Correlates of hospitalization among the oldest old: results of the AgeCoDe-AgeQualiDe prospective cohort study

Validation of MyFORTA: An Automated Tool to Improve Medications in Older People Based on the FORTA List

BACKGROUND

Listing tools have been developed to improve medications in older patients, including the Fit fOR The Aged (FORTA) list, a clinically validated, positive-negative list of medication appropriateness. Here, we aim to validate MyFORTA, an automated tool for individualized application of the FORTA list.

METHODS

331 participants of a multi-center cohort study (AgeCoDe) for whom the FORTA score (sum of overtreatment and undertreatment errors) had been determined manually (gold standard [GS]) were reassessed using the automated MyFORTA (MF) tool. This tool determines the score from ATC and ICD codes combined with clinical parameters.

RESULTS

The FORTA scores were 9.01 ± 2.91 (mean ± SD, MF) versus 6.02 ± 2.52 (GS) (p < 0.00001). Removing undertreatment errors for calcium/vitamin D (controversial guidelines) and influenza/pneumococcal vaccinations (no robust information in the database), the difference decreased: 7.5 ± 2.7 (MF) versus 5.98 ± 2.55 (GS) (p < 0.00001). The remaining difference was driven by, for example, missing nitro spray in coronary heart disease/acute coronary syndrome as the related information was rarely found in the database, but notoriously detected by MF. Three hundred and forty errors from those 100 patients with the largest score deviation accounted for 68% of excess errors by MF.

CONCLUSION

MF was more sensitive to detect medication errors than GS, all frequent errors only detected by MF were plausible, and almost no adaptations of the MF algorithm seem indicated. This automated tool to check medication appropriateness according to the FORTA list is now validated and represents the first clinically directed algorithm in this context. It should ease the application of FORTA and help to implement the proven beneficial effects of FORTA on clinical endpoints.

Family Conferences to Facilitate Deprescribing in Older Outpatients With Frailty and With Polypharmacy: The COFRAIL Cluster Randomized Trial

Importance

For older adults with frailty syndrome, reducing polypharmacy may have utility as a safety-promoting treatment option.

Objective

To investigate the effects of family conferences on medication and clinical outcomes in community-dwelling older adults with frailty receiving polypharmacy.

Design, Setting, and Participants

This cluster randomized clinical trial was conducted from April 30, 2019, to June 30, 221, at 110 primary care practices in Germany. The study included community-dwelling adults aged 70 years or older with frailty syndrome, daily use of at least 5 different medications, a life expectancy of at least 6 months, and no moderate or severe dementia.

Interventions

General practitioners (GPs) in the intervention group received 3 training sessions on family conferences, a deprescribing guideline, and a toolkit with relevant nonpharmacologic interventions. Three GP-led family conferences for shared decision-making involving the participants and family caregivers and/or nursing services were subsequently held per patient at home over a period of 9 months. Patients in the control group received care as usual.

Main Outcomes and Measures

The primary outcome was the number of hospitalizations within 12 months, as assessed by nurses during home visits or telephone interviews. Secondary outcomes included the number of medications, the number of European Union list of the number of potentially inappropriate medication (EU[7]-PIM) for older people, and geriatric assessment parameters. Both per-protocol and intention-to-treat analyses were conducted.

Results

The baseline assessment included 521 individuals (356 women [68.3%]; mean [SD] age, 83.5 [6.17] years). The intention-to-treat analysis with 510 patients showed no significant difference in the adjusted mean (SD) number of hospitalizations between the intervention group (0.98 [1.72]) and the control group (0.99 [1.53]). In the per-protocol analysis including 385 individuals, the mean (SD) number of medications decreased from 8.98 (3.56) to 8.11 (3.21) at 6 months and to 8.49 (3.63) at 12 months in the intervention group and from 9.24 (3.44) to 9.32 (3.59) at 6 months and to 9.16 (3.42) at 12 months in the control group, with a statistically significant difference at 6 months in the mixed-effect Poisson regression model (P = .001). After 6 months, the mean (SD) number of EU(7)-PIMs was significantly lower in the intervention group (1.30 [1.05]) than in the control group (1.71 [1.25]; P = .04). There was no significant difference in the mean number of EU(7)-PIMs after 12 months.

