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Brunetti E, Lucà F, Presta R, Marchionni N, Boccanelli A, Ungar A, Rao CM, Ingianni N, Lettino M, Del Sindaco D, Murrone A, Riccio C, Colivicchi F, Grimaldi M, Gulizia MM, Oliva F, Bo M, Parrini I. A Comprehensive Geriatric Workup and Frailty Assessment in Older Patients with Severe Aortic Stenosis. J Clin Med 2024; 13:4169. [PMID: 39064209 PMCID: PMC11278149 DOI: 10.3390/jcm13144169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 07/04/2024] [Accepted: 07/09/2024] [Indexed: 07/28/2024] Open
Abstract
Aortic stenosis (AS) represents a notable paradigm for cardiovascular (CV) and geriatric disorders owing to comorbidity. Transcatheter aortic valve replacement (TAVR) was initially considered a therapeutic strategy in elderly individuals deemed unsuitable for or at high risk of surgical valve replacement. The progressive improvement in TAVR technology has led to the need to refine older patients' stratification, progressively incorporating the concept of frailty and other geriatric vulnerabilities. Recognizing the intricate nature of the aging process, reliance exclusively on chronological age for stratification resulted in an initial but inadequate tool to assess both CV and non-CV risks effectively. A comprehensive geriatric evaluation should be performed before TAVR procedures, taking into account both physical and cognitive capabilities and post-procedural outcomes through a multidisciplinary framework. This review adopts a multidisciplinary perspective to delve into the diagnosis and holistic management of AS in elderly populations in order to facilitate decision-making, thereby optimizing outcomes centered around patient well-being.
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Affiliation(s)
- Enrico Brunetti
- Geriatric Unit, Department of Medical Sciences, University of Turin, Hospital Città della Salute e della Scienza di Torino, 10126 Turin, Italy (R.P.); (M.B.)
- Department of Experimental and Clinical Medicine, University of Florence, Largo G. Brambilla 3, 50134 Florence, Italy
| | - Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano di Reggio, 89124 Reggio Calabria, Italy
| | - Roberto Presta
- Geriatric Unit, Department of Medical Sciences, University of Turin, Hospital Città della Salute e della Scienza di Torino, 10126 Turin, Italy (R.P.); (M.B.)
| | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine, University of Florence, Largo G. Brambilla 3, 50134 Florence, Italy
| | | | - Andrea Ungar
- Department of Experimental and Clinical Medicine, University of Florence, Largo G. Brambilla 3, 50134 Florence, Italy
| | | | | | - Maddalena Lettino
- Department for Cardiac, Thoracic and Vascular Diseases, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
| | | | - Adriano Murrone
- S.C. Cardiologia-UTIC, Ospedali di Città di Castello e di Gubbio-Gualdo Tadino, AUSL Umbria 1, 06127 Perugia, Italy
| | - Carmine Riccio
- Division of Clinical Cardiology, A.O.R.N. ‘Sant’Anna e San Sebastiano’, 81100 Caserta, Italy
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Unit, San Filippo Neri Hospital, 00135 Rome, Italy
| | - Massimo Grimaldi
- Cardiology Department, Miulli Hospital, Acquaviva delle Fonti, 70021 Bari, Italy
| | | | - Fabrizio Oliva
- Cardiovascular Department “A. De Gasperis”, ASST Niguarda Hospital, 20162 Milano, Italy
| | - Mario Bo
- Geriatric Unit, Department of Medical Sciences, University of Turin, Hospital Città della Salute e della Scienza di Torino, 10126 Turin, Italy (R.P.); (M.B.)
| | - Iris Parrini
- Department of Cardiology, Mauriziano Hospital, 10128 Turin, Italy
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Jimenez EE, Rosland AM, Stockdale SE, Reddy A, Wong MS, Torrence N, Huynh A, Chang ET. Implementing evidence-based practices to improve primary care for high-risk patients: study protocol for the VA high-RIsk VETerans (RIVET) type III effectiveness-implementation trial. Implement Sci Commun 2024; 5:75. [PMID: 39010160 PMCID: PMC11251253 DOI: 10.1186/s43058-024-00613-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 07/08/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND Patients with significant multimorbidity and other factors that make healthcare challenging to access and coordinate are at high risk for poor health outcomes. Although most (93%) of Veterans' Health Administration (VHA) patients at high risk for hospitalization or death ("high-risk Veterans") are primarily managed by primary care teams, few of these teams have implemented evidence-based practices (EBPs) known to improve outcomes for the high-risk patient population's complex healthcare issues. Effective implementation strategies could increase adoption of these EBPs in primary care; however, the most effective implementation strategies to increase evidence-based care for high-risk patients are unknown. The high-RIsk VETerans (RIVET) Quality Enhancement Research Initiative (QUERI) will compare two variants of Evidence-Based Quality Improvement (EBQI) strategies to implement two distinct EBPs for high-risk Veterans: individual coaching (EBQI-IC; tailored training with individual implementation sites to meet site-specific needs) versus learning collaborative (EBQI-LC; implementation sites trained in groups to encourage collaboration among sites). One EBP, Comprehensive Assessment and Care Planning (CACP), guides teams in addressing patients' cognitive, functional, and social needs through a comprehensive care plan. The other EBP, Medication Adherence Assessment (MAA), addresses common challenges to medication adherence using a patient-centered approach. METHODS We will recruit and randomize 16 sites to either EBQI-IC or EBQI-LC to implement one of the EBPs, chosen by the site. Each site will have a site champion (front-line staff) who will participate in 18 months of EBQI facilitation. ANALYSIS We will use a mixed-methods type 3 hybrid Effectiveness-Implementation trial to test EBQI-IC versus EBQI-LC versus usual care using a Concurrent Stepped Wedge design. We will use the Practical, Robust Implementation and Sustainability Model (PRISM) framework to compare and evaluate Reach, Effectiveness, Adoption, Implementation, and costs. We will then assess the maintenance/sustainment and spread of both EBPs in primary care after the 18-month implementation period. Our primary outcome will be Reach, measured by the percentage of eligible high-risk patients who received the EBP. DISCUSSION Our study will identify which implementation strategy is most effective overall, and under various contexts, accounting for unique barriers, facilitators, EBP characteristics, and adaptations. Ultimately this study will identify ways for primary care clinics and teams to choose implementation strategies that can improve care and outcomes for patients with complex healthcare needs. TRIAL REGISTRATION ClinicalTrials.gov, NCT05050643. Registered September 9th, 2021, https://clinicaltrials.gov/study/NCT05050643 PROTOCOL VERSION: This protocol is Version 1.0 which was created on 6/3/2020.
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Affiliation(s)
- Elvira E Jimenez
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA, 90073, USA.
- Department of Neurology, David Gefen School of Medicine, University of California Los Angeles (UCLA), 760 Westwood Plaza, Los Angeles, CA, 90095, USA.
| | - Ann-Marie Rosland
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, 1 University Dr, Pittsburgh, PA, 15240, USA
- Caring for Complex Chronic Conditions Research Center & Division of General Internal Medicine, School of Medicine, University of Pittsburgh, 3550 Terrace St, Pittsburgh, PA, 15213, USA
| | - Susan E Stockdale
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA, 90073, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles (UCLA), 760 Westwood Plaza, Los Angeles, CA, 90095, USA
| | - Ashok Reddy
- Department of Medicine, Division of General Internal Medicine, Harborview Medical Center, University of Washington, 325 Ninth Ave, Box 359780, Seattle, WA, 98104, USA
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA, 98108, USA
| | - Michelle S Wong
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA, 90073, USA
| | - Natasha Torrence
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, 1 University Dr, Pittsburgh, PA, 15240, USA
- Caring for Complex Chronic Conditions Research Center & Division of General Internal Medicine, School of Medicine, University of Pittsburgh, 3550 Terrace St, Pittsburgh, PA, 15213, USA
| | - Alexis Huynh
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA, 90073, USA
| | - Evelyn T Chang
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA, 90073, USA
- Division of General Internal Medicine, Department of Medicine, David Gefen School of Medicine, UCLA, 740 Charles E Young Dr S, Los Angeles, CA, 90095, USA
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Checa‐López M, Costa‐Grille A, Álvarez‐Bustos A, Carnicero‐Carreño JA, Sinclair A, Scuteri A, Landi F, Solano‐Jaurrieta JJ, Bellary S, Rodríguez‐Mañas L. Effectiveness of a randomized intervention by a geriatric team in frail hospital inpatients in non-geriatric settings: FRAILCLINIC project. J Cachexia Sarcopenia Muscle 2024; 15:361-369. [PMID: 38014479 PMCID: PMC10834340 DOI: 10.1002/jcsm.13374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 09/05/2023] [Accepted: 10/18/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Little research has been undertaken on the benefits of frailty management within different hospital settings. The objective of this study is to provide evidence on the viability and effectiveness of frailty management in non-geriatric hospital settings on mortality and functional decline after discharge. METHODS Data from the FRAILCLINIC (NCT02643069) study were used. FRAILCLINIC is a randomized controlled trial developed in non-geriatric hospital inpatient settings (emergency room, cardiology and surgery) from Spain (2), Italy (2) and the United Kingdom (1). Inpatients must met frailty criteria (according to the Frailty Phenotype and/or FRAIL scale), ≥75 years old. The control group (CG) received usual care. The intervention group (IG) received comprehensive geriatric assessment (CGA) and a coordinated intervention consisting in recommendations to the treating physician about polypharmacy, delirium, falls, nutrition and physical exercise plus a discharge plan. The main outcomes included functional decline (worsening ≥5 points in Barthel Index) and mortality at 3 months. We used multivariate logistic regression models adjusted by age, gender and the Charlson index. Intention-to-treat (ITT) and per-protocol (PP) analyses were used. RESULTS Eight hundred twenty one participants (IG: 416; mean age 83.00 ± 4.91; 51.44% women; CG: 405; mean age 82.46 ± 6.03; 52.35% women) were included. In the IG, 77.16% of the participants followed the geriatric team's recommendations as implemented by the treating physicians. The intervention showed a benefit on functional decline and mortality [OR: 0.67(0.47-0.96), P-value 0.027 and 0.29(0.14-0.57), P-value < 0.001, respectively) when fully followed by the treating physician. A trend to benefit (close to statistical significance) in functional decline and mortality were also observed when any of the recommendations were not followed [OR (95% CI): 0.72 (0.51-1.01), P-value: 0.055; and 0.64 (0.37-1.10), P-value: 0.105, respectively]. CONCLUSIONS An individualized intervention in frail in-patients reduces the risk of functional deterioration and mortality at 3 months of follow-up when a care management plan is designed and followed.
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Affiliation(s)
| | - Alba Costa‐Grille
- Servicio de GeriatríaHospital Universitario de GetafeGetafeSpain
- Fundación para la Investigación e Innovación Biosanitaria de Atención Primaria (FIIBAP)MadridSpain
| | - Alejandro Álvarez‐Bustos
- Centro de Investigación Biomédica en Red sobre Fragilidad y Envejecimiento Saludable (CIBERFES)Instituto de Salud Carlos IIIMadridSpain
| | - Jose A. Carnicero‐Carreño
- Centro de Investigación Biomédica en Red sobre Fragilidad y Envejecimiento Saludable (CIBERFES)Instituto de Salud Carlos IIIMadridSpain
- Fundación de Investigación BiomédicaHospital Universitario de GetafeGetafeSpain
| | - Alan Sinclair
- Foundation for Diabetes Research in Older People, Diabetes FrailMedici Medical PracticeLutonUK
- School of Life and Health SciencesAston UniversityBirminghamUK
| | - Angelo Scuteri
- Department of Clinical and Experimental MedicineUniversity of SassariSassariItaly
| | - Francesco Landi
- Department of Geriatrics, Neurosciences and OrthopedicsCatholic University of the Sacred Heart School of MedicineRomeItaly
| | - Juan José Solano‐Jaurrieta
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA) and Geriatric Service, Monte Naranco HospitalOviedoSpain
| | | | - Leocadio Rodríguez‐Mañas
- Servicio de GeriatríaHospital Universitario de GetafeGetafeSpain
- Centro de Investigación Biomédica en Red sobre Fragilidad y Envejecimiento Saludable (CIBERFES)Instituto de Salud Carlos IIIMadridSpain
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Fox ST, Janda M, Hubbard R. Understanding how comprehensive geriatric assessment works: the importance of varied methodological approaches. Aging Clin Exp Res 2023; 35:417-423. [PMID: 36451033 DOI: 10.1007/s40520-022-02305-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 11/10/2022] [Indexed: 12/05/2022]
Abstract
Comprehensive geriatric assessment (CGA) is the gold standard model of care for older adults with frailty. However, despite a large number of published clinical trials, there remain many unanswered questions about how CGA works in different circumstances. This uncertainty stems from CGA being a deeply complex intervention that is heavily modified by context. This review describes recent and novel methodological approaches that explore the active ingredients of CGA and their interaction with context. Future research should continue to embrace broad methodologies that can help us better understand this intervention, in such a way that it can be implemented with fidelity and associated with positive outcomes for older adults.
