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Yamada K, Iwata K, Yoshimura Y, Ota H, Oki Y, Mitani Y, Oki Y, Yamada Y, Yamamoto A, Ono K, Kitai T, Tachikawa R, Tomii K, Kohara N, Ishikawa A. Activities of daily living limitation and functional decline during hospitalization predict 180-day readmission and mortality in older patients with pneumonia: A single-center, retrospective cohort study. Respir Med 2024; 234:107830. [PMID: 39368559 DOI: 10.1016/j.rmed.2024.107830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Revised: 10/02/2024] [Accepted: 10/03/2024] [Indexed: 10/07/2024]
Abstract
BACKGROUND The role of activities of daily living (ADL) as a predictor of adverse outcomes in patients with pneumonia is unclear. This study aimed to assess the association between ADL, including physical and cognitive function, and death or readmission in older inpatients with pneumonia. METHODS This retrospective, single-center, observational study included consecutive older inpatients with pneumonia between October 2018 and December 2019. ADL was assessed using the Functional Independence Measure (FIM). Functional decline during hospitalization was defined as a decrease of at least 1 point in FIM at discharge from admission. The primary outcome was the time to composite 180-day mortality and readmission from any cause after discharge. RESULTS In total, 363 patients (median [interquartile range] age: 80 [73-86] years, male: 68 %) were divided according to the median FIM scores (≥100, n = 183 and < 100, n = 180). Among the patients, 25 experienced functional decline during hospitalization, 69 were readmitted, and 17 died. In the Kaplan-Meier analysis, both the lower FIM group and the functional decline group had significantly lower event-free rates than the higher FIM groups and the non-functional decline groups (log-rank test, p < 0.001), respectively. After multivariate analysis, both the lower FIM (adjusted HR, 2.11; 95 % CI, 1.24-3.58; p = 0.006) and functional decline (adjusted HR, 3.18; 95 % CI, 1.44-7.05; p = 0.005) were significantly associated with the primary outcome. CONCLUSIONS In older patients hospitalized with pneumonia, ADL limitations at discharge and a decline in ADL were associated with poor outcomes.
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Affiliation(s)
- Kanji Yamada
- Department of Rehabilitation, Kobe City Medical Center General Hospital, Kobe, Japan; Department of Public Health, Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Kentaro Iwata
- Department of Rehabilitation, Kobe City Medical Center General Hospital, Kobe, Japan; Department of Public Health, Kobe University Graduate School of Health Sciences, Kobe, Japan.
| | - Yoshihiro Yoshimura
- Center for Sarcopenia and Malnutrition Research, Kumamoto Rehabilitation Hospital, Kumamoto, Japan
| | - Hiroaki Ota
- Department of Rehabilitation, Shinshu University Hospital, Nagano, Japan
| | - Yutaro Oki
- Department of Public Health, Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Yuji Mitani
- Department of Public Health, Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Yukari Oki
- Department of Public Health, Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Yoji Yamada
- Department of Public Health, Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Akio Yamamoto
- Department of Public Health, Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Kumiko Ono
- Department of Public Health, Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Takeshi Kitai
- Department of Rehabilitation, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Ryo Tachikawa
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Keisuke Tomii
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Nobuo Kohara
- Department of Rehabilitation, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Akira Ishikawa
- Department of Public Health, Kobe University Graduate School of Health Sciences, Kobe, Japan
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Andersson ÅG, Dahlkvist L, Kurland L. Patient-centered outcomes and outcome measurements for people aged 65 years and older-a scoping review. BMC Geriatr 2024; 24:528. [PMID: 38890618 PMCID: PMC11186133 DOI: 10.1186/s12877-024-05134-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 06/10/2024] [Indexed: 06/20/2024] Open
Abstract
INTRODUCTION The aging population is a challenge for the healthcare system that must identify strategies that meet their needs. Practicing patient-centered care has been shown beneficial for this patient-group. The effect of patient-centered care is called patient-centered outcomes and can be appraised using outcomes measurements. OBJECTIVES The main aim was to review and map existing knowledge related to patient-centered outcomes and patient-centered outcomes measurements for older people, as well as identify key-concepts and knowledge-gaps. The research questions were: How can patient-centered outcomes for older people be measured, and which patient-centered outcomes matters the most for the older people? STUDY DESIGN Scoping review. METHODS Search for relevant publications in electronical databases, grey literature databases and websites from year 2000 to 2021. Two reviewers independently screened titles and abstracts, followed by full text review and extraction of data using a data extraction framework. RESULTS Eighteen studies were included, of which six with involvement of patients and/or experts in the process on determine the outcomes. Outcomes that matter the most to older people was interpreted as: access to- and experience of care, autonomy and control, cognition, daily living, emotional health, falls, general health, medications, overall survival, pain, participation in decision making, physical function, physical health, place of death, social role function, symptom burden, and time spent in hospital. The most frequently mentioned/used outcomes measurements tools were the Adult Social Care Outcomes Toolkit (ASCOT), EQ-5D, Gait Speed, Katz- ADL index, Patient Health Questionnaire (PHQ9), SF/RAND-36 and 4-Item Screening Zarit Burden Interview. CONCLUSIONS Few studies have investigated the older people's opinion of what matters the most to them, which forms a knowledge-gap in the field. Future research should focus on providing older people a stronger voice in what they think matters the most to them.