Conclusions and Relevance

In this cluster randomized clinical trial with older adults taking 5 or more medications, the intervention consisting of GP-led family conferences did not achieve sustainable effects in reducing the number of hospitalizations or the number of medications and EU(7)-PIMs after 12 months.

Trial Registration

German Clinical Trials Register: DRKS00015055.

Pathways to reduced overnight hospitalizations in older adults: Evaluating 62 physical, behavioral, and psychosocial factors

As our society ages and healthcare costs escalate, researchers and policymakers urgently seek potentially modifiable predictors of reduced healthcare utilization. We aimed to determine whether changes in 62 candidate predictors were associated with reduced frequency, and duration, of overnight hospitalizations. We used data from 11,374 participants in the Health and Retirement Study—a national sample of adults aged >50 in the United States. Using generalized linear regression models with a lagged exposure-wide approach, we evaluated if changes in 62 predictors over four years (between t0;2006/2008 and t1;2010/2012) were associated with subsequent hospitalizations during the two years prior to t2 (2012–2014 (Cohort A) or 2014–2016 (Cohort B)). After robust covariate-adjustment, we observed that changes in some health behaviors (e.g., those engaging in frequent physical activity had 0.80 the rate of overnight hospital stays (95% CI [0.74, 0.87])), physical health conditions (e.g., those with cancer had 1.57 the rate of overnight hospital stays (95% CI [1.35, 1.82])), and psychosocial factors (e.g., those who helped friends/neighbors/relatives 100–199 hours/year had 0.73 the rate of overnight hospital stays (95% CI [0.63, 0.85])) were associated with subsequent hospitalizations. Findings for both the frequency, and duration, of hospitalizations were mostly similar. Changes in a number of diverse factors were associated with decreased frequency, and duration, of overnight hospitalizations. Notably, some psychosocial factors (e.g., informal helping) had effect sizes equivalent to or larger than some physical health conditions (e.g., diabetes) and health behaviors (e.g., smoking). These psychosocial factors are mostly modifiable and with further research could be novel intervention targets for reducing hospitalizations.

Higher FORTA (Fit fOR The Aged) scores are associated with poor functional outcomes, dementia, and mortality in older people

PURPOSE

Higher Fit fOR The Aged (FORTA) scores have been shown to be negatively associated with adverse clinical outcomes in older hospitalized patients. This has not been evaluated in other health care settings. The aim of this study was to examine the association of the FORTA score with relevant outcomes in the prospective AgeCoDe-AgeQualiDe cohort of community-dwelling older people. In particular, the longitudinal relation between the FORTA score and mortality and the incidence of dementia was evaluated.

METHODS

Univariate and multivariate correlations between the FORTA score and activities of daily living (ADL) or instrumental activities of daily living (IADL) as well as comparisons between high vs. low FORTA scores were conducted.

RESULTS

The FORTA score was significantly correlated with ADL/IADL at baseline and at all follow-up visits (p < 0.0001). ADL/IADL results of participants with a low FORTA score were significantly better than in those with high FORTA scores (p < 0.0001). The FORTA score was also significantly (p < 0.0001) correlated with ADL/IADL in the multivariate analysis. Moreover, the mean FORTA scores of participants with dementia were significantly higher (p < 0.0001) than in those without dementia at follow-up visits 6 through 9. The mean FORTA scores of participants who died were significantly higher than those of survivors at follow-up visits 7 (p < 0.05), 8 (p < 0.001), and 9 (p < 0.001).

CONCLUSION

In this study, an association between higher FORTA scores and ADL as well as IADL was demonstrated in community-dwelling older adults. Besides, higher FORTA scores appear to be linked to a higher incidence of dementia and even mortality.