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Affiliation(s)
- Sarah T Fox
- Consultant Geriatrician, The Prince Charles Hospital, Brisbane, Australia.
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia.
| | - Monika Janda
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | - Ruth Hubbard
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
- Consultant Geriatrician, Princess Alexandra Hospital, Brisbane, Australia
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Ijadi Maghsoodi A, Pavlov V, Rouse P, Walker CG, Parsons M. Efficacy of acute care pathways for older patients: a systematic review and meta-analysis. Eur J Ageing 2022; 19:1571-1585. [PMID: 36692788 PMCID: PMC9729482 DOI: 10.1007/s10433-022-00743-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2022] [Indexed: 11/18/2022] Open
Abstract
Meeting the needs of acute geriatric patients is often challenging, and although evidence shows that older patients need tailored care, it is still unclear which interventions are most appropriate. The objective of this study is to systematically evaluate the hospital-wide acute geriatric models compared with conventional pathways. The design of the study includes hospital-wide geriatric-specific models characterized by components including patient-centered care, frequent medical review, early rehabilitation, early discharge planning, prepared environment, and follow-up after discharge. Primary and secondary outcomes were considered, including functional decline, activities of daily living (ADL), length-of-stay (LoS), discharge destination, mortality, costs, and readmission. A systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. A total of 20 studies reporting on 15 trials and acutely admitted patients with an average age of 79, complex conditions and comorbidities to acute geriatric-specific pathways (N = 13,595) were included. Geriatric-specific models were associated with lower costs (weighted mean difference, WMD = - $174.98, 95% CI = -$332.14 to - $17.82; P = 0.03), and shorter LoS (WMD = - 1.11, 95% CI = - 1.39 to - 0.83; P < 0.001). No differences were found in functional decline, ADL, mortality, case fatalities, discharge destination, or readmissions. Geriatric-specific models are valuable for improving patient and system-level outcomes. Although several interventions had positive results, further research is recommended to study hospital-wide geriatric-specific models.
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Affiliation(s)
- Abtin Ijadi Maghsoodi
- Department of Information Systems and Operations Management, Faculty of Business and Economics, University of Auckland, Auckland, New Zealand ,Department of Intelligence & Insights, Te Whatu Ora Health New Zealand Waikato District, Hamilton, New Zealand
| | - Valery Pavlov
- Department of Information Systems and Operations Management, Faculty of Business and Economics, University of Auckland, Auckland, New Zealand
| | - Paul Rouse
- Department of Accounting and Finance, Faculty of Business and Economics , University of Auckland, Auckland, New Zealand
| | - Cameron G. Walker
- Department of Engineering Science, Faculty of Engineering , University of Auckland, Auckland, New Zealand
| | - Matthew Parsons
- School of Health , University of Waikato, Hamilton, New Zealand ,Te Whatu Ora Health New Zealand Waikato District, Hamilton, New Zealand
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Martinez M, Falvey JR, Cifu A. Deconditioned, disabled, or debilitated? Formalizing management of functional mobility impairments in the medical inpatient setting. J Hosp Med 2022; 17:843-846. [PMID: 35818341 PMCID: PMC9796863 DOI: 10.1002/jhm.12910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/14/2022] [Accepted: 06/16/2022] [Indexed: 01/07/2023]
Affiliation(s)
- Maylyn Martinez
- Department of Medicine, Section of Hospital MedicineUniversity of ChicagoChicagoIllinoisUSA
| | - Jason R. Falvey
- Department of Physical Therapy and Rehabilitation ScienceUniversity of Maryland School of MedicineBaltimoreMarylandUSA
- Department of Epidemiology and Public HealthUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Adam Cifu
- Department of Medicine, Section of General Internal MedicineUniversity of ChicagoChicagoIllinoisUSA
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Xin J, Li L. Mobility and Quality of Life in Chinese Elderly and Geriatric Patients and Biomedical Diagnosis. COMPUTATIONAL INTELLIGENCE AND NEUROSCIENCE 2022; 2022:7457161. [PMID: 36164429 PMCID: PMC9509261 DOI: 10.1155/2022/7457161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/24/2022] [Accepted: 07/29/2022] [Indexed: 11/29/2022]
Abstract
Mobilization hugely affects the personal satisfaction of old people. We found that preparing old and geriatric patients expands their personal satisfaction using statistical comparisons of observed groups. As a technique of evaluation, we employed the nonparametric Mann-Whitney test. The Pearson correlation coefficient was employed to determine relationships between variables. In both the BREF questionnaire (item 15) and the ADL test, geriatric individuals had similar mobility rates. Physical activity is a crucial feature of mobility in seniors, according to findings from other studies. In hospitalized geriatric patients, reduced mobility is the most significant impediment. Seniors' confidence in their own talents grew as a result of the favourable overall influence of physical activity. Geriatric patients must be mobilized on a regular basis in nursing, depending on their level of dependency. Physical activity had a positive overall effect on older people's confidence in their own abilities, and this was shown in how they felt about themselves. Nursing staff must constantly move geriatric patients based on how much assistance they require.
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Affiliation(s)
- Jing Xin
- School of Public Administration, Zhongnan University of Economics and Law, Wuhan 430073, China
- Fanling Business School, Nanyang Institute of Technology, Nanyang 473004, China
| | - Liyuan Li
- Fanling Business School, Nanyang Institute of Technology, Nanyang 473004, China
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Mizutani T. Practical management of older adults with cancer: geriatric oncology in Japan. Jpn J Clin Oncol 2022; 52:1073-1081. [PMID: 35863011 PMCID: PMC9538777 DOI: 10.1093/jjco/hyac118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 07/07/2022] [Indexed: 11/30/2022] Open
Abstract
Japan has the highest proportion of older adults globally, and the average life expectancy of the Japanese population has increased in recent decades. Given that the incidence of cancer increases with age, it is a major health concern for older adults. However, geriatric oncology is a relatively new field and collaboration between oncologists and geriatricians in Japan is limited. Hence, oncologists and other healthcare professionals engaged in cancer care have not been able to adequately understand geriatric care, and information and experience are insufficient for this specific population. Thus, they may struggle with the assessment and management of older adults with cancer. Recently, several Japanese academic societies for cancer have developed practical guidelines and research policy with regard to geriatric research in older adults with cancer, in addition to organizing symposia and workshops focusing especially on geriatric oncology. Furthermore, because the Japan Geriatrics Society established a discipline committee on cancer, close collaboration between oncologists and geriatricians has grown steadily. Geriatric oncology is currently recognized as an important field of cancer care in Japan. The integration of oncology and geriatric care is anticipated in the near future. However, understanding the aspects of geriatric care and meanings of technical jargons used in geriatric oncology is difficult. Accordingly, this article provides an overview of the current knowledge and recent advancements in geriatric oncology. In addition, it outlines the current status and problems of geriatric oncology in Japan.
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Affiliation(s)
- Tomonori Mizutani
- Department of Medical Oncology, Kyorin University Faculty of Medicine, Japan
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9
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Baztán Cortés JJ, Rodríguez-Mañas L. [Effectiveness and efficiency of acute geriatric units: A classic topic revisited]. Rev Esp Geriatr Gerontol 2022; 57:230-235. [PMID: 35840443 DOI: 10.1016/j.regg.2022.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 06/19/2022] [Accepted: 06/20/2022] [Indexed: 10/17/2022]
Abstract
Previous meta-analyses have shown that the hospital admission of older patients in acute geriatric units (AGU) compared to admission to other conventional units, significantly reduced the risk of functional deterioration during hospitalization, increasing the possibility of returning home, with an added reduction in cost of hospitalization. A new meta-analysis on the subject has recently been published in Age and Aging, which adds six new studies to the five clinical trials analyzed in previous meta-analyses. This article analyzes the results of this new meta-analysis, delving into the characteristics of the new studies included and making some considerations on the implications for care in the future development of AGU.
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Affiliation(s)
- Juan José Baztán Cortés
- Servicio de Geriatría, Hospital Central Cruz Roja San José y Santa Adela, SERMAS, Madrid, España.
| | - Leocadio Rodríguez-Mañas
- Servicio de Geriatría, Hospital Universitario de Getafe, Getafe, Madrid, España; CIBER de Fragilidad y Envejecimiento Saludable (CIBERFES), ISCIII, Madrid, España
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10
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Loke SS, Lee CT, Huang S, Chen CT. A Pilot Study of the Effects on an Inpatient Geriatric Consultation Team on Geriatric Syndrome Patients. Int J Gen Med 2022; 15:5051-5060. [PMID: 35607357 PMCID: PMC9123904 DOI: 10.2147/ijgm.s363543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/27/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Song-Seng Loke
- Division of Geriatric Medicine, Department of Family Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City, Taiwan
- Correspondence: Song-Seng Loke, Division of Geriatric Medicine, Department of Family Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123, Dapi Road, Niaosong District, Kaohsiung City, 833, Taiwan, Tel +886-7-7317123, Email
| | - Chien-Te Lee
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Shan Huang
- Department of Management, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung City, Taiwan
| | - Chao-Tung Chen
- Department of Family Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City, Taiwan
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11
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Rozzini R, Bianchetti A, Alboni P, Baldasseroni S, Bo M, Boccanelli A, Desideri G, Marchionni N, Palazzo G, Terrosu P, Ungar A, Vetta F, Zito G. The older patient with cardiovascular disease: background and clinical implications of the comprehensive geriatric assessment (CGA). Minerva Med 2022; 113:609-615. [PMID: 35332761 DOI: 10.23736/s0026-4806.22.08086-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Principles and processes of Comprehensive Geriatric Assessment (CGA) are increasingly being applied to subspecialties and subspecialty conditions, including cardiovascular patients (i.e. infective endocarditis; considerations of surgery or transcatheter aortic valve replacement, TAVR, for patients with aortic stenosis; vascular surgery) and postoperative mortality risk. In cardiovascular field CGA has mainly the aim to define ideal management according to the different typology of older adult patients (eg, robust versus intermediate versus physical and cognitively disabled versus end-stage or dying), allowing physicians to select different therapeutic goals according to life expectancy; Aspect to be valued are by CGA are global health status and patient's decision-making capacity: CGA allows the individualized treatment definition and optimize the preprocedure condition.
