Effectiveness of hospital avoidance interventions among elderly patients: A systematic review

Predicting unplanned admissions to hospital in older adults using routinely recorded general practice data: development and validation of a prediction model

BACKGROUND

Unplanned admissions to hospital represent a hazardous event for older people. Timely identification of high-risk individuals using a prediction tool may facilitate preventive interventions.

AIM

To develop and validate an easy-to-use prediction model for unplanned admissions to hospital in community-dwelling older adults using readily available data to allow rapid bedside assessment by GPs.

DESIGN AND SETTING

This was a retrospective study using the general practice electronic health records of 243 324 community-dwelling adults aged ≥65 years linked with national administrative data to predict unplanned admissions to hospital within 6 months.

METHOD

The dataset was geographically split into a development (n = 142 791/243 324, 58.7%) and validation (n = 100 533/243 324, 41.3%) sample to predict unplanned admissions to hospital within 6 months. The performance of three different models was evaluated with increasingly smaller selections of candidate predictors (optimal, readily available, and easy-to-use models). Logistic regression was used with backward selection for model development. The models were validated internally and externally. Predictive performance was assessed by area under the curve (AUC) and calibration plots.

RESULTS

In both samples, 7.6% (development cohort: n = 10 839/142 791, validation cohort: n = 7675/100 533) had ≥1 unplanned hospital admission within 6 months. The discriminative ability of the three models was comparable and remained stable after geographic validation. The easy-to-use model included age, sex, prior admissions to hospital, pulmonary emphysema, heart failure, and polypharmacy. Its discriminative ability after validation was AUC 0.72 (95% confidence interval = 0.71 to 0.72). Calibration plots showed good calibration.

CONCLUSION

The models showed satisfactory predictive ability. Reducing the number of predictors and geographic validation did not have an impact on predictive performance, demonstrating the robustness of the model. An easy-to-use tool has been developed in this study that may assist GPs in decision making and with targeted preventive interventions.

Drug Burden Index Is a Modifiable Predictor of 30-Day Hospitalization in Community-Dwelling Older Adults With Complex Care Needs: Machine Learning Analysis of InterRAI Data

BACKGROUND

Older adults (≥65 years) account for a disproportionately high proportion of hospitalization and in-hospital mortality, some of which may be avoidable. Although machine learning (ML) models have already been built and validated for predicting hospitalization and mortality, there remains a significant need to optimize ML models further. Accurately predicting hospitalization may tremendously affect the clinical care of older adults as preventative measures can be implemented to improve clinical outcomes for the patient.

METHODS

In this retrospective cohort study, a data set of 14 198 community-dwelling older adults (≥65 years) with complex care needs from the International Resident Assessment Instrument-Home Care database was used to develop and optimize 3 ML models to predict 30-day hospitalization. The models developed and optimized were Random Forest (RF), XGBoost (XGB), and Logistic Regression (LR). Variable importance plots were generated for all 3 models to identify key predictors of 30-day hospitalization.

RESULTS

The area under the receiver-operating characteristics curve for the RF, XGB, and LR models were 0.97, 0.90, and 0.72, respectively. Variable importance plots identified the Drug Burden Index and alcohol consumption as important, immediately potentially modifiable variables in predicting 30-day hospitalization.

CONCLUSIONS

Identifying immediately potentially modifiable risk factors such as the Drug Burden Index and alcohol consumption is of high clinical relevance. If clinicians can influence these variables, they could proactively lower the risk of 30-day hospitalization. ML holds promise to improve the clinical care of older adults. It is crucial that these models undergo extensive validation through large-scale clinical studies before being utilized in the clinical setting.

Strategies for improving ED-related outcomes of older adults who seek care in emergency departments: a systematic review

BACKGROUND

Despite constituting 14% of the general population, older adults make up almost a quarter of all emergency department (ED) visits. These visits often do not adequately address patient needs, with nearly 80% of older patients discharged from the ED carrying at least one unattended health concern. Many interventions have been implemented and tested in the ED to care for older adults, which have not been recently synthesized.