The Utilization of Mobile Phones in Health Information Seeking in Rural China

This study aims to investigate the mobile phone utilization for health information seeking among adults who are 45 years or older in rural areas in China. Using Andersen’s Behavioral Model (BM), we examine the factors that influence the target group’s behaviors of online health information seeking and contacting healthcare providers via mobile phones. By using stratified sampling method, we conducted a survey among 607 rural adults who were 45 years or older from six villages in Jiangsu Province, China. The results reveal that participants can be excluded from such services for not using a smartphone. eHealth information literacy could serve as a strong influential factor for online health information seeking and contacting healthcare providers via mobile phones. Participants with lower emotional wellbeing are more inclined to seek health information online via mobile phones. The results indicate variables such as utilization of technological devices and eHealth literacy should be included in Andersen’s model when investigating the utilization of mHealth services. This study contributes to the literature on mHealth adoption in rural areas in China and has implications for practitioners to tailor the mHealth service for socio-economically disadvantaged groups.

Health care utilization in very advanced ages: A study on predisposing, enabling and need factors

This study aims to examine the effects of predisposing, enabling, and need factors on healthcare utilization in advanced age. Data from a sample of 270 Portuguese community-dwelling persons aged ≥80 years was used. Face-to-face interviews were conducted and included the application of a research protocol addressing a set of sociodemographic and health-related variables that expressed the Andersen Behavioral model (i.e., predisposing, enabling, and need factors). Predictors of visits to general practitioners (GP) and specialist physicians, as well as emergency department (ED) use and hospitalizations were investigated. Multivariate linear and logistic regression analyzes were used to model the effects of predictor factors specified in the Andersen Behavioral model. Our findings underscore that younger age and having multimorbidity were significantly associated with having GP visits. Specialist physician visits were associated with younger age and a higher number of daily medications. ED use was associated with being male, having formal social support and a higher number of daily medications. Hospitalizations were associated with being younger, being male and having multimorbidity. Our findings revealed that need and predisposing factors determined the most healthcare use.

Determinants of Healthcare Use Based on the Andersen Model: A Systematic Review of Longitudinal Studies

The aim was to give an overview of longitudinal observational studies investigating the determinants of healthcare use explicitly using the Andersen model. To this end, three electronic databases (Medline, PsycINFO and CINAHL) were searched (and an additional hand search was performed). Longitudinal observational studies examining the determinants of healthcare use (outpatient physician services and hospital stays) based on the Andersen model were included, whereas disease-specific samples were excluded. Study quality was evaluated. The selection of studies, extraction of data and assessment of the studies were conducted by two reviewers. The following determinants of healthcare use were displayed based on the (extended) Andersen model: predisposing characteristics, enabling resources, need factors and psychosocial factors. In sum, n = 10 longitudinal studies have been included in our systematic review. The included studies particularly showed a longitudinal association between increased needs and higher healthcare use. Study quality was rather high. However, several studies did not conduct robustness checks or clarify the handling of missing data. In conclusion, this systematic review adds to our current understanding of the factors associated with healthcare use (mainly based on cross-sectional studies). It showed mixed evidence with regard to the association between predisposing characteristics, enabling resources and healthcare use longitudinally. In contrast, increased need factors (in particular, self-rated health and chronic conditions) were almost consistently associated with increased healthcare use. This knowledge may assist in managing healthcare use. Since most of the studies were conducted in North America or Europe, future longitudinal studies from other regions are urgently required.

[Use of Health Care by Homeless Individuals: Results of the Hamburg Survey of Homeless Individuals]

OBJECTIVE

There is a lack of studies focusing on the use of health care facilities by homeless people. The aim of this study was to survey health care use by the homeless.

METHODS

Data were taken from the Hamburg survey of homeless individuals (n=150, mean age:12,5 years; SD: 12,5 years). Assessment covered details of health insurance status, use of ambulatory and hospital care, medication use, and reasons for not accessing health services.

RESULTS

In total, 61,2% of the homeless individuals had health insurance. About two thirds of homeless individuals (65,9%) had accessed some sort of medical services in the past 12 months. The key reason for not making use of health services was the absence of any need for treatment (74,6%). In sum, 39,8% of homeless individuals had made at least one hospital visit in the past 12 months. About one third (34,2%) had used mobile support services (mainly a mobile doctor's office). In total, 37,7% of homeless individuals took medications regularly, with 'prices too high' (63,6%) being the key reason for difficulties in access to medications. Almost one half of homeless individuals (47,0%) had not made a visit to a physician in the past three months.