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Affiliation(s)
- Renzo Rozzini
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy - .,Fondazione Poliambulanza, Istituto Ospedaliero, Brescia, Italy -
| | | | - Paolo Alboni
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | | | - Mario Bo
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | | | | | | | - Giuseppe Palazzo
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | | | - Andrea Ungar
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | - Francesco Vetta
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
| | - Giovanni Zito
- SICGe Società Italiana di Cardiologia Geriatrica, Florence, Italy
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Cords CI, Spronk I, Mattace-Raso FUS, Verhofstad MHJ, van der Vlies CH, van Baar ME. The feasibility and reliability of frailty assessment tools applicable in acute in-hospital trauma patients: A systematic review. J Trauma Acute Care Surg 2022; 92:615-626. [PMID: 34789703 DOI: 10.1097/ta.0000000000003472] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Assessing frailty in patients with an acute trauma can be challenging. To provide trustworthy results, tools should be feasible and reliable. This systematic review evaluated existing evidence on the feasibility and reliability of frailty assessment tools applied in acute in-hospital trauma patients. METHODS A systematic search was conducted in relevant databases until February 2020. Studies evaluating the feasibility and/or reliability of a multidimensional frailty assessment tool used to identify frail trauma patients were identified. The feasibility and reliability results and the risk of bias of included studies were assessed. This study was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and registered in Prospective Register of Systematic Reviews (ID: CRD42020175003). RESULTS Nineteen studies evaluating 12 frailty assessment tools were included. The risk of bias of the included studies was fair to good. The most frequently evaluated tool was the Clinical Frailty Scale (CFS) (n = 5). All studies evaluated feasibility in terms of the percentage of patients for whom frailty could be assessed; feasibility was high (median, 97%; range, 49-100%). Other feasibility aspects, including time needed for completion, tool availability and costs, availability of instructions, and necessity of training for users, were hardly reported. Reliability was only assessed in three studies, all evaluating the CFS. The interrater reliability varied between 42% and >90% agreement, with a Krippendorff α of 0.27 to 0.41. CONCLUSION Feasibility of most instruments was generally high. Other aspects were hardly reported. Reliability was only evaluated for the CFS with results varying from poor to good. The reliability of frailty assessment tools for acute trauma patients needs further critical evaluation to conclude whether assessment leads to trustworthy results that are useful in clinical practice. LEVEL OF EVIDENCE Systematic review, Level II.
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Affiliation(s)
- Charlotte I Cords
- From the Association of Dutch Burn Centres (C.I.C., I.S., M.E.v.B.), Maasstad Hospital; Department of Public Health (I.S., M.E.v.B.), Section of Geriatric Medicine, Department of Internal Medicine (F.U.S.M.-R.), and Trauma Research Unit Department of Surgery (C.I.C., M.H.J.V., C.H.v.d.V.), Erasmus MC, University Medical Center; and Burn Center (C.H.v.d.V.), Maasstad Hospital, Rotterdam, the Netherlands
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Intersectoral Ward Rounds on Patients Admitted to Temporary Twenty-Four-Hour Accommodations in Denmark: Case Study. Int J Integr Care 2022; 22:12. [PMID: 35221828 PMCID: PMC8833261 DOI: 10.5334/ijic.5688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 01/28/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction: Temporary twenty-four-hour accommodations (TTAs) are municipal beds for elderly patients discharged from the hospital with acute treatment, care and/or rehabilitation needs that cannot be met in their own homes. TTAs are staffed by nurses and nursing assistants who are not authorized to prescribe or modify medications. At North Zealand Hospital one third of the many readmissions from a TTA within eight days after discharge have been assessed as preventable. Description: A hospital-based team rounded on 268 patients at TTAs from May 2017 to October 2019 to promote integrated care. This study aimed to assess the efficacy of the rounding by auditing patient cases. A physician, a nurse, and a pharmacist from the hospital; a general practitioner; and one or two TTA nurses audited 17 cases. Discussion: Obtaining access to all electronic patient records and reconstructing information shared across sectors were not feasible in all cases. Conclusion
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Lee JY, Yang YS, Cho E. Transitional care from hospital to home for frail older adults: A systematic review and meta-analysis. Geriatr Nurs 2021; 43:64-76. [PMID: 34823079 DOI: 10.1016/j.gerinurse.2021.11.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 10/30/2021] [Accepted: 11/02/2021] [Indexed: 11/04/2022]
Abstract
Frail older adults are vulnerable to hospitalization and transitional care is needed to maintain care continuity; however, there exists no review regarding transitional care focusing on frailty. This study aimed to investigate transitional care for frail older adults and its effectiveness. Search terms were (P) frail older adults; (I) transitional care initiated before discharge; (C) usual care; (O) all health outcomes. Fourteen trials were identified. The most measured outcome was readmission (n = 13), followed by mortality (n = 9), function (n = 7), quality of life (n = 5), and self-rated health (n = 5). Statistical significance effects were reported in the followings: n = 6, readmission; n = 0, mortality; n = 3, function; n = 2, quality of life; and n = 4, self-rated health. The meta-analysis demonstrated that transitional care reduced readmission at six months but not other time points nor mortality or quality of life. The intervention effectiveness was inconclusive; therefore, an evidence-based yet novel approach is necessary to establish an adequate transitional care intervention for frail older adults.
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Affiliation(s)
- Ji Yeon Lee
- Yonsei University College of Nursing, Seoul, 03722, South Korea
| | - Yong Sook Yang
- Yonsei University College of Nursing, Seoul, 03722, South Korea
| | - Eunhee Cho
- Mo-Im Kim Nursing Research Institute, Yonsei University College of Nursing, Seoul, 03722, South Korea.
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15
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Alonso Bouzón C. [Comprehensive geriatric assessment. Position statement of the Spanish Society of Geriatric Medicine]. Rev Esp Geriatr Gerontol 2021; 56:248-249. [PMID: 33892993 DOI: 10.1016/j.regg.2021.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 02/20/2021] [Indexed: 06/12/2023]
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Westgård T, Andersson Hammar I, Dahlin-Ivanoff S, Wilhelmson K. Can Comprehensive Geriatric Assessment Meet Frail Older People's Needs? Results from the Randomized Controlled Study CGA-Swed. Geriatrics (Basel) 2020; 5:E101. [PMID: 33291834 PMCID: PMC7768486 DOI: 10.3390/geriatrics5040101] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The comprehensive geriatric assessment (CGA) designed to manage frail older people requiring acute medical care, is responsible for diagnostics, assessment, treatment, and planning while addressing a person's medical, psychological, social, and functional capabilities. The aim was to investigate if CGA had an impact on frail older people's activities of daily living (ADL) status, self-rated health, and satisfaction with hospital care. METHODS A two-armed design with frail people aged 75 or older who required an unplanned hospital admission were randomized to either the CGA ward or to an acute medical ward. Analyses were made based on the intention-to-treat principle (ITT). The primary outcome was ADL. Data were analyzed using Chi-square and odds ratio. A subgroup analysis was performed due to non-adherence and contamination. RESULTS One-hundred and fifty-five people participated in the study; 78 in the intervention and 77 in the control. Participants in the intervention group had a higher odds ratio of reporting having received written information and felt that care met their needs during their hospital stay. No additional statistically significant results for the primary or secondary outcomes in the ITT analysis were achieved. CONCLUSION Participants felt that the care they received with the CGA ward met their needs. The lack of additional results supporting the CGA could be due to difficulties performing pragmatic intervention trials in clinical hospital settings, and because a CGA during one hospital stay is probably not enough to have long-term effects.
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Affiliation(s)
- Theresa Westgård
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden; (I.A.H.); (K.W.)
- Centre of Aging and Health-AGECAP, University of Gothenburg, 405 30 Gothenburg, Sweden;
| | - Isabelle Andersson Hammar
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden; (I.A.H.); (K.W.)
- Centre of Aging and Health-AGECAP, University of Gothenburg, 405 30 Gothenburg, Sweden;
| | - Synneve Dahlin-Ivanoff
- Centre of Aging and Health-AGECAP, University of Gothenburg, 405 30 Gothenburg, Sweden;
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden
| | - Katarina Wilhelmson
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden; (I.A.H.); (K.W.)
- Centre of Aging and Health-AGECAP, University of Gothenburg, 405 30 Gothenburg, Sweden;
- Department of Geriatrics, The Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
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Abstract
Frailty is defined as a reduced physiologic reserve vulnerable to external stressors. For older individuals, frailty plays a decisive role in increasing adverse health outcomes in most clinical situations. Many tools or criteria have been introduced to define frailty in recent years, and the definition of frailty has gradually converged into several consensuses. Frail older adults often have multi-domain risk factors in terms of physical, psychological, and social health. Comprehensive geriatric assessment (CGA) is the process of identifying and quantifying frailty by examining various risky domains and body functions, which is the basis for geriatric medicine and research. CGA provides physicians with information on the reversible area of frailty and the leading cause of deterioration in frail older adults. Therefore frailty assessment based on understanding CGA and its relationship with frailty, can help establish treatment strategies and intervention in frail older adults. This review article summarizes the recent consensus and evidence of frailty and CGA.
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Affiliation(s)
- Heayon Lee
- Division of Geriatrics, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eunju Lee
- Division of Geriatrics, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Il Young Jang
- Division of Geriatrics, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Gardner M, Shepperd S, Godfrey M, Mäkelä P, Tsiachristas A, Singh-Mehta A, Ellis G, Khanna P, Langhorne P, Makin S, Stott DJ. Comprehensive Geriatric Assessment in hospital and hospital-at-home settings: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07100] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundThe Comprehensive Geriatric Assessment (CGA) is a multidisciplinary process that determines a frail older person’s medical, functional, psychological and social capability to ensure that they have a co-ordinated plan for treatment and follow-up.ObjectivesTo improve our understanding of the effectiveness, cost-effectiveness and implementation of the CGA across hospital and hospital-at-home settings.MethodsWe used a variety of methods. We updated a Cochrane review of randomised trials of the CGA in hospital for older people aged ≥ 65 years, conducted a national survey of community CGA, analysed data from three health boards using propensity score matching (PSM) and regression analysis, conducted a qualitative study and used a modified Delphi method.ResultsWe included 29 trials recruiting 13,766 participants in the Cochrane review of the CGA. Older people admitted to hospital who receive the CGA are more likely to be living at home at 3–12 months’ follow-up [relative risk (RR) 1.06, 95% confidence interval (CI) 1.01 to 1.10] (high certainty). The probability that the CGA would be cost-effective at a £20,000 ceiling ratio for quality-adjusted life-years (QALYs), life-years (LYs) and LYs living at home was 0.50, 0.89, and 0.47, respectively (low-certainty evidence). After PSM and regression analysis comparing CGA hospital with CGA hospital at home, we found that the health-care cost (from admission to 6 months after discharge) in site 1 was lower in hospital at home (ratio of means 0.82, 95% CI 0.76 to 0.89), in site 2 there was little difference (ratio of means 1.00, 95% CI 0.92 to 1.09) and in site 3 it was higher (ratio of means 1.15, 95% CI 0.99 to 1.33). Six months after discharge (excluding the index admission), the ratio of means cost in site 1 was 1.27 (95% CI 1.14 to 1.41), in site 2 was 1.09 (95% CI 0.95 to 1.24) and in site 3 was 1.70 (95% CI 1.40 to 2.07). At 6 months’ follow-up (excluding the index admission), there may be an increased risk of mortality (adjusted) in the three hospital-at-home cohorts (site 1: RR 1.09, 95% CI 1.00 to 1.19; site 2: RR 1.29, 95% CI 1.15 to 1.44; site 3: RR 1.27, 95% CI 1.06 to 1.54). The qualitative research indicates the importance of relational aspects of health care, incorporating caregivers’ knowledge in care planning, and a lack of clarity about the end of an episode of health care. Core components that should be included in CGA focus on functional, physical and mental well-being, medication review and a caregiver’s ability to care.LimitationsThe risk of residual confounding limits the certainty of the findings from the PSM analysis; a second major limitation is that the research plan did not include an investigation of social care or primary care.ConclusionsThe CGA is an effective way to organise health care for older people in hospital and may lead to a small increase in costs. There may be an increase in cost and the risk of mortality in the population who received the CGA hospital at home compared with those who received the CGA in hospital; randomised evidence is required to confirm or refute this. Caregiver involvement in the CGA process could be strengthened.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Mike Gardner
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sasha Shepperd
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Mary Godfrey
- Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Petra Mäkelä
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Amina Singh-Mehta
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Graham Ellis
- Monklands Hospital, NHS Lanarkshire, Glasgow, UK
| | | | - Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Stephen Makin
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - David J Stott
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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19
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Schubert CC, Parks R, Coffing JM, Daggy J, Slaven JE, Weiner M. Lessons and Outcomes of Mobile Acute Care for Elders Consultation in a Veterans Affairs Medical Center. J Am Geriatr Soc 2018; 67:818-824. [PMID: 30575012 DOI: 10.1111/jgs.15730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 11/16/2018] [Accepted: 11/17/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Describe the implementation and effects of Mobile Acute Care for Elders (MACE) consultation at a Veterans Affairs Medical Center (VAMC). DESIGN Retrospective cohort analysis. INTERVENTION Veterans aged 65 or older who were admitted to the medicine service between October 1, 2012, and September 30, 2014, were screened for geriatric syndromes via review of medical records within 48 hours of admission. If the screen was positive, the MACE team offered the admitting team a same-day consultation involving comprehensive geriatric assessment and ongoing collaboration with the admitting team and supportive services to implement patient-centric recommendations for geriatric syndromes. RESULTS Veterans seen by MACE (n = 421) were compared with those with positive screens but without consultation (n = 372). The two groups did not significantly differ in age, comorbidity, sex, or race. All outcomes (30-day readmission, 30-day mortality, readmission costs) were in the expected direction for patients receiving MACE but did not reach statistical significance. Patients receiving MACE had lower odds of 30-day readmission (11.9% vs 14.8%; odds ratio [OR] = 0.82; 95% confidence interval [CI] = 0.54-1.25; p = .360) and 30-day mortality (5.5% vs 8.6%; OR = 0.64; CI = 0.36-1.12; p = .115), and they had lower 30-day readmission costs (MACE $15,502; CI = $12,242-$19,631; comparison = $18,335; CI = $14,641-$22,962; p = .316) than those who did not receive MACE after adjusting for age and Charlson Comorbidity Index. CONCLUSION Our MACE consultation model for older veterans with geriatric syndromes leverages the limited supply of clinicians with expertise in geriatrics. Although not statistically significant in this study of 793 subjects, MACE patients had lower odds of 30-day readmission and mortality, and lower readmission costs. J Am Geriatr Soc 67:818-824, 2019.
