortality among acute dyspnea patients admitted to an Emergency Department.

Methods

We included 798 patients with acute dyspnea admitted to the ED of Skåne University Hospital, Malmö, Sweden from 2013 to 2016. Exposures were living in the immigrant-dense urban part of Malmö (IDUD), country of birth, annual income, comorbidities, smoking habits, medical triage priority and severity of dyspnea. Mean follow-up time was 2.2 years. Exposures were related to risk of all-cause mortality using Cox proportional hazard model.

Results

During follow-up 40% died. In models adjusted for age and gender, low annual income, previous or ongoing smoking, certain comorbidities, high medical triage priority and severe dyspnea were all significantly associated with increased mortality. After adjusting for age, gender and all significant exposures, the lowest quintile of income, ongoing or previous smoking, history of serious infection, anemia, hip fracture, high medical triage priority and severe dyspnea significantly and independently predicted mortality. In contrast, neither country of birth nor living in IDUD predicted a mortality risk.

Conclusion

Apart from several clinical risk factors, low annual income predicts two-year mortality risk in patients with acute dyspnea. This is not the case for country of birth and living in IDUD. Our results underline the wide range of mortality risk factors in acute dyspnea patients. Knowledge of patients' annual income as well as certain clinical features may aid risk stratification and determining the need of follow-up both in hospital and after discharge from an ED.

Activities of daily living at hospital admission associated with mortality in geriatric patients with dementia: a Danish nationwide population-based cohort study

PURPOSE

Determining life expectancy in patients with dementia are challenging. We aimed at studying the association between basic activities of daily living as measured by the Barthel Index at hospital admission and mortality among older patients with dementia.

METHODS

All patients aged ≥ 65 years with diagnosed dementia in the population-based National Danish Geriatric Database from 2005 to 2014 were included and followed until death, emigration, or study termination (31.12.2015). Data on Barthel Index (BI) were used to assess ADL. Patients were categorized into four predefined standard BI subcategories according to the national Danish version of the statistical classification of diseases [BI = 0-24 (very low ADL), BI = 25-49 (low ADL), BI = 50-79 (moderate reduced ADL), and BI = 80-100 (independent ADL)]. Association with mortality was assessed using multivariable Cox regression analysis adjusting for age, marital status, Charlson Comorbidity Index, BMI, prior hospitalizations, year of admission and polypharmacy.

RESULTS

In total, 6550 patients (women 62%) were included, median (IQR) age 84 (79-88) years and BI 37 (13-63). Mortality increased significantly with decreasing BI in both the crude and multivariable analysis. In subcategories BI = (80-100) and BI = (0-24), survival time (median (95%)) was 3.6 (3.4-3.9) years and 0.8 (0.7-0.9) years, respectively. Also, in patients with BI = (0-24), the overall mortality risk (HR (95% CI)) was 2.5 (2.2-2.8), 30-day risk 11.8 (5.8-23.9), and 1-year risk 4.4 (3.6-5.5) when using BI = (80-100) as reference.

CONCLUSION

Barthel Index is independently associated with all-cause mortality among older patients with dementia admitted to hospital. BI may be a helpful tool for clinicians when discussing treatment and care strategies with patients and their families.

SARC-F Predicts Mortality Risk of Older Adults during Hospitalization

OBJECTIVES

To determine the association between SARC-F scores and the in-hospital mortality risk among older patients admitted to acute care hospitals.

DESIGN

Single-center retrospective study.

SETTING

A university hospital.

PARTICIPANTS

All consecutive patients aged older than 65 were admitted and discharged from the study hospital between July 2019 and September 2019.

MEASUREMENTS

Relevant patient data included age, sex, body mass index, nutritional status, fat-free mass, disease, activities of daily living (ADL), duration of hospital stay, SARC-F, and occurrence of death within 30 days of hospitalization. The diseases that caused hospitalization and comorbidities (Charlson Comorbidity Index; CCI) were obtained from medical records. The Eastern Cooperative Oncology Group-performance status (PS) was used to determine ADL, and the in-hospital mortality rate within 30 days of hospitalization as the outcome.

RESULTS

We analyzed 2,424 patients. The mean age was 75.9±6.9 and 55.5% were male. Fifty-three in-hospital mortalities occurred among the participants within the first 30 days of hospitalization. Patients who died in-hospital were older, had poorer nutritional status and severer PS scores, and more comorbidities than those who did not. A SARC-F score of ≥4 predicted a higher mortality risk within those 30 days with the following precision: sensitivity 0.792 and specificity 0.805. There were significantly more deaths in Kaplan-Meier curves regarding a score of SARC-F≥4 than a score of SARC-F<4 (p<0.001). Cox proportional hazard analysis was used to identify the clinical indicators most associated with in-hospital mortality. SARC-F≥4 (Hazard Ratio: HR 5.65, p<0.001), CCI scores (HR1.11, p=0.004), and infectious and parasitic diseases (HR3.13, p=0.031) were associated with in-hospital mortality. The SARC-F items with significant in-hospital mortality effects were assistance with walking (HR 2.55, p<0.001) and climbing stairs (HR 2.46, p=0.002).

CONCLUSION

The SARC-F questionnaire is a useful prognostic indicator for older adults because a SARC-F ≥4 score during admission to an acute care hospital predicts in-hospital mortality within 30 days of hospitalization.