METHODS

A systematic review was conducted to identify interventions initiated in the ED to address the needs of older adults. Embase, MEDLINE, CINAHL, Cochrane CENTRAL, the Cochrane Database of Systematic Reviews, and grey literature were searched from January 2013 to January 18, 2023. Comparative studies assessing interventions for older adults in the ED were included. The quality of controlled trials was assessed with the Cochrane risk-of-bias tool for randomized trials, and the quality of observational studies was assessed with the risk of bias in non-randomized studies of interventions tool. Due to heterogeneity, meta-analysis was not possible.

RESULTS

Sixteen studies were included, assessing 12 different types of interventions. Overall study quality was low to moderate: 10 studies had a high risk of bias, 5 had a moderate risk of bias, and only 1 had a low risk of bias. Follow-up telephone calls, referrals, geriatric assessment, pharmacist-led interventions, physical therapy services, care plans, education, case management, home visits, care transition interventions, a geriatric ED, and care coordination were assessed, many of which were combined to create multi-faceted interventions. Care coordination with additional support and early assessment and intervention were the only two interventions that consistently reported improved outcomes. Most studies did not report significant improvements in ED revisits, hospitalization, time spent in the ED, costs, or outpatient utilization. Two studies reported on patient perspectives.

CONCLUSION

Few interventions demonstrate promise in reducing ED revisits for older adults, and this review identified significant gaps in understanding other outcomes, patient perspectives, and the effectiveness in addressing underlying health needs. This could suggest, therefore, that most revisits in this population are unavoidable manifestations of frailty and disease trajectory. Efforts to improve older patients' needs should focus on interventions initiated outside the ED.

Effectiveness of care models for chronic disease management: A scoping review of systematic reviews

OBJECTIVE

To conduct a scoping review of models of care for chronic disease management to identify potentially effective components for management of chronic traumatic brain injury (TBI).

METHODS

Information sources: Systematic searches of three databases (Ovid MEDLINE, Embase, and Cochrane Database of Systematic Reviews) from January 2010 to May 2021.

ELIGIBILITY CRITERIA

Systematic reviews and meta-analyses reporting on the effectiveness of the Chronic Care Model (CCM), collaborative/integrated care, and other chronic disease management models.

DATA

Target diseases, model components used (n = 11), and six outcomes (disease-specific, generic health-related quality of life and functioning, adherence, health knowledge, patient satisfaction, and cost/health care use).

SYNTHESIS

Narrative synthesis, including proportion of reviews documenting outcome benefits.

RESULTS

More than half (55%) of the 186 eligible reviews focused on collaborative/integrated care models, with 25% focusing on CCM and 20% focusing on other chronic disease management models. The most common health conditions were diabetes (n = 22), depression (n = 16), heart disease (n = 12), aging (n = 11), and kidney disease (n = 8). Other single medical conditions were the focus of 22 reviews, multiple medical conditions of 59 reviews, and other or mixed mental health/behavioral conditions of 20 reviews. Some type of quality rating for individual studies was conducted in 126 (68%) of the reviews. Of reviews that assessed particular outcomes, 80% reported disease-specific benefits, and 57% to 72% reported benefits for the other five types of outcomes. Outcomes did not differ by the model category, number or type of components, or target disease.

CONCLUSIONS

Although there is a paucity of evidence for TBI per se, care model components proven effective for other chronic diseases may be adaptable for chronic TBI care.

Comprehensive geriatric assessment delivered by advanced nursing practitioners within primary care setting: a mixed-methods pilot feasibility randomised controlled trial

BACKGROUND

Comprehensive Geriatric Assessment (CGA)is a widely accepted intervention for frailty and can be cost-effective within a primary care setting.

OBJECTIVE

To explore the feasibility of identifying older adults with frailty and assess the subsequent implementation of a tailored CGA with care and support plan by Advanced Nursing Practitioners (ANPs).