CONCLUSION

Additional efforts are required to improve access to health care by homeless individuals. Future research in this area is therefore necessary.

Determinants of healthcare use based on the Andersen model: a study protocol for a systematic review of longitudinal studies

INTRODUCTION

A previous systematic review published in 2012 focused on the use of health services based on the Andersen model. Extending this review, we will exclusively focus on systematically synthesising longitudinal studies examining the determinants of healthcare use based on the Andersen model. Therefore, our aim of this systematic review is to provide an overview of longitudinal observational studies investigating the predictors of healthcare use explicitly using this model.

METHODS AND ANALYSIS

We will search three electronic databases (Medline, PsycINFO and CINAHL). Furthermore, reference lists will be searched manually. Longitudinal observational studies will be investigating the determinants of healthcare use (in terms of use of outpatient physician services (like general practitioner's visits or specialist visits in total) and hospitalisation). We will exclude disease-specific samples. Data extraction will focus on methods (eg, assessment of healthcare use), sample characteristics and main findings. A suitable tool will be used to assess the study quality. Study selection, data extraction and evaluation of study quality will be conducted by two reviewers. The findings will be presented by means of figures, summary tables, narrative summaries and meta-analysis (if possible).

ETHICS AND DISSEMINATION

No primary data will be collected. Therefore, approval by an ethics committee is not required. Our findings are planned to be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42020193198.

Associations of psychosocial factors, knowledge, attitudes and practices with hospitalizations in internal medicine divisions in different population groups in Israel

BACKGROUND

Inequalities in healthcare utilization exist across ethnic groups; however, the contributions of health-related knowledge and psychosocial factors to these inequalities remain unclear. We examined associations of social determinants of health, psychological factors, knowledge, attitudes and health practices, with hospitalizations in internal medicine divisions, among Israeli adults, Jews and Arabs, with non-communicable diseases, in a setting of universal health insurance.

METHODS

A retrospective study was undertaken among 520 Jews and Arabs aged 40 years or older with non-communicable diseases, members of a large health maintenance organization. Hospitalization (at least once during 2008) in an internal medicine division was determined based on documentation in electronic health records. Participants were randomly selected in strata of sex, population-group and hospitalization status (yes/no). Data were collected from medical records and via face-to-face interviews using a structured questionnaire. Main independent variables included comorbidity burden, health behaviors, mental health wellbeing and self-rated health. Scales measuring health knowledge and attitudes/beliefs were constructed using factor analysis.

RESULTS

Comorbidity burden (OR 1.41 [95% CI 1.24-1.61]) and self-rated health (not good vs. good) (OR 1.88 [95% CI 1.13-3.12]) were positively associated with hospitalizations in an internal medicine division, while an inverse association was found with better mental health wellbeing (OR 0.98 [95% CI 0.96-0.99, for each 1-point score increase). Among Jewish participants, positive associations were found of the number of offspring, comorbidity burden and perceived difficulty, with hospitalizations. No significant associations were found with hospitalizations of other sociodemographics, health behaviors, knowledge and attitudes/beliefs.

CONCLUSIONS

Comorbidity burden was the main risk factor of hospitalizations in internal medicine divisions. Psychosocial factors, such as self-rated health, a complex variable affected by social capital, mental wellbeing, the number of offspring, and perceived burden and difficulty, seem also to contribute. These findings suggest the involvement of broad family and social factors, beyond individual level characteristics and medical needs, in hospitalizations in internal medicine divisions. Interventions to reduce hospitalizations should be comprehensive and integrate aspects of mental health wellbeing; they should build on familial characteristics (e.g., number of offspring), factors related to social capital such as self-rated health, and perceived burden and difficulty.

Determinants of health care use among homeless individuals: evidence from the Hamburg survey of homeless individuals

BACKGROUND

To identify the determinants of health care use among homeless individuals.

METHODS

Data were taken from the Hamburg survey of homeless individuals (n = 100 individuals in the here used model, mean age 44.8 years, SD 12.5) focusing on homeless individuals in Hamburg, Germany. The number of physician visits in the past 3 months and hospitalization in the preceding 12 months were used as outcome measures. Drawing on the Andersen model of health care use as a conceptual framework, predisposing characteristics, enabling resources and need factors as well as psychosocial variables were included as correlates.