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Affiliation(s)
- Cathy C Schubert
- Indiana University School of Medicine, Indianapolis, Indiana.,Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
| | - Rebecca Parks
- Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
| | - Jessica M Coffing
- Center for Health Information and Communication, U.S. Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Indianapolis, Indiana
| | - Joanne Daggy
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana
| | - James E Slaven
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Michael Weiner
- Indiana University School of Medicine, Indianapolis, Indiana.,Richard L. Roudebush VA Medical Center, Indianapolis, Indiana.,Center for Health Information and Communication, U.S. Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Indianapolis, Indiana.,Regenstrief Institute, Inc., Indianapolis, Indiana
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20
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Penney LS, Nahid M, Leykum LK, Lanham HJ, Noël PH, Finley EP, Pugh J. Interventions to reduce readmissions: can complex adaptive system theory explain the heterogeneity in effectiveness? A systematic review. BMC Health Serv Res 2018; 18:894. [PMID: 30477576 PMCID: PMC6260570 DOI: 10.1186/s12913-018-3712-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 11/14/2018] [Indexed: 11/13/2022] Open
Abstract
Background Successfully transitioning patients from hospital to home is a complex, often uncertain task. Despite significant efforts to improve the effectiveness of care transitions, they remain a challenge across health care systems. The lens of complex adaptive systems (CAS) provides a theoretical approach for studying care transition interventions, with potential implications for intervention effectiveness. The aim of this study is to examine whether care transition interventions that are congruent with the complexity of the processes and conditions they are trying to improve will have better outcomes. Methods We identified a convenience sample of high-quality care transition intervention studies included in a care transition synthesis report by Kansagara and colleagues. After excluding studies that did not meet our criteria, we scored each study based on (1) the presence or absence of 5 CAS characteristics (learning, interconnections, self-organization, co-evolution, and emergence), as well as system-level interdependencies (resources and processes) in the intervention design, and (2) scored study readmission-related outcomes for effectiveness. Results Forty-four of the 154 reviewed articles met our inclusion criteria; these studies reported on 46 interventions. Nearly all the interventions involved a change in interconnections between people compared with care as usual (96% of interventions), and added resources (98%) and processes (98%). Most contained elements impacting learning (67%) and self-organization (69%). No intervention reflected either co-evolution or emergence. Almost 40% of interventions were rated as effective in terms of impact on hospital readmissions. Chi square testing for an association between outcomes and CAS characteristics was not significant for learning or self-organization, however interventions rated as effective were significantly more likely to have both of these characteristics (78%) than interventions rated as having no effect (32%, p = 0.005). Conclusions Interventions with components that influenced learning and self-organization were associated with a significant improvement in hospital readmissions-related outcomes. Learning alone might be necessary but not be sufficient for improving transitions. However, building self-organization into the intervention might help people effectively respond to problems and adapt in uncertain situations to reduce the likelihood of readmission. Electronic supplementary material The online version of this article (10.1186/s12913-018-3712-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lauren S Penney
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX, 78229, USA. .,Department of Medicine, The University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.
| | - Musarrat Nahid
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX, 78229, USA.,Department of Medicine, The University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
| | - Luci K Leykum
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX, 78229, USA.,Department of Medicine, The University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.,Department of Information, Risk and Operations Management, McCombs School of Business, The University of Texas at Austin, 2110 Speedway Stop B6500, Austin, TX, 78712-1277, USA
| | - Holly Jordan Lanham
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX, 78229, USA.,Department of Medicine, The University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.,Department of Information, Risk and Operations Management, McCombs School of Business, The University of Texas at Austin, 2110 Speedway Stop B6500, Austin, TX, 78712-1277, USA.,Department of Family & Community Medicine, The University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
| | - Polly H Noël
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX, 78229, USA.,Department of Family & Community Medicine, The University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
| | - Erin P Finley
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX, 78229, USA.,Department of Medicine, The University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.,Department of Psychiatry, The University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
| | - Jacqueline Pugh
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX, 78229, USA.,Department of Medicine, The University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
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Bernstein JM, Graven P, Drago K, Dobbertin K, Eckstrom E. Higher Quality, Lower Cost with an Innovative Geriatrics Consultation Service. J Am Geriatr Soc 2018; 66:1790-1795. [PMID: 30094830 DOI: 10.1111/jgs.15473] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 03/27/2018] [Accepted: 05/11/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To design a value-driven, interprofessional inpatient geriatric consultation program coordinated with systems-level changes and studied outcomes and costs. DESIGN Propensity-matched case-control study of older adults hospitalized at an academic medical center (AMC) who did or did not receive geriatric consultation. SETTING Single tertiary-care AMC in Portland, Oregon. PARTICIPANTS Adults aged 70 and older who received an inpatient geriatric consultation (n=464) and propensity-matched controls admitted before development of the consultation program (n=2,381). Pre- and postintervention controls were also incorporated into cost difference-in-difference analyses. MEASUREMENTS Daily charges, total charges, length of stay (LOS), 30-day readmission, intensive care unit (ICU) days, Foley catheter days, total medication doses per day, high-risk medication doses per day, advance directive and Physician Orders for Life Sustaining Treatment (POLST) documentation, restraint orders, discharge to home, and mortality. RESULTS On average, individuals who received a geriatric consultation had $611 lower charges per day than those without a consultation (p=.02). They spent on average 0.36 fewer days in the ICU (p<.001). They were less likely to have restraint orders (20.0% vs 27.9%, p<0.001), more likely to have a POLST (58.2% vs 44.6%, p<.001), and more likely to be discharged to home (33.4% vs 28.2%, p=.03). They received fewer doses of antipsychotics, benzodiazepines, and antiemetics (10, 5, and 7 fewer doses per 100 patient-days, respectively) and had lower in-hospital mortality (2.4% vs 4%, p=.01). There was no difference in hospital LOS or 30-day readmission. CONCLUSION Our consultation program resulted in significant reductions in daily charges, ICU days, potentially inappropriate medication use, and use of physical restraints and increased end-of-life planning. This model has potential for dissemination to other institutions operating in resource-scarce, value-driven settings.
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Affiliation(s)
- Juliana M Bernstein
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, Oregon
| | - Peter Graven
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon
| | - Kathleen Drago
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, Oregon
| | - Konrad Dobbertin
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon
| | - Elizabeth Eckstrom
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, Oregon
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International practice settings, interventions and outcomes of nurse practitioners in geriatric care: A scoping review. Int J Nurs Stud 2018; 78:61-75. [DOI: 10.1016/j.ijnurstu.2017.09.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 07/28/2017] [Accepted: 09/13/2017] [Indexed: 01/15/2023]
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Ellis G, Gardner M, Tsiachristas A, Langhorne P, Burke O, Harwood RH, Conroy SP, Kircher T, Somme D, Saltvedt I, Wald H, O'Neill D, Robinson D, Shepperd S. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev 2017; 9:CD006211. [PMID: 28898390 PMCID: PMC6484374 DOI: 10.1002/14651858.cd006211.pub3] [Citation(s) in RCA: 333] [Impact Index Per Article: 47.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Comprehensive geriatric assessment (CGA) is a multi-dimensional, multi-disciplinary diagnostic and therapeutic process conducted to determine the medical, mental, and functional problems of older people with frailty so that a co-ordinated and integrated plan for treatment and follow-up can be developed. This is an update of a previously published Cochrane review. OBJECTIVES We sought to critically appraise and summarise current evidence on the effectiveness and resource use of CGA for older adults admitted to hospital, and to use these data to estimate its cost-effectiveness. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, three other databases, and two trials registers on 5 October 2016; we also checked reference lists and contacted study authors. SELECTION CRITERIA We included randomised trials that compared inpatient CGA (delivered on geriatric wards or by mobile teams) versus usual care on a general medical ward or on a ward for older people, usually admitted to hospital for acute care or for inpatient rehabilitation after an acute admission. DATA COLLECTION AND ANALYSIS We followed standard methodological procedures expected by Cochrane and Effective Practice and Organisation of Care (EPOC). We used the GRADE approach to assess the certainty of evidence for the most important outcomes. For this update, we requested individual patient data (IPD) from trialists, and we conducted a survey of trialists to obtain details of delivery of CGA. We calculated risk ratios (RRs), mean differences (MDs), or standardised mean differences (SMDs), and combined data using fixed-effect meta-analysis. We estimated cost-effectiveness by comparing inpatient CGA versus hospital admission without CGA in terms of cost per quality-adjusted life year (QALY) gained, cost per life year (LY) gained, and cost per life year living at home (LYLAH) gained. MAIN RESULTS We included 29 trials recruiting 13,766 participants across nine, mostly high-income countries. CGA increases the likelihood that patients will be alive and in their own homes at 3 to 12 months' follow-up (risk ratio (RR) 1.06, 95% confidence interval (CI) 1.01 to 1.10; 16 trials, 6799 participants; high-certainty evidence), results in little or no difference in mortality at 3 to 12 months' follow-up (RR 1.00, 95% CI 0.93 to 1.07; 21 trials, 10,023 participants; high-certainty evidence), decreases the likelihood that patients will be admitted to a nursing home at 3 to 12 months follow-up (RR 0.80, 95% CI 0.72 to 0.89; 14 trials, 6285 participants; high-certainty evidence) and results in little or no difference in dependence (RR 0.97, 95% CI 0.89 to 1.04; 14 trials, 6551 participants; high-certainty evidence). CGA may make little or no difference to cognitive function (SMD ranged from -0.22 to 0.35 (5 trials, 3534 participants; low-certainty evidence)). Mean length of stay ranged from 1.63 days to 40.7 days in the intervention group, and ranged from 1.8 days to 42.8 days in the comparison group. Healthcare costs per participant in the CGA group were on average GBP 234 (95% CI GBP -144 to GBP 605) higher than in the usual care group (17 trials, 5303 participants; low-certainty evidence). CGA may lead to a slight increase in QALYs of 0.012 (95% CI -0.024 to 0.048) at GBP 19,802 per QALY gained (3 trials; low-certainty evidence), a slight increase in LYs of 0.037 (95% CI 0.001 to 0.073), at GBP 6305 per LY gained (4 trials; low-certainty evidence), and a slight increase in LYLAH of 0.019 (95% CI -0.019 to 0.155) at GBP 12,568 per LYLAH gained (2 trials; low-certainty evidence). The probability that CGA would be cost-effective at a GBP 20,000 ceiling ratio for QALY, LY, and LYLAH was 0.50, 0.89, and 0.47, respectively (17 trials, 5303 participants; low-certainty evidence). AUTHORS' CONCLUSIONS Older patients are more likely to be alive and in their own homes at follow-up if they received CGA on admission to hospital. We are uncertain whether data show a difference in effect between wards and teams, as this analysis was underpowered. CGA may lead to a small increase in costs, and evidence for cost-effectiveness is of low-certainty due to imprecision and inconsistency among studies. Further research that reports cost estimates that are setting-specific across different sectors of care are required.