METHODS

A mixed-method parallel randomised controlled trial was conducted. Participants were recruited from two General Practice (GP) centres between January and June 2019. Older adults with confirmed frailty, as assessed by practice nurses, were randomised, using a web service, to the intervention or treatment-as-usual (TAU) groups for six months with an interim and a final review. Data were collected on feasibility, health service usage, function, quality of life, loneliness, and participants' experience and perception of the intervention. Non-parametric tests were used to analyse within and between-group differences. P-values were adjusted to account for type I error. Thematic analysis of qualitative data was conducted.

RESULTS

One hundred sixty four older adults were invited to participate, of which 44.5% (n = 72) were randomised to either the TAU (n = 37) or intervention (n = 35) groups. All participants in the intervention group were given the baseline, interim and final reviews. Eight participants in each group were lost to post-intervention outcome assessment. The health service use (i.e. hospital admissions, GP/emergency calls and GP/Accident Emergency attendance) was slightly higher in the TAU group; however, none of the outcome data showed statistical significance between-group differences. The TAU group showed a deterioration in the total functional independence and its motor and cognition components post-intervention (p < .05), though the role limitation due to physical function and pain outcomes improved (p < .05). The qualitative findings indicate that participants appreciated the consistency of care provided by ANPs, experienced positive therapeutic relationship and were connected to wider services.

DISCUSSION

Frailty identification and intervention delivery in the community by ANPs were feasible. The study shows that older adults with frailty living in the community might benefit from intervention delivered by ANPs. It is suggested to examine the cost-effectiveness of the intervention in sufficiently powered future research.

TRIAL REGISTRATIONS

The protocol is available at clinicaltirals.gov, ID: NCT03394534; 09/01/2018.

Evaluation of the Nurse Practitioner Offsite Model

Rural older adults residing in assisted living (AL) (herein referred to as residents) have limited access to health care for urgent and chronic management of diseases. The current project aimed to assess rural residents, families, and staff satisfaction with the Nurse Practitioner (NP) Offsite Visit Program. Residents and their families were asked to complete the NP Satisfaction Survey. The survey comprised three subscales (satisfaction, communication, and accessibility) and measured residents' and families' satisfaction. AL staff attended a 1-hour focus interview. Mean survey scores were 81.5 for satisfaction, 26.4 for communication, and 16.9 for accessibility subscales. Focus interview themes included Care Coordination, Prevention of Acute Care Utilization, and Access to Care. Findings suggest that residents, families, and site staff believe the NP Offsite Visit Program was beneficial and improved care coordination between residents and the provider team. The next step is to evaluate the program's impact on residents' health outcomes and further evaluate the Offsite team membership. [Journal of Gerontological Nursing, 49(7), 25-30.].

Frequent users of health services among community-based older Australians: Characteristics and association with mortality

OBJECTIVES

To investigate characteristics of frequent users of general practice (GP; ≥21 visits in a year), medical specialist (≥10 visits), emergency department (ED; ≥2 presentations) and hospital services (≥2 overnight hospitalisations) and the association with mortality for people aged over 75 years.

METHODS

The study included residents from Central and Eastern Sydney, Australia, aged over 75 years who participated in a large community-dwelling cohort study. Demographic, social and health characteristics data were extracted from the 45 and Up Study survey. Health service (GP, medical specialist, ED and hospitalisations) use and mortality data were extracted from linked administrative data. We calculated adjusted prevalence ratios to identify independent characteristics associated with frequent users of services at baseline (approx. 2008) and adjusted hazard ratios to assess the association between frequent users of services and mortality.

RESULTS

Frequent users of services (GPs, medical specialists, EDs and hospitals) were more likely to be associated with ever having had heart disease and less likely to be associated with reporting good quality of life. Characteristics varied by service type. Frequent users of services were 1.5-2.0 times more likely to die within 7 years compared to those who were less frequent service users after controlling for all significant factors.