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Affiliation(s)
- Åsa G Andersson
- Department of Geriatrics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
| | | | - Lisa Kurland
- Department of Emergency, School of Medical Sciences, Faculty of Medicineand , Health Örebro University, Örebro, Sweden
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Grenier A, Viscogliosi C, Delli-Colli N, Mortenson WB, Macleod H, Lemieux-Courchesne AC, Provencher V. The Performance Assessment of Self-Care Skills to Predict Adverse Events Post-Discharge. Can J Occup Ther 2022; 89:190-200. [PMID: 35275507 DOI: 10.1177/00084174221084459] [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] [Indexed: 11/15/2022]
Abstract
Background. The Performance Assessment of Self-Care Skills (PASS) is a standardized assessment of the ability to perform daily activities. Purposes. This preliminary exploratory study aimed to 1) explore the ability of four PASS tasks to predict adverse events (readmissions and injuries) in older adults following hospitalization; 2) compare PASS's predictive validity to that of a generic tool (SMAF) and OT clinical judgement. Method.Twenty-two older patients were assessed in hospital at discharge and at home one week later. Adverse events were documented for six months post-discharge. Sensitivity and specificity analyses (ROC curves, Fisher's exact tests) were performed. Findings. Two PASS tasks (telephone, medication), the SMAF-Social and OT clinical judgement could identify individuals at risk of readmission (AUC > 0.7; p < 0.05). Implications. Using the PASS to assess more cognitively demanding tasks could be a promising way to predict adverse events after discharge, as a complement to clinical judgment.
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Mitchell RJ, Goggins R, Lystad RP. Synthesis of evidence on the use of ecological momentary assessments to monitor health outcomes after traumatic injury: rapid systematic review. BMC Med Res Methodol 2022; 22:119. [PMID: 35459086 PMCID: PMC9027879 DOI: 10.1186/s12874-022-01586-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 03/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND With the increasing use of mobile technology, ecological momentary assessments (EMAs) may enable routine monitoring of patient health outcomes and patient experiences of care by health agencies. This rapid review aims to synthesise the evidence on the use of EMAs to monitor health outcomes after traumatic unintentional injury. METHOD A rapid systematic review of nine databases (MEDLINE, Web of Science, Embase, CINAHL, Academic Search Premier, PsychINFO, Psychology and Behavioural Sciences Collection, Scopus, SportDiscus) for English-language articles from January 2010-September 2021 was conducted. Abstracts and full-text were screened by two reviewers and each article critically appraised. Key information was extracted by population characteristics, age and sample size, follow-up time period(s), type of EMA tools, physical health or pain outcome(s), psychological health outcome(s), general health or social outcome(s), and facilitators or barriers of EMA methods. Narrative synthesis was undertaken to identify key EMA facilitator and barrier themes. RESULTS There were 29 articles using data from 25 unique studies. Almost all (84.0%) were prospective cohort studies and 11 (44.0%) were EMA feasibility trials with an injured cohort. Traumatic and acquired brain injuries and concussion (64.0%) were the most common injuries examined. The most common EMA type was interval (40.0%). There were 10 key facilitator themes (e.g. feasibility, ecological validity, compliance) and 10 key barrier themes (e.g. complex technology, response consistency, ability to capture a participant's full experience, compliance decline) identified in studies using EMA to examine health outcomes post-injury. CONCLUSIONS This review highlighted the usefulness of EMA to capture ecologically valid participant responses of their experiences post-injury. EMAs have the potential to assist in routine follow-up of the health outcomes of patients post-injury and their use should be further explored.