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Affiliation(s)
- Graham Ellis
- Monklands HospitalMedicine for the ElderlyMonkscourt AvenueAirdrieUKML6 0JS
| | - Mike Gardner
- University of OxfordNuffield Department of Population HealthRichard Doll Building, Old Road CampusOxfordUKOX3 7LF
| | - Apostolos Tsiachristas
- University of OxfordNuffield Department of Population HealthRichard Doll Building, Old Road CampusOxfordUKOX3 7LF
| | - Peter Langhorne
- ICAMS, University of GlasgowAcademic Section of Geriatric MedicineLevel 2, New Lister BuildingGlasgow Royal InfirmaryGlasgowUKG31 2ER
| | - Orlaith Burke
- University of OxfordNuffield Department of Population HealthRichard Doll Building, Old Road CampusOxfordUKOX3 7LF
| | - Rowan H Harwood
- Queen's Medical Centre, Nottingham University Hospitals NHS TrustHealth Care of Older PeopleNottinghamUKNG7 2UH
| | - Simon P Conroy
- University of LeicesterDepartment of Health SciencesLeicesterUKLE1 5WW
| | - Tilo Kircher
- Philipps‐Universität Marburg ‐ UKGMKlinik für Psychiatrie und PsychotherapieRudolf‐Bultmann‐Straße 8MarburgGermanyD‐35039
| | - Dominique Somme
- Hôpital PontchaillouFaculté de Médecine, Université de Rennes 1, Service de
Gériatrie CHU de Rennes, Centre de Recherche sur l'Action Politique en
Europe2 rue Henri Le GuillouxRennesFrance35033
| | - Ingvild Saltvedt
- Norwegian University of Science and Technology (NTNU)Department of Neuromedicine and Movement ScienceTrondheimNorway
| | - Heidi Wald
- University of Colorado School of MedicineDivision of Health Care Policy and Research, Department of MedicineHCPR, Campus Box F480, Suite 400 13199 E. Montview BlvdAuroraUSA
| | - Desmond O'Neill
- Trinity CollegeCentre for Ageing, Neuroscience and the HumanitiesTrinity Centre for Health Sciences, Tallaght HospitalDublinIreland24
| | - David Robinson
- St James’s HospitalMedicine for the ElderlyDublinIrelandDublin 8
| | - Sasha Shepperd
- University of OxfordNuffield Department of Population HealthRichard Doll Building, Old Road CampusOxfordUKOX3 7LF
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Shamliyan TA, Khalil DH, Middleton M. Interventions for Community-dwelling Patients with Multiple Chronic Illnesses. Am J Med 2017; 130:148-152. [PMID: 27838377 DOI: 10.1016/j.amjmed.2016.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 10/19/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Tatyana A Shamliyan
- Senior Director, Evidence-Based Medicine Quality Assurance, Elsevier, 1600 JFK Blvd 20(th) floor, Philadelphia, PA 19103.
| | - Dr Hanan Khalil
- Senior Lecturer/Pharmacist Academic, Faculty of Medicine, Nursing and Health Sciences, Monash Rural Heath, Monash University; Editor-in-Chief- International Journal of Evidence-Based Healthcare
| | - Maria Middleton
- Project Coordinator, Evidence-Based Medicine Center, Elsevier, 1600 JFK Blvd 20(th) floor, Philadelphia, PA 19103
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Chen P, Steinman MA. Perception of primary care physicians on the impact of comprehensive geriatric assessment: what is the next step? Isr J Health Policy Res 2016; 5:46. [PMID: 27733902 PMCID: PMC5045624 DOI: 10.1186/s13584-016-0106-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 09/09/2016] [Indexed: 11/15/2022] Open
Abstract
Older adults are at high risk of developing multimorbidity, and the high levels of clinical and psychosocial complexity in this population pose special challenges for primary care physicians (PCPs). As a way to improve the care for the older adults, a number of health systems have developed programs to provide comprehensive geriatric assessment (CGA), which generally refers to an intensive interprofessional evaluation and management of geriatric syndromes with the goals of maximizing health in aging. Sternberg and Bentur examined the impact of CGA as perceived by PCPs, the PCPs attitude toward CGA, and their satisfaction with CGA. In this commentary, we seek to provide additional context to the current state of outpatient consultative CGA and how it relates to the findings in the study by Sternberg and Bentur. The knowledge gained from this study begs for future investigations, especially in the areas of PCPs’ understanding of outpatient consultative CGA, the perceived benefit in health outcomes and actual health outcomes, perceived needs in geriatric consultation, preference in management of complex geriatric syndromes, and interests in continuing education in geriatrics. Insight into these factors could allow for improvement of the current outpatient consultative CGA model and allow for adaption of the model to local needs.
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Affiliation(s)
- Pei Chen
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, 3333 California St, Suite 380, San Francisco, CA 94143 USA
| | - Michael A Steinman
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, 3333 California St, Suite 380, San Francisco, CA 94143 USA ; San Francisco VA Medical Center, 4150 Clement St, San Francisco, CA 94121 USA
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Franchi C, Tettamanti M, Djade CD, Pasina L, Mannucci PM, Onder G, Gussoni G, Manfellotto D, Bonassi S, Salerno F, Nobili A. E-learning in order to improve drug prescription for hospitalized older patients: a cluster-randomized controlled study. Br J Clin Pharmacol 2016; 82:53-63. [PMID: 26922904 PMCID: PMC4917810 DOI: 10.1111/bcp.12922] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 02/19/2016] [Accepted: 02/23/2016] [Indexed: 01/12/2023] Open
Abstract
AIMS The aim of the study was to evaluate the effect of an e-learning educational program meant to foster the quality of drug prescription in hospitalized elderly patients. METHODS Twenty geriatric and internal medicine wards were randomized to intervention (e-learning educational program) or control (basic geriatric pharmacology notions). Logistic regression analysis was used in order to assess the effect of the intervention on the use of potentially inappropriate medication (PIM, primary outcome) at hospital discharge. Secondary outcomes were a reduced prevalence of at least one potential drug-drug interaction (DDI) and potentially severe DDI at discharge. Mortality rate and incidence of re-hospitalizations were other secondary outcomes assessed at the 12-month follow-up. RESULTS A total of 697 patients (347 in the intervention and 350 in the control arms) were enrolled. No difference in the prevalence of PIM at discharge was found between arms (OR 1.29 95%CI 0.87-1.91). We also found no decrease in the prevalence of DDI (OR 0.67 95%CI 0.34-1.28) and potentially severe DDI (OR 0.86 95%CI 0.63-1.15) at discharge, nor in mortality rates and incidence of re-hospitalization at 12-month follow-up. CONCLUSIONS This e-learning educational program had no clear effect on the quality of drug prescription and clinical outcomes in hospitalized elderly patients. Given the high prevalence of PIMs and potential DDIs recorded in the frame of this study, other approaches should be developed in order to improve the quality of drug prescription in this population.
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Affiliation(s)
- Carlotta Franchi
- Laboratory for Quality Assessment of Geriatric Therapies and Services, Department of NeuroscienceIRCCS – Istituto di Ricerche Farmacologiche “Mario Negri”MilanItaly
| | - Mauro Tettamanti
- Laboratory for Quality Assessment of Geriatric Therapies and Services, Department of NeuroscienceIRCCS – Istituto di Ricerche Farmacologiche “Mario Negri”MilanItaly
| | - Codjo Dgnefa Djade
- Laboratory for Quality Assessment of Geriatric Therapies and Services, Department of NeuroscienceIRCCS – Istituto di Ricerche Farmacologiche “Mario Negri”MilanItaly
| | - Luca Pasina
- Laboratory for Quality Assessment of Geriatric Therapies and Services, Department of NeuroscienceIRCCS – Istituto di Ricerche Farmacologiche “Mario Negri”MilanItaly
| | - Pier Mannuccio Mannucci
- A. Bianchi Bonomi Hemophilia and Thrombosis CenterIRCCS – Maggiore Hospital FoundationMilanItaly
| | - Graziano Onder
- Department of Geriatrics, Policlinico A. GemelliCatholic University of the Sacred HeartRomeItaly
| | | | - Dario Manfellotto
- Department of Internal MedicineOspedale Fatebenefratelli‐AFaRRomeItaly
| | - Stefano Bonassi
- Area of Clinical and Molecular EpidemiologyIRCCS – San Raffaele PisanaRomeItaly
| | - Francesco Salerno
- Department of Medical and Surgery SciencesIRCCS Policlinico San Donato, University of MilanItaly
| | - Alessandro Nobili
- Laboratory for Quality Assessment of Geriatric Therapies and Services, Department of NeuroscienceIRCCS – Istituto di Ricerche Farmacologiche “Mario Negri”MilanItaly
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Deschodt M, Claes V, Van Grootven B, Van den Heede K, Flamaing J, Boland B, Milisen K. Structure and processes of interdisciplinary geriatric consultation teams in acute care hospitals: A scoping review. Int J Nurs Stud 2016; 55:98-114. [DOI: 10.1016/j.ijnurstu.2015.09.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 09/02/2015] [Accepted: 09/25/2015] [Indexed: 01/16/2023]
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Abstract
BACKGROUND Discharge planning is a routine feature of health systems in many countries. The aim of discharge planning is to reduce hospital length of stay and unplanned readmission to hospital, and to improve the co-ordination of services following discharge from hospital.This is the third update of the original review. OBJECTIVES To assess the effectiveness of planning the discharge of individual patients moving from hospital. SEARCH METHODS We updated the review using the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 9), MEDLINE, EMBASE, CINAHL, the Social Science Citation Index (last searched in October 2015), and the US National Institutes of Health trial register (ClinicalTrials.gov). SELECTION CRITERIA Randomised controlled trials (RCTs) that compared an individualised discharge plan with routine discharge care that was not tailored to individual participants. Participants were hospital inpatients. DATA COLLECTION AND ANALYSIS Two authors independently undertook data analysis and quality assessment using a pre-designed data extraction sheet. We grouped studies according to patient groups (elderly medical patients, patients recovering from surgery, and those with a mix of conditions) and by outcome. We performed our statistical analysis according to the intention-to-treat principle, calculating risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous data using fixed-effect meta-analysis. When combining outcome data was not possible because of differences in the reporting of outcomes, we summarised the reported data in the text. MAIN RESULTS We included 30 trials (11,964 participants), including six identified in this update. Twenty-one trials recruited older participants with a medical condition, five recruited participants with a mix of medical and surgical conditions, one recruited participants from a psychiatric hospital, one from both a psychiatric hospital and from a general hospital, and two trials recruited participants admitted to hospital following a fall. Hospital length of stay and readmissions to hospital were reduced for participants admitted to hospital with a medical diagnosis and who were allocated to discharge planning (length of stay MD - 0.73, 95% CI - 1.33 to - 0.12, 12 trials, moderate certainty evidence; readmission rates RR 0.87, 95% CI 0.79 to 0.97, 15 trials, moderate certainty evidence). It is uncertain whether discharge planning reduces readmission rates for patients admitted to hospital following a fall (RR 1.36, 95% CI 0.46 to 4.01, 2 trials, very low certainty evidence). For elderly patients with a medical condition, there was little or no difference between groups for mortality (RR 0.99, 95% CI 0.79 to 1.24, moderate certainty). There was also little evidence regarding mortality for participants recovering from surgery or who had a mix of medical and surgical conditions. Discharge planning may lead to increased satisfaction for patients and healthcare professionals (low certainty evidence, six trials). It is uncertain whether there is any difference in the cost of care when discharge planning is implemented with patients who have a medical condition (very low certainty evidence, five trials). AUTHORS' CONCLUSIONS A discharge plan tailored to the individual patient probably brings about a small reduction in hospital length of stay and reduces the risk of readmission to hospital at three months follow-up for older people with a medical condition. Discharge planning may lead to increased satisfaction with healthcare for patients and professionals. There is little evidence that discharge planning reduces costs to the health service.