RESULTS

Negative binomial regressions showed that increased physician visits were associated with being female (IRR: 4.02 [95% CI: 1.60-10.11]), absence of chronic alcohol consume (IRR: 0.26 [95% CI: 0.12-0.57]) and lower health-related quality of life (IRR: 0.97 [95% CI: 0.96-0.98]). Furthermore, logistic regressions showed that the likelihood of hospitalization was positively associated with lower age (OR: 0.93 [95% CI: 0.89-0.98]), having health insurance (OR: 8.11 [2.11-30.80]) and lower health-related quality of life (OR: 0.97 [95% CI: 0.94-0.99]).

CONCLUSIONS

Our study showed that predisposing characteristics (both age and sex), enabling resources (i.e., health insurance) and need factors in terms of health-related quality of life are main drivers of health care use among homeless individuals. This knowledge may assist in managing health care use.

Association between Changes in Nutrient Intake and Changes in Muscle Strength and Physical Performance in the SarcoPhAge Cohort

Muscle weakness and physical performance impairment are common geriatric conditions that raise morbidity and mortality. They are known to be affected by nutrition, but only a few longitudinal studies exist. This study aims to fill this gap by exploring the association, over 3 years, between variations of nutrient intakes, as well as, on one side, the variations of handgrip strength, as a surrogate of muscle strength, and on the other side, the physical performance, assessed by gait speed. Participants from the SarcoPhAge study, a Belgian cohort of people aged 65 years and older, were asked to complete a self-administered food frequency questionnaire (FFQ) at the second (T2) and the fifth (T5) year of follow-up. Daily macro- and micronutrient intakes were measured and their changes in consumption over the three years of follow-up were then calculated. The association between changes in nutrients consumption and the variations in muscle parameters were investigated through multiple linear regressions. Out of the 534 participants included in the cohort, 238 had complete data at T2 and T5 (median age of 72.0 years (70.0-78.0 years), 60.9% women). In the cross-sectional analysis, calories, omega-3 fatty acids, potassium, and vitamins D, A, and K intakes were positively correlated with muscle strength. In the longitudinal analysis, neither the gait speed nor the muscle strength changes were significantly impacted by the variations. Other longitudinal investigations with longer follow-up are required to improve knowledge about these interrelations.

The Educational Value of Outpatient Consultation-Liaison Rotations: A White Paper From the Academy of Consultation-Liaison Psychiatry Residency Education Subcommittee

Background

As mental health services in outpatient medical clinics expand, psychiatrists must be trained to practice in these settings.

Objectives

The Academy of Consultation-Liaison Psychiatry residency education subcommittee convened a writing group with the goal of summarizing the current evidence about outpatient consultation-liaison psychiatry (CLP) training and providing a framework for CLP educators who are interested in developing outpatient CLP rotations within their programs.

Method

MEDLINE (via PubMed), Embase, and PsycINFO (via OVID) were reviewed each from inception to December 2019, for psychiatric CLP services in ambulatory settings that involved residents or fellows. The CLP education guidelines were reviewed for recommendations relevant to outpatient CLP. We also searched MedEd portal for published curriculums relevant to CLP. The group held 2 conferences to reach consensus about recommendations in setting up outpatient CLP rotations.

Results

Seventeen articles, 3 Academy of Consultation-Liaison Psychiatry–supported guidelines, and 8 online didactic resources were identified as directly reporting on the organization and/or impact of an outpatient CLP rotation. These manuscripts indicated that residents found outpatient CLP rotations effective and relevant to their future careers. However, the literature provided few recommendations for establishing formal outpatient CLP training experiences.

Conclusions

Outpatient CLP rotations offer multiple benefits for trainees, including exposure to specific clinical scenarios and therapeutic interventions applicable only in the outpatient setting, increased continuity of care, and the unique experience of providing liaison and education to non-mental health providers. The article outlines recommendations and examples for developing outpatient CLP rotations which CLP educators can incorporate in their programs.