CONCLUSIONS

Our analysis found that frequent service users aged over 75 years had poorer quality of life, more complex health conditions and higher mortality and so their health service use was not inappropriate. However, better management of these frequent service users may lead to better health outcomes.

Outcomes as experienced by older patients after hospitalisation: satisfaction, acceptance, frustration and hope-a grounded theory study

Background

outcomes of hospitalisation are often described in quantitative terms. It is unknown how older frail patients describe their own outcomes.

Objective

to discover how older frail persons describe their own hospitalisation outcomes and the meaning of these outcomes for their daily lives.

Design

Constructivist Grounded Theory approach.

Participants

frail older people discharged from hospital.

Methods

Open interviews in the participant’s home. Transcripts were coded inductively according to the Constructivist Grounded Theory approach.

Results

Twenty-four interviews were conducted involving 20 unique participants. Although for some participants hospitalisation was just a ripple, for others, it was a turning point. It could have positive or negative impacts on outcomes, including remaining alive, disease, fatigue/condition, complaints, daily functioning, social activities and intimate relationships, hobbies, living situation and mental well-being. Few participants were completely satisfied, but for many, a discrepancy between expectation and reality existed. Some participants could accept this, others remained hopeful and some were frustrated. Factors associated with these categories were research and treatment options, (un)clarity about the situation, setting the bar too high or pushing boundaries, confidence in physicians, character traits and social factors.

Conclusions

of the persons whose outcomes did not meet their expectations, some were frustrated, others hopeful and others accepted the situation. The following interventions can help patients to accept: clear communication about options and expectations before, during and after hospitalisation; giving room for emotions; help finding social support, encouragement to engage in pleasant activities and find meaning in small things. For some patients, psychological treatment may be needed.

Municipal acute care teams as a flexible solution for the treatment of acutely ill patients at-home: a mixed-method study of patients' and caregivers' experiences with an acute care team

OBJECTIVE

Development of initiatives to reduce hospitalisations is a major focus of healthcare planning. Strengthening the community with municipal acute care teams or units is a newly implemented Danish initiative aimed at preventing hospitalisations and supporting more flexible services. This study aims to describe patients treated by a municipal acute care team and to explore patients' and caregivers' experiences with at-home treatment.

DESIGN

A mixed-method study consisting of descriptive statistics of patients treated by an acute care team, and quantitative and qualitative data from follow-up telephone questionnaires with patients and caregivers.

SETTING

The acute care team, 'Acute Team Odense' (ATO), in the Odense Municipality, Denmark.

PARTICIPANTS

Patients treated by ATO and their caregivers. ATO treated 3231 patients (5676 contacts) in the period of 2018-2019.

RESULTS

Average number of new contacts per day was 7.8, and the median treatment-length was 1 day. Patients were referred by various healthcare providers and most often by general practitioners, municipal staff and hospital staff. The median age of the patients was 80 years, and 20% were independent before the treatment. In total, 787/5676 contacts received at-home intravenous therapy, which corresponded to 3.6 hospital beds saved per day. The questionnaires were completed by 307/478 patients and 168/254 caregivers. Most respondents stated they would prefer at-home treatment in future similar situations as it enabled them to maintain their lives. Several respondents also experienced that ATO avoided hospitalisations or reduced hospital stays, which was described as a relief.

CONCLUSION

ATO was frequently used, indicating the demand for community-based acute healthcare. The patients and caregivers experienced that this solution avoided hospitalisations and allowed them to maintain their lives, and this was described as less burdensome. As a result of these findings, this initiative has been continued with an ongoing focus on searching for possibilities aimed to prevent hospitalisations.

Predictors of short-term hospitalization and emergency department presentations in aged care

OBJECTIVES

To examine individual, medication, system, and healthcare related predictors of hospitalization and emergency department (ED) presentation within 90 days of entering the aged care sector, and to create risk-profiles associated with these outcomes.