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Affiliation(s)
| | - Natasha A Lannin
- Alfred HealthOccupational TherapyThe Alfred55 Commercial RoadPrahranVictoriaAustralia3004
| | - Lindy M Clemson
- University of SydneyFaculty of Health SciencesJ005, East St. LidcombeLidcombeNSWAustralia1825
| | - Ian D Cameron
- Kolling Institute, Northern Sydney Local Health DistrictJohn Walsh Centre for Rehabilitation ResearchSt LeonardsNSWAustralia2065
| | - Sasha Shepperd
- University of OxfordNuffield Department of Population HealthOxfordUK
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Ekdahl AW, Alwin J, Eckerblad J, Husberg M, Jaarsma T, Mazya AL, Milberg A, Krevers B, Unosson M, Wiklund R, Carlsson P. Long-Term Evaluation of the Ambulatory Geriatric Assessment: A Frailty Intervention Trial (AGe-FIT): Clinical Outcomes and Total Costs After 36 Months. J Am Med Dir Assoc 2016; 17:263-8. [PMID: 26805750 DOI: 10.1016/j.jamda.2015.12.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Revised: 11/27/2015] [Accepted: 12/03/2015] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To compare the effects of care based on comprehensive geriatric assessment (CGA) as a complement to usual care in an outpatient setting with those of usual care alone. The assessment was performed 36 months after study inclusion. DESIGN Randomized, controlled, assessor-blinded, single-center trial. SETTING A geriatric ambulatory unit in a municipality in the southeast of Sweden. PARTICIPANTS Community-dwelling individuals aged ≥ 75 years who had received inpatient hospital care 3 or more times in the past 12 months and had 3 or more concomitant medical diagnoses were eligible for study inclusion. Participants were randomized to the intervention group (IG) or control group (CG). INTERVENTION Participants in the IG received CGA-based care for 24 to 31 months at the geriatric ambulatory unit in addition to usual care. OUTCOME MEASURES Mortality, transfer to nursing home, days in hospital, and total costs of health and social care after 36 months. RESULTS Mean age (SD) of participants was 82.5 (4.9) years. Participants in the IG (n = 208) lived 69 days longer than did those in the CG (n = 174); 27.9% (n = 58) of participants in the IG and 38.5% (n = 67) in the CG died (hazard ratio 1.49, 95% confidence interval 1.05-2.12, P = .026). The mean number of inpatient days was lower in the IG (15.1 [SD 18.4]) than in the CG (21.0 [SD 25.0], P = .01). Mean overall costs during the 36-month period did not differ between the IG and CG (USD 71,905 [SD 85,560] and USD 65,626 [SD 66,338], P = .43). CONCLUSIONS CGA-based care resulted in longer survival and fewer days in hospital, without significantly higher cost, at 3 years after baseline. These findings add to the evidence of CGA's superiority over usual care in outpatient settings. As CGA-based care leads to important positive outcomes, this method should be used more extensively in the treatment of older people to meet their needs.
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Affiliation(s)
- Anne W Ekdahl
- Department of Neurobiology, Care Sciences and Society, Division of Clinical Geriatrics, Karolinska Institutet, Stockholm, Sweden; Department of Research and Education, Helsingborg Hospital, Helsingborg, Skåne Region, Sweden.
| | - Jenny Alwin
- Department of Medical and Health Sciences, Faculty of Health Sciences, Division of Health Care Analysis, Linköping University, Linköping, Sweden
| | - Jeanette Eckerblad
- Department of Social and Welfare Studies, Linköping University, Norrköping, Sweden
| | - Magnus Husberg
- Department of Medical and Health Sciences, Faculty of Health Sciences, Division of Health Care Analysis, Linköping University, Linköping, Sweden
| | - Tiny Jaarsma
- Department of Social and Welfare Studies, Linköping University, Norrköping, Sweden
| | - Amelie Lindh Mazya
- Department of Neurobiology, Care Sciences and Society, Division of Clinical Geriatrics, Karolinska Institutet, Stockholm, Sweden; Department of Geriatric Medicine, Danderyd Hospital, Stockholm, Sweden
| | - Anna Milberg
- Department of Social and Welfare Studies, Linköping University, Norrköping, Sweden; Department of Advanced Home Care and Department of Social and Welfare Studies, Linköping University, Norrköping, Sweden
| | - Barbro Krevers
- Department of Medical and Health Sciences, Faculty of Health Sciences, Division of Health Care Analysis, Linköping University, Linköping, Sweden
| | - Mitra Unosson
- Department of Social and Welfare Studies, Linköping University, Norrköping, Sweden
| | - Rolf Wiklund
- Department of Analysis of Health Care, Östergötland Region, Linköping, Sweden
| | - Per Carlsson
- Department of Medical and Health Sciences, Faculty of Health Sciences, Division of Health Care Analysis, Linköping University, Linköping, Sweden
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Frailty and comprehensive geriatric assessment organized as CGA-ward or CGA-consult for older adult patients in the acute care setting: A systematic review and meta-analysis. Eur Geriatr Med 2015. [DOI: 10.1016/j.eurger.2015.10.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Stevens JP, Nyweide D, Maresh S, Zaslavsky A, Shrank W, MD MDH, Landon BE. Variation in Inpatient Consultation Among Older Adults in the United States. J Gen Intern Med 2015; 30:992-9. [PMID: 25693650 PMCID: PMC4471009 DOI: 10.1007/s11606-015-3216-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 01/08/2015] [Accepted: 01/16/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Differences among hospitals in the use of inpatient consultation may contribute to variation in outcomes and costs for hospitalized patients, but basic epidemiologic data on consultations nationally are lacking. OBJECTIVE The purpose of the study was to identify physician, hospital, and geographic factors that explain variation in rates of inpatient consultation. DESIGN This was a retrospective observational study. SETTING AND PARTICIPANTS This work included 3,118,080 admissions of Medicare patients to 4,501 U.S. hospitals in 2009 and 2010. MAIN MEASURES The primary outcome measured was number of consultations conducted during the hospitalization, summarized at the hospital level as the number of consultations per 1,000 Medicare admissions, or "consultation density." KEY RESULTS Consultations occurred 2.6 times per admission on average. Among non-critical access hospitals, use of consultation varied 3.6-fold across quintiles of hospitals (933 versus 3,390 consultations per 1,000 admissions, lowest versus highest quintiles, p < 0.001). Sicker patients received greater intensity of consultation (rate ratio [RR] 1.18, 95% CI 1.17-1.18 for patients admitted to ICU; and RR 1.19, 95% CI 1.18-1.20 for patients who died). However, even after controlling for patient-level factors, hospital characteristics also predicted differences in rates of consultation. For example, hospital size (large versus small, RR 1.31, 95% CI 1.25-1.37), rural location (rural versus urban, RR 0.78, CI 95% 0.76-0.80), ownership status (public versus not-for-profit, RR 0.94, 95% CI 0.91-0.97), and geographic quadrant (Northeast versus West, RR 1.17, 95% CI 1.12-1.21) all influenced the intensity of consultation use. CONCLUSIONS Hospitals exhibit marked variation in the number of consultations per admission in ways not fully explained by patient characteristics. Hospital "consultation density" may constitute an important focus for monitoring resource use for hospitals or health systems.
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Affiliation(s)
- Jennifer P. Stevens
- />Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA USA
- />Division for Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA USA
| | - David Nyweide
- />Center for Medicare and Medicaid Innovation, Centers for Medicare and Medicaid Services, Department of Health and Human Services, Baltimore, MD USA
| | - Sha Maresh
- />Center for Medicare and Medicaid Innovation, Centers for Medicare and Medicaid Services, Department of Health and Human Services, Baltimore, MD USA
| | - Alan Zaslavsky
- />Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115 USA
| | - William Shrank
- />Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Michael D. Howell MD
- />Center for Quality, University of Chicago, Chicago, IL USA
- />Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL USA
| | - Bruce E. Landon
- />Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA USA
- />Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115 USA
- />Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, MA USA
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Franchi C, Mari D, Tettamanti M, Pasina L, Djade CD, Mannucci PM, Onder G, Bernabei R, Gussoni G, Bonassi S, Nobili A. E-learning to improve the drug prescribing in the hospitalized elderly patients: the ELICADHE feasibility pilot study. Aging Clin Exp Res 2014; 26:435-43. [PMID: 24343853 DOI: 10.1007/s40520-013-0187-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 12/02/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND E-learning is an efficient and cost-effective educational method. AIMS This study aimed at evaluating the feasibility of an educational e-learning intervention, focused on teaching geriatric pharmacology and notions of comprehensive geriatric assessment, to improve drug prescribing to hospitalized elderly patients. METHODS Eight geriatric and internal medicine wards were randomized to intervention (e-learning educational program) or control. Clinicians of the two groups had to complete a specific per group e-learning program in 30 days. Then, ten patients (aged ≥75 years) had to be consecutively enrolled collecting clinical data at hospital admission, discharge, and 3 months later. The quality of prescription was evaluated comparing the prevalence of potentially inappropriate medications through Beer's criteria and of potential drug-drug interactions through a specific computerized database. RESULTS The study feasibility was confirmed by the high percentage (90 %) of clinicians who completed the e-learning program, the recruitment, and follow-up of all planned patients. The intervention was well accepted by all participating clinicians who judged positively (a mean score of >3 points on a scale of 5 points: 0 = useless; 5 = most useful) the specific contents, the methodology applied, the clinical relevance and utility of e-learning contents and tools for the evaluation of the appropriateness of drug prescribing. CONCLUSIONS The pilot study met all the requested goals. The main study is currently ongoing and is planned to finish on July 2015.
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Affiliation(s)
- C Franchi
- Laboratory for Quality Assessment of Geriatric Therapies and Services, Department of Neuroscience, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Via Giuseppe La Masa, 19, 20156, Milan, Italy,
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Ishii S, Kojima T, Yamaguchi K, Akishita M. Guidance statement on appropriate medical services for the elderly. Geriatr Gerontol Int 2014. [DOI: 10.1111/ggi.12310] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Shinya Ishii
- Department of Geriatric Medicine; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
| | - Taro Kojima
- Department of Geriatric Medicine; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
| | - Kiyoshi Yamaguchi
- Department of Geriatric Medicine; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
| | - Masahiro Akishita
- Department of Geriatric Medicine; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
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Guidance statement on appropriate medical services for the elderly by the study group of the Ministry of Health, Labour and Welfare. Nihon Ronen Igakkai Zasshi 2014; 51:89-96. [PMID: 24747506 DOI: 10.3143/geriatrics.51.89] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Elements of a High-Quality Inpatient Consultation in the Intensive Care Unit. A Qualitative Study. Ann Am Thorac Soc 2013; 10:220-7. [DOI: 10.1513/annalsats.201212-120oc] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Deschodt M, Flamaing J, Haentjens P, Boonen S, Milisen K. Impact of geriatric consultation teams on clinical outcome in acute hospitals: a systematic review and meta-analysis. BMC Med 2013; 11:48. [PMID: 23433471 PMCID: PMC3626668 DOI: 10.1186/1741-7015-11-48] [Citation(s) in RCA: 127] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 02/22/2013] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Comprehensive geriatric assessment for older patients admitted to dedicated wards has proven to be beneficial, but the impact of comprehensive geriatric assessment delivered by mobile inpatient geriatric consultation teams remains unclear. This review and meta-analysis aims to determine the impact of inpatient geriatric consultation teams on clinical outcomes of interest in older adults. METHODS An electronic search of Medline, CINAHL, EMBASE, Web of Science and Invert for English, French and Dutch articles was performed from inception to June 2012. Three independent reviewers selected prospective cohort studies assessing functional status, readmission rate, mortality or length of stay in adults aged 60 years or older. Twelve studies evaluating 4,546 participants in six countries were identified. Methodological quality of the included studies was assessed with the Methodological Index for Non-Randomized Studies. RESULTS The individual studies show that an inpatient geriatric consultation team intervention has favorable effects on functional status, readmission and mortality rate. None of the studies found an effect on the length of the hospital stay. The meta-analysis found a beneficial effect of the intervention with regard to mortality rate at 6 months (relative risk 0.66; 95% confidence interval 0.52 to 0.85) and 8 months (relative risk 0.51; confidence interval 0.31 to 0.85) after hospital discharge. CONCLUSIONS Inpatient geriatric consultation team interventions have a significant impact on mortality rate at 6 and 8 months postdischarge, but have no significant impact on functional status, readmission or length of stay. The reason for the lack of effect on these latter outcomes may be due to insufficient statistical power or the insensitivity of the measuring method for, for example, functional status. The questions of to whom IGCT intervention should be targeted and what can be achieved remain unanswered and require further research. TRIAL REGISTRATION CRD42011001420 (http://www.crd.york.ac.uk/PROSPERO).