Factors Associated with In-Hospital Mortality in Acute Care Hospital Settings: A Prospective Observational Study

Background: In-hospital mortality is a key indicator of the quality of care. Studies so far have demonstrated the influence of patient and hospital-related factors on in-hospital mortality. Currently, new variables, such as nursing workload or the level of dependency, are being incorporated. We aimed to identify which individual, clinical and hospital characteristics are related to hospital mortality. Methods: A multicentre prospective observational study design was used. Sampling was conducted between February 2015 and October 2017. Patients over 16 years, admitted to medical or surgical units at 11 public hospitals in Andalusia (Spain), with a foreseeable stay of at least 48 h were included. Multivariate regression analyses were performed to analyse the data. Results: The sample consisted of 3821 assessments conducted in 1004 patients. The mean profile was that of a male (52%), mean age of 64.5 years old, admitted to a medical unit (56.5%), with an informal caregiver (60%). In-hospital mortality was 4%. The INICIARE (Inventario del Nivel de Cuidados Mediante Indicadores de Clasificación de Resultados de Enfermería) scale yielded an adjusted odds ratio [AOR] of 0.987 (95% confidence interval [CI]: 0.97–0.99) and the nurse staffing level (NSL) yielded an AOR of 1.197 (95% CI: 1.02–1.4). Conclusion: Nursing care dependency measured by INICIARE and nurse staffing level was associated with in-hospital mortality.

Prognostic implications of pre-existing medical comorbidity in Takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TC) is associated with significant short-term morbidity and mortality. Several risk factors for poor outcomes have been identified; however, the prognostic implications of pre-existing comorbidity in TC are poorly delineated. We sought to assess the association of aggregate pre-existing comorbidity with short-term outcomes in TC. We performed a retrospective observational study of adult subjects diagnosed with TC at two academic tertiary care hospitals between 2005 and 2018. Overall burden of medical comorbidity was estimated using the Charlson comorbidity index (CCI). Multivariable logistic regression was used to test for independent association of CCI with 30-day mortality and severe shock at index presentation. Multivariable poisson regression was performed to assess the association of CCI with duration of hospitalization. Five-hundred and thirty-eight subjects were diagnosed with TC during the study period. The median CCI score of all subjects was 2 (IQR 1-4). Among subjects with physical triggers of TC, the median CCI score was 2 (IQR 1-4) compared to a median CCI score of 1 (IQR 0-1) in subjects with non-physical triggers of TC (P < 0.001). Seventy-six (14%) subjects died within 30 days of index diagnosis and 185 (34%) subjects experienced severe shock. The median duration of hospitalization was 7 days (IQR 3-14 days). In multivariable logistic regression, CCI was not associated with 30-day mortality or severe shock. In multivariable Poisson regression, CCI (IRR 1.17, 95% CI 1.16-1.18, P < 0.001) was associated with duration of hospitalization. Increased burden of pre-existing medical comorbidity was not independently associated with 30-day mortality or severe shock at index presentation, but was associated with increased duration of hospitalization after diagnosis of TC.

Identifying elderly patients at risk of readmission after discharge from a short-stay unit in the emergency department using performance-based tests of daily activities

Background

Readmission is a serious and adverse event for elderly patients. Despite efforts, predicting the risk of readmission remains imprecise. The objective of this study is to examine if performance-based tests of daily activities can identify elderly patients at risk of readmission within 26 weeks after discharge from a short-stay unit in the emergency department.

Methods

The current study is an observational study based on data from 144 elderly patients included in a previous non-randomised controlled trial. Before discharge, patients were assessed for limitations in performing daily activities using three performance-based tests with predetermined cut-off values: the Assessment of Motor and Process Skills, Timed Up and Go and the 30s-Chair Stand Test. Outcome was risk of readmission within 26 weeks after discharge.

Results

Limitations in performing daily activities were associated with risk of readmission as measured by the Assessment of Motor and Process Skills motor scale (Crude OR = 4.38 [1.36; 14.12]), (Adjusted OR = 4.17 [1.18; 14.75]) and the 30s-Chair Stand Test (Adjusted OR = 3.36 [1.42; 7.93]). No significant associations were found in regards to other measures.

Conclusion

The Assessment of Motor and Process Skills motor scale and the age, gender and comorbidity adjusted 30s-Chair Stand Test can identify elderly patients at increased risk of readmission after discharge from the emergency department. The results were limited by one-third of the patients did not perform the Assessment of Motor and Process Skills and the association between 30s-Chair Stand Test and risk of readmission were only positive when adjusted for age, gender and comorbidity.

[Elderly people, dependency and vulnerability in the coronavirus pandemic: an emergency for a social and health integration]

La pandemia actual por SARS-CoV-2 (COVID-19) afecta con mayor incidencia y gravedad a las personas mayores en todo el mundo. En España, el 68% del total de hospitalizaciones por coronavirus, corresponden a mayores de 60 años. Este trabajo tiene como objetivo incrementar la evidencia sobre las medidas a implementar con directrices actuales y futuras en diferentes escenarios. Destaca la necesidad de prepararnos para la acción mediante la implementación de protocolos de carácter internacional. Existe una tendencia hacia la atención biopsicosocial de las personas mayores en todos los entornos donde se encuentran, adecuando la atención y personalizando decisiones de ingresos hospitalarios, cuidados paliativos, atendiendo, entre otros criterios, a los años ajustados a la calidad de vida, así como alternativas para el monitoreo y tratamiento de la patología por COVID-19 y otras ya existentes. Son necesarias medidas de reducción de la transmisión del virus a través de la higiene y el distanciamiento, atendiendo a la salud biopsicosocial de los mayores aislados. Como alternativas innovadoras se propone la comunicación intersectorial, y el uso de herramientas tecnológicas, acompañado de una adecuada alfabetización digital en salud. Las líneas futuras se centran en garantizar los derechos sociales y sanitarios, equiparando al mismo nivel el sistema social y de salud, y consiguiendo una coordinación real. Un nuevo marco de atención centrada en la persona podría ser un gran aliado para conseguir una atención integrada a los mayores, guiada por un aumento de los recursos destinados a la financiación de proyectos de investigación sobre longevidad.