DESIGN AND SETTING

Retrospective population-based cohort study using data from the Registry of Senior Australians.

PARTICIPANTS

Older people (aged 65 and older) with an aged care eligibility assessment in South Australia between January 1, 2013 and May 31, 2016 (N = 22,130).

MEASUREMENTS

Primary outcomes were unplanned hospitalization and ED presentation within 90 days of assessment. Individual, medication, system, and healthcare related predictors of the outcomes at the time of assessment, within 90 days or 1-year prior. Fine-Gray models were used to calculate subdistribution hazard ratios (sHR) and 95% confidence intervals (CI). Harrell's C-index assessed predictive ability.

RESULTS

Four thousand nine-hundred and six (22.2%) individuals were hospitalized and 5028 (22.7%) had an ED presentation within 90 days. Predictors of hospitalization included: being a man (hospitalization sHR = 1.33, 95% CI 1.26-1.42), ≥3 urgent after-hours attendances (hospitalization sHR = 1.21, 95% CI 1.06-1.39), increasing frailty index score (hospitalization sHR = 1.19, 95% CI 1.11-1.28), individuals using glucocorticoids (hospitalization sHR = 1.11, 95% CI 1.02-1.20), sulfonamides (hospitalization sHR = 1.18, 95% CI 1.10-1.27), trimethoprim antibiotics (hospitalization sHR = 1.15, 95% CI 1.03-1.29), unplanned hospitalizations 30 days prior (hospitalization sHR = 1.13, 95% CI 1.04-1.23), and ED presentations 1 year prior (hospitalization sHR = 1.07, 95% CI 1.04-1.10). Similar predictors and hazard estimates were also observed for ED presentations. The hospitalization models out-of-sample predictive ability (C-index = 0.653, 95% CI 0.635-0.670) and ED presentations (C-index = 0.647, 95% CI 0.630-0.663) were moderate.

CONCLUSIONS

One in five individuals with aged care eligibility assessments had unplanned hospitalizations and/or ED presentation within 90 days with several predictors identified at the time of aged care eligibility assessment. This is an actionable period for targeting at-risk individuals to reduce hospitalizations.

Functional Effects of Intervening Illnesses and Injuries After Critical Illness in Older Persons

OBJECTIVES

Intervening illnesses and injuries have pronounced deleterious effects on functional status in older persons, but have not been carefully evaluated after critical illness. We set out to evaluate the functional effects of intervening illnesses and injuries in the year after critical illness.

DESIGN

Prospective longitudinal study of 754 nondisabled community-living persons, 70 years old or older.

SETTING

Greater New Haven, CT, from March 1998 to December 2018.

PATIENTS

The analytic sample included 250 ICU admissions from 209 community-living participants who were discharged from the hospital.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Functional status (13 activities) and exposure to intervening illnesses and injuries leading to hospitalization, emergency department visit, or restricted activity were assessed each month. Comprehensive assessments (for covariates) were completed every 18 months. In the year after critical illness, recovery of premorbid function was observed for 169 of the ICU admissions (67.6%), and the mean (sd) number of episodes of functional decline (from 1 mo to the next) was 2.2 (1.6). The adjusted hazard ratios (95% CI) for recovery were 0.18 (0.09-0.39), 0.46 (0.17-1.26), and 0.75 (0.48-1.18) for intervening hospitalizations, emergency department visits, and restricted activity, respectively. For functional decline, the corresponding odds ratios (95% CI) were 2.06 (1.56-2.73), 1.78 (1.12-2.83), and 1.25 (0.92-1.69). The effect sizes for hospitalization and emergency department visit were larger than those for any of the covariates.

CONCLUSIONS

In the year after critical illness, intervening illnesses and injuries leading to hospitalization and emergency department visit are strongly associated with adverse functional outcomes, with effect sizes larger than those of traditional risk factors. To improve functional outcomes, more aggressive efforts will be needed to prevent and manage intervening illnesses and injuries after critical illness.