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Affiliation(s)
- Mieke Deschodt
- Center for Health Services and Nursing Research, KU Leuven, Kapucijnenvoer 35/4, 3000 Leuven, Belgium.
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Shepperd S, Lannin NA, Clemson LM, McCluskey A, Cameron ID, Barras SL. Discharge planning from hospital to home. Cochrane Database Syst Rev 2013:CD000313. [PMID: 23440778 DOI: 10.1002/14651858.cd000313.pub4] [Citation(s) in RCA: 145] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Discharge planning is a routine feature of health systems in many countries. The aim of discharge planning is to reduce hospital length of stay and unplanned readmission to hospital, and improve the co-ordination of services following discharge from hospital. OBJECTIVES To determine the effectiveness of planning the discharge of individual patients moving from hospital. SEARCH METHODS We updated the review using the Cochrane EPOC Group Trials Register, MEDLINE, EMBASE and the Social Science Citation Index (last searched in March 2012). SELECTION CRITERIA Randomised controlled trials (RCTs) that compared an individualised discharge plan with routine discharge care that was not tailored to the individual patient. Participants were hospital inpatients. DATA COLLECTION AND ANALYSIS Two authors independently undertook data analysis and quality assessment using a pre designed data extraction sheet. Studies are grouped according to patient group (elderly medical patients, patients recovering from surgery and those with a mix of conditions) and by outcome. Our statistical analysis was done on an intention to treat basis, we calculated risk ratios for dichotomous outcomes and mean differences for continuous data using fixed-effect meta-analysis. When combining outcome data was not possible, because of differences in the reporting of outcomes, we have presented the data in narrative summary tables. MAIN RESULTS We included twenty-four RCTs (8098 patients); three RCTS were identified in this update. Sixteen studies recruited older patients with a medical condition, four recruited patients with a mix of medical and surgical conditions, one recruited patients from a psychiatric hospital, one from both a psychiatric hospital and from a general hospital, and two trials patients admitted to hospital following a fall (110 patients). Hospital length of stay and readmissions to hospital were statistically significantly reduced for patients admitted to hospital with a medical diagnosis and who were allocated to discharge planning (mean difference length of stay -0.91, 95% CI -1.55 to -0.27, 10 trials; readmission rates RR 0.82, 95% CI 0.73 to 0.92, 12 trials). For elderly patients with a medical condition there was no statistically significant difference between groups for mortality (RR 0.99, 95% CI 0.78 to 1.25, five trials) or being discharged from hospital to home (RR 1.03, 95% CI 0.93 to 1.14, two trials). This was also the case for trials recruiting patients recovering from surgery and a mix of medical and surgical conditions. In three trials, patients allocated to discharge planning reported increased satisfaction. There was little evidence on overall healthcare costs. AUTHORS' CONCLUSIONS The evidence suggests that a discharge plan tailored to the individual patient probably brings about reductions in hospital length of stay and readmission rates for older people admitted to hospital with a medical condition. The impact of discharge planning on mortality, health outcomes and cost remains uncertain.
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Affiliation(s)
- Sasha Shepperd
- Department of Public Health, University of Oxford, Rosemary Rue Building, Headington, Oxford, Oxfordshire, UK.
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Parke B, Hunter KF, Bostrom AM, Chambers T, Manraj C. Identifying modifiable factors to improve quality for older adults in hospital: a scoping review. Int J Older People Nurs 2012; 9:8-24. [PMID: 23067226 DOI: 10.1111/opn.12007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Accepted: 07/26/2012] [Indexed: 01/20/2023]
Abstract
BACKGROUND Traditional ways of viewing hospitalisation do not always recognise how elements within the hospital environment contribute to disability. Four theoretical dimensions of older adult-hospital environment fit have been proposed in previous research on elder-friendly hospitals: social climate, physical design, care systems and processes, policies and procedures; however, modifiable factors for each dimension are not yet identified. DESIGN Exploratory iterative design guided by Arksey and O'Malley (2005, International Journal of Social Research Methodology 8, 19) scoping review methodology. METHOD We undertook a scoping review of primary research related to hospitalised community-dwelling older adults. Keys search terms and criteria were used to identify relevant articles with modifiable factors extracted from articles meeting study criteria. RESULTS A total of 66 studies were included and evaluated for modifiable factor mapping. We were able to map all 66 studies to the four dimensions. The majority of included studies described care systems and processes, with little relating to social climate, physical design and policies and procedures. Thirty-nine potentially modifiable factors were identified and mapped to the theoretical dimensions according to four overarching themes: models of care; assessment of potential geriatric issues; targeting care to a specific clinical issue and supporting transitions home themes. CONCLUSION The dimensions of older adult-hospital fit help us to organise key features of an elder-friendly hospital and identify potentially modifiable factors. Although it makes intuitive sense to cluster and organise according to the dimensions to help with understanding, this tells us little about the synergy of interactions and hierarchical relationships. Our results highlight the importance of competent gerontological nursing in care for hospitalised older adults and the need for further understanding of the older adult and family as a unit of care. IMPLICATIONS FOR PRACTICE Registered nurses have a leadership role to ensure safe quality care for older people in hospital. This leadership role can be framed in interventions that focus on fixing the fit between what older people need and what the hospital environment provides. Modifiable factors for improvement are within the scope and competency of the registered nurse.
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Affiliation(s)
- Belinda Parke
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
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Yoo JW, Kim S, Choi JH, Ryu WS. Intensified rehabilitation therapy and transitions to skilled nursing facilities in community-living seniors with acute medical illnesses. Geriatr Gerontol Int 2012; 13:547-54. [PMID: 22963368 DOI: 10.1111/j.1447-0594.2012.00932.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM To examine whether rehabilitation therapy type would be associated with transitions to skilled nursing facilities (SNF) in community-living seniors with acute medical illnesses. METHODS Using administrative and clinical data, multivariate regression analysis examined the relationship between the extent of rehabilitation therapy and transitions to SNF in all participants, as well as participants by physical function at admission. RESULTS In all participants (n=929), the intensified rehabilitation therapy was associated with a lower probability of transitions to SNF (14% vs 21%; odds ratio [OR] 0.59; 95% confidence intervals [CI] 0.22-0.96; P=0.02). In participants with mild physical limitations (n=270), less frequent transitions to SNF occurred when patients received intensified rehabilitation therapy [16% vs 23%; OR 0.46; 95% CI 0.17-0.94; P=0.01]. In participants with moderate to severe physical limitations (n=265), the decreased frequency of transitions to SNF associated with rehabilitation therapy became more pronounced (18% vs 28%; OR 0.34; 95% CI 0.07-0.89; P=0.004). By contrast, in participants without physical limitation (n=394), the number of transitions to SNF did not change significantly when they received intensified rehabilitation therapy (P=0.53). CONCLUSIONS We found a significant relationship between intensified rehabilitation therapy and the decrease of transitions to SNF in community-living seniors with acute medical illness. The magnitude of this relationship increased in participants with more physical limitations, but not in participants without physical limitations at admission.
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Affiliation(s)
- Ji Won Yoo
- Department of Internal Medicine, University of Michigan Medical School, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan 48109, USA.
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Baztán Cortés JJ, Vidán Astiz MT, López-Dóriga P, Cruz-Jentoft AJ, Petidier Torregrosa R, Gil Gregorio P, Serra Rexach JA. [Which patients benefit the most from hospital geriatric care in the opinion of the geriatricians?]. Rev Esp Geriatr Gerontol 2012; 47:205-209. [PMID: 22537916 DOI: 10.1016/j.regg.2012.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Revised: 02/23/2012] [Accepted: 02/28/2012] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To assess the most appropriate criteria considered by geriatricians to select patients who might benefit the most from geriatric hospital care. MATERIAL AND METHODS We carried out a survey that consisted of various socio-demographic, clinical, functional and mental criteria included in the definition of the geriatric and frail elderly patient. The survey was sent to all specialists in geriatrics in the different hospitals of the Madrid Health Service. They were asked to answer to each criterion indicating whether they considered it as high priority, priority, low priority or no priority. The responses were clustered by type of hospital: acute hospitals with or without a post-graduate geriatric program for medical residents, and medium and long stay hospitals. RESULTS A total of 83 questionnaires were completed (70% of the study population): 42 teaching hospitals a post-graduate geriatric program (74% of possible), 20 of those with an emergency department but without a post-graduate geriatric program (56% of possible), and 21 medium and long stay hospitals (84% of potential). All proposed criteria were considered individually as priority or high-priority by more than 50% of respondents. An age 85 years and over, admission for hip fracture, the presence of severe cognitive or functional impairment, frailty, and unexplained deterioration of health status, were considered individually as criteria for selecting high-priority target population by more than 85% of respondents. CONCLUSIONS Certain criteria, such as advanced age, or the presence of geriatrics-specific conditions, such as hip fracture or severe functional or cognitive impairment, are identified by geriatricians as useful to select patients to receive geriatric specialist hospital care.
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Affiliation(s)
- Juan J Baztán Cortés
- Comité Técnico para la elaboración del Plan Estratégico de Geriátrica de la Comunidad de Madrid.
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Demographic characteristics and clinical benefits of outpatient geriatric evaluation and management service in Taiwan. Arch Gerontol Geriatr 2012; 55:42-4. [DOI: 10.1016/j.archger.2011.04.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Revised: 04/15/2011] [Accepted: 04/16/2011] [Indexed: 11/19/2022]
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Greenhalgh J, Abhyankar P, McCluskey S, Takeuchi E, Velikova G. How do doctors refer to patient-reported outcome measures (PROMS) in oncology consultations? Qual Life Res 2012; 22:939-50. [DOI: 10.1007/s11136-012-0218-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2012] [Indexed: 10/28/2022]
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González González GR, López Esqueda FJ. Functional and nutritional status correlation in elderly patients with hip fracture. Medwave 2012. [DOI: 10.5867/medwave.2012.05.5425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Boustani MA, Campbell NL, Khan BA, Abernathy G, Zawahiri M, Campbell T, Tricker J, Hui SL, Buckley JD, Perkins AJ, Farber MO, Callahan CM. Enhancing care for hospitalized older adults with cognitive impairment: a randomized controlled trial. J Gen Intern Med 2012; 27:561-7. [PMID: 22302355 PMCID: PMC3326116 DOI: 10.1007/s11606-012-1994-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Revised: 10/03/2011] [Accepted: 01/09/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Approximately 40% of hospitalized older adults have cognitive impairment (CI) and are more prone to hospital-acquired complications. The Institute of Medicine suggests using health information technology to improve the overall safety and quality of the health care system. OBJECTIVE Evaluate the efficacy of a clinical decision support system (CDSS) to improve the quality of care for hospitalized older adults with CI. DESIGN A randomized controlled clinical trial. SETTING A public hospital in Indianapolis. POPULATION A total of 998 hospitalized older adults were screened for CI, and 424 patients (225 intervention, 199 control) with CI were enrolled in the trial with a mean age of 74.8, 59% African Americans, and 68% female. INTERVENTION A CDSS alerts the physicians of the presence of CI, recommends early referral into a geriatric consult, and suggests discontinuation of the use of Foley catheterization, physical restraints, and anticholinergic drugs. MEASUREMENTS Orders of a geriatric consult and discontinuation orders of Foley catheterization, physical restraints, or anticholinergic drugs. RESULTS Using intent-to-treat analyses, there were no differences between the intervention and the control groups in geriatric consult orders (56% vs 49%, P = 0.21); discontinuation orders for Foley catheterization (61.7% vs 64.6%, P = 0.86); physical restraints (4.8% vs 0%, P = 0.86), or anticholinergic drugs (48.9% vs 31.2%, P = 0.11). CONCLUSION A simple screening program for CI followed by a CDSS did not change physician prescribing behaviors or improve the process of care for hospitalized older adults with CI.
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Affiliation(s)
- Malaz A Boustani
- Indiana University Center for Aging Research, Indianapolis, IN, USA.
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Yates JW, Thein M, Ershler WB. Opinion on opinions about geriatric assessment. Arch Gerontol Geriatr 2012; 54:273-7. [DOI: 10.1016/j.archger.2011.07.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Revised: 07/12/2011] [Accepted: 07/19/2011] [Indexed: 10/17/2022]
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Saad M, Harisingani R, Katinas L. Impact of geriatric consultation on the number of medications in hospitalized older patients. ACTA ACUST UNITED AC 2012; 27:42-8. [PMID: 22231997 DOI: 10.4140/tcp.n.2012.42] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study aims to determine the impact of the geriatric consultation on the number of medications in hospitalized older adults and the corresponding financial impact. DESIGN Retrospective chart review of patients seen by geriatric consultants. SETTING Tertiary-care teaching hospital. MAIN OUTCOME MEASURES The number of medications prescribed before hospitalization, at time of consult, and at discharge, and the number and category of medications adjusted by the geriatrician. The monthly cost of the pharmaceutical interventions was computed based on the drugstore.com cost of acquisition of drugs. RESULTS A cohort of 62 patients was reviewed with a mean age of 84.6 (± 7.3) years; 79% were women. The patients presented with an average of 5.6 (± 2.1) comorbidities of which hypertension, dementia, and musculoskeletal disorders were the most common. The most common reasons for geriatric consultations were neuropsychiatric, nutritional, and gait-related issues. The geriatric consultant identified 2.96 (± 1.5) additional diagnoses, of which debility, delirium, and pain were the most prevalent. The average number of medications on admission was 7.7 (± 3.7) and at discharge was 9.5 (± 2.12). The average number of medications adjusted by the geriatric consultant was 2.96 (± 2.12). The most common classes of adjusted medications were pain medications (22%), nutrition (13%), bowel regimens (8.5%), antipsychotics (8%), and osteoporosis (8%). The cost impact of the pharmaceutical intervention ranged between -$343 and $2,607, with an average increase of $102 (± 368). CONCLUSION Geriatric consultations increased the total number of medications and the cost of medications used by elderly patients.
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Affiliation(s)
- Maha Saad
- Clinical Pharmacy Department, St. John's University School of Pharmacy and Allied Health Professions, Queens, NY, USA.
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Anderson O, Boshier PR, Hanna GB. Interventions designed to prevent healthcare bed-related injuries in patients. Cochrane Database Syst Rev 2012; 1:CD008931. [PMID: 22258994 DOI: 10.1002/14651858.cd008931.pub3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Every patient in residential healthcare has a bed. Falling out of bed is associated with preventable patient harm. Various interventions to prevent injury are available. Bed rails are the most common intervention designed to prevent patients falling out of bed; however, their effectiveness is uncertain and bed rail entrapment can also result in injuries. OBJECTIVES To assess the effectiveness of interventions designed to prevent patient injuries and falls from their beds. SEARCH METHODS We searched the Cochrane Injuries Group Specialised Register, Cochrane Central Register of Controlled Trials 2010, Issue 2 (The Cochrane Library), MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO), ISOI Web of Science and Web-based trials registers (all to December 2010) as well as reference lists. SELECTION CRITERIA Randomised controlled trials of interventions designed to prevent patient injuries from their beds which were conducted in hospitals, nursing care facilities or rehabilitation units were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the risk of bias and extracted data from the included studies. Authors contacted investigators to obtain missing information. MAIN RESULTS Two studies met the inclusion criteria, involving a total of 22,106 participants. One study tested low height beds and the other tested bed exit alarms. Both studies used standard care for their control group and both studies were conducted in hospitals. No study investigating bed rails met the inclusion criteria. Due to the clinical heterogeneity of the interventions in the included studies pooling of data and meta-analysis was inappropriate, and so the results of the studies are described.A single cluster randomised trial of low height beds in 18 hospital wards, including 22,036 participants, found no significant reduction in the frequency of patient injuries due to their beds (there were no injuries in either group), patient falls in the bedroom (rate ratio 0.69, 95% CI 0.35 to 1.34), all falls (rate ratio 1.26, 95% CI 0.83 to 1.90) or patient injuries due to all falls (rate ratio 1.35, 95% CI 0.68 to 2.68).One randomised controlled trial of bed exit alarms in one hospital geriatric ward, involving 70 participants, found no significant reduction in the frequency of patient injuries due to their beds (there were no injuries in either group), patient falls out of bed (rate ratio 0.25, 95% CI 0.03 to 2.24), all falls (rate ratio 0.42, 95% CI 0.15 to 1.18) or patient injuries due to all falls (no injuries in either group). AUTHORS' CONCLUSIONS The effectiveness of interventions designed to prevent patient injuries from their beds (including bed rails, low height beds and bed exit alarms) remains uncertain. The available evidence shows no significant increase or decrease in the rate of injuries with the use of low height beds and bed exit alarms. Limitations of the two included studies include lack of blinding and insufficient power. No randomised controlled trials of bed rails were identified. Future reports should fully describe the standard care received by the control group.
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Affiliation(s)
- Oliver Anderson
- Department of Surgery and Cancer, Imperial College London, London, UK.
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Linertová R, García-Pérez L, Vázquez-Díaz JR, Lorenzo-Riera A, Sarría-Santamera A. Interventions to reduce hospital readmissions in the elderly: in-hospital or home care. A systematic review. J Eval Clin Pract 2011; 17:1167-75. [PMID: 20630005 DOI: 10.1111/j.1365-2753.2010.01493.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Unplanned hospital readmissions of elderly people represent an increasing burden on health care systems. This burden could theoretically be reduced by adequate preventive interventions, although there is uncertainty about the effectiveness of different types of interventions. The objective of this systematic review was to identify interventions that effectively reduce the risk of hospital readmissions in patients of 75 years and older, and to assess the role of home follow-up. METHODS We searched studies in MEDLINE, CINAHL, CENTRAL and seven other electronic databases up to October 2007, and we updated the MEDLINE search in October 2009. Clinical trials (randomized or controlled) evaluating the effectiveness of an intervention aimed at reducing readmissions in elderly patients were selected. Quality was assessed using the SIGN tool and the information extracted is presented in text and tables. RESULTS Thirty-two clinical trials were included and they were divided into two groups: in-hospital interventions (17 studies) and interventions with home follow-up (15 studies). A positive effect of the intervention evaluated on the readmission outcome was found in three studies from the first group and in seven from the second group. CONCLUSIONS Most of the interventions evaluated did not have any effect on the readmission of elderly patients. However, those interventions that included home care components seem to be more likely to reduce readmissions in the elderly.
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Affiliation(s)
- Renata Linertová
- Canary Islands Foundation for Health and Research (FUNCIS), Santa Cruz de Tenerife, Spain.
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Anderson O, Boshier PR, Hanna GB. Interventions designed to prevent healthcare bed-related injuries in patients. Cochrane Database Syst Rev 2011:CD008931. [PMID: 22071860 DOI: 10.1002/14651858.cd008931.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Every patient in residential healthcare has a bed. Falling out of bed is associated with preventable patient harm. Various interventions to prevent injury are available. Bed rails are the most common intervention designed to prevent patients falling out of bed; however, their effectiveness is uncertain and bed rail entrapment can also result in injuries. OBJECTIVES To assess the effectiveness of interventions designed to prevent patient injuries and falls from their beds. SEARCH METHODS We searched the Cochrane Injuries Group Specialised Register, Cochrane Central Register of Controlled Trials 2010, Issue 2 (The Cochrane Library), MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO), ISOI Web of Science and Web-based trials registers (all to December 2010) as well as reference lists. SELECTION CRITERIA Randomised controlled trials of interventions designed to prevent patient injuries from their beds which were conducted in hospitals, nursing care facilities or rehabilitation units were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the risk of bias and extracted data from the included studies. Authors contacted investigators to obtain missing information. MAIN RESULTS Two studies met the inclusion criteria, involving a total of 22,106 participants. One study tested low height beds and the other tested bed exit alarms. Both studies used standard care for their control group and both studies were conducted in hospitals. No study investigating bed rails met the inclusion criteria. Due to the clinical heterogeneity of the interventions in the included studies pooling of data and meta-analysis was inappropriate, and so the results of the studies are described.A single cluster randomised trial of low height beds in 18 hospital wards, including 22,036 participants, found no significant reduction in the frequency of patient injuries due to their beds (there were no injuries in either group), patient falls in the bedroom (rate ratio 0.69, 95% CI 0.35 to 1.34), all falls (rate ratio 1.26, 95% CI 0.83 to 1.90) or patient injuries due to all falls (rate ratio 1.35, 95% CI 0.68 to 2.68).One randomised controlled trial of bed exit alarms in one hospital geriatric ward, involving 70 participants, found no significant reduction in the frequency of patient injuries due to their beds (there were no injuries in either group), patient falls out of bed (rate ratio 0.25, 95% CI 0.03 to 2.24), all falls (rate ratio 0.42, 95% CI 0.15 to 1.18) or patient injuries due to all falls (no injuries in either group). AUTHORS' CONCLUSIONS The effectiveness of interventions designed to prevent patient injuries from their beds (including bed rails, low height beds and bed exit alarms) remains uncertain. The available evidence shows no significant increase or decrease in the rate of injuries with the use of low height beds and bed exit alarms. Limitations of the two included studies include lack of blinding and insufficient power. No randomised controlled trials of bed rails were identified. Future reports should fully describe the standard care received by the control group.
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Affiliation(s)
- Oliver Anderson
- Department of Surgery and Cancer, Imperial College London, London, UK.
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Ellis G, Whitehead MA, Robinson D, O'Neill D, Langhorne P. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ 2011; 343:d6553. [PMID: 22034146 PMCID: PMC3203013 DOI: 10.1136/bmj.d6553] [Citation(s) in RCA: 625] [Impact Index Per Article: 48.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of comprehensive geriatric assessment in hospital for older adults admitted as an emergency. SEARCH STRATEGY We searched the EPOC Register, Cochrane's Controlled Trials Register, the Database of Abstracts of Reviews of Effects (DARE), Medline, Embase, CINAHL, AARP Ageline, and handsearched high yield journals. SELECTION CRITERIA Randomised controlled trials of comprehensive geriatric assessment (whether by mobile teams or in designated wards) compared with usual care. Comprehensive geriatric assessment is a multidimensional interdisciplinary diagnostic process used to determine the medical, psychological, and functional capabilities of a frail elderly person to develop a coordinated and integrated plan for treatment and long term follow-up. DATA COLLECTION AND ANALYSIS Three independent reviewers assessed eligibility and trial quality and extracted published data. Two additional reviewers moderated. RESULTS Twenty two trials evaluating 10,315 participants in six countries were identified. For the primary outcome "living at home," patients who underwent comprehensive geriatric assessment were more likely to be alive and in their own homes at the end of scheduled follow-up (odds ratio 1.16 (95% confidence interval 1.05 to 1.28; P = 0.003; number needed to treat 33) at a median follow-up of 12 months versus 1.25 (1.11 to 1.42; P < 0.001; number needed to treat 17) at a median follow-up of six months) compared with patients who received general medical care. In addition, patients were less likely to be living in residential care (0.78, 0.69 to 0.88; P < 0.001). Subgroup interaction suggested differences between the subgroups "wards" and "teams" in favour of wards. Patients were also less likely to die or experience deterioration (0.76, 0.64 to 0.90; P = 0.001) and were more likely to experience improved cognition (standardised mean difference 0.08, 0.01 to 0.15; P = 0.02) in the comprehensive geriatric assessment group. CONCLUSIONS Comprehensive geriatric assessment increases patients' likelihood of being alive and in their own homes after an emergency admission to hospital. This seems to be especially true for trials of wards designated for comprehensive geriatric assessment and is associated with a potential cost reduction compared with general medical care.
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Affiliation(s)
- Graham Ellis
- Medicine for the Elderly, Monklands Hospital, Airdrie, North Lanarkshire, Scotland, UK.
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