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Affiliation(s)
- Rebecca J Mitchell
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia.
| | - Rory Goggins
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia
| | - Reidar P Lystad
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia
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Auerswald T, Hendker A, Ratz T, Lippke S, Pischke CR, Peters M, Meyer J, von Holdt K, Voelcker-Rehage C. Impact of Activity Tracker Usage in Combination with a Physical Activity Intervention on Physical and Cognitive Parameters in Healthy Adults Aged 60+: A Randomized Controlled Trial. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19073785. [PMID: 35409466 PMCID: PMC8997555 DOI: 10.3390/ijerph19073785] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/04/2022] [Accepted: 03/07/2022] [Indexed: 02/01/2023]
Abstract
Regular physical activity (PA) is of central importance for healthy aging and has a well-known impact on helping older adults maintain their cognitive and physical health. Thus, we aimed to compare the effectiveness of two physical activity interventions primarily conducted at home (print-based or web-based vs. web-based plus the use of an activity tracker) on cognitive and physical health parameters in older adults. Data of participants (n = 551, 60–80 years) were analyzed after being randomly allocated to a waitlist control group (CG), a web-based or print-based intervention group (IG) or a web-based intervention group that also included the use of an activity tracker (AG). Measured parameters were grip strength, endurance (two-minute step test), gait speed (four-meter walk test), cognition (Simon task; balanced integration score (BIS), reaction time and accuracy) and physical self-concept (Physical Self-Description Questionnaire (PSDQ)). We found the highest effect sizes in all measured dimensions for AG (grip strength, endurance, gait speed, reaction time, physical self-concept), followed by IG (endurance, gait speed, reaction time, physical self-concept) and CG (endurance, gait speed, BIS). Findings suggest that a combined web-based and activity tracker intervention may improve physical functions, physical self-concept, and cognition in community-dwelling older adults.
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Affiliation(s)
- Tina Auerswald
- Institute of Human Movement Science and Health, Faculty of Behavioral and Social Sciences, Chemnitz University of Technology, 09126 Chemnitz, Germany;
| | - Anna Hendker
- Department of Neuromotor Behavior and Exercise, Institute of Sport and Exercise Sciences, University of Muenster, 48149 Muenster, Germany;
| | - Tiara Ratz
- Department of Psychology & Methods, Jacobs University Bremen GmbH, 28759 Bremen, Germany; (T.R.); (S.L.)
| | - Sonia Lippke
- Department of Psychology & Methods, Jacobs University Bremen GmbH, 28759 Bremen, Germany; (T.R.); (S.L.)
| | - Claudia R. Pischke
- Institute of Medical Sociology, Centre for Health and Society, Medical Faculty, Heinrich Heine University Duesseldorf, 40225 Duesseldorf, Germany;
| | - Manuela Peters
- Leibniz Institute for Prevention Research and Epidemiology–BIPS, 28359 Bremen, Germany;
| | - Jochen Meyer
- OFFIS–Institute for Information Technology, 26121 Oldenburg, Germany; (J.M.); (K.v.H.)
| | - Kai von Holdt
- OFFIS–Institute for Information Technology, 26121 Oldenburg, Germany; (J.M.); (K.v.H.)
| | - Claudia Voelcker-Rehage
- Institute of Human Movement Science and Health, Faculty of Behavioral and Social Sciences, Chemnitz University of Technology, 09126 Chemnitz, Germany;
- Department of Neuromotor Behavior and Exercise, Institute of Sport and Exercise Sciences, University of Muenster, 48149 Muenster, Germany;
- Correspondence: ; Tel.: +49-251-83-32461
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Delgado B, Novo A, Lopes I, Rebelo C, Almeida C, Pestana S, Gomes B, Froelicher E, Klompstra L. The effects of early rehabilitation on functional exercise tolerance in decompensated heart failure patients: Results of a multicenter randomized controlled trial (ERIC-HF study). Clin Rehabil 2022; 36:813-821. [PMID: 35313751 PMCID: PMC9082976 DOI: 10.1177/02692155221088684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To analyze (1) the effect of an aerobic training program on functional exercise tolerance in decompensated heart failure (DHF) patients; (2) to assess the effects of an aerobic training program on functional independence; and (3) dyspnea during activities of daily living. Design A randomized controlled clinical trial with follow-up at discharge. Settings Eight hospitals. Recruitment took place between 9/ 2017 and 3/2019. Group Assignments Patients with DHF who were admitted to the hospital, were randomly assigned to usual rehabilitation care guideline recommended (control group) or aerobic training program (exercise group). Main outcome Functional exercise tolerance was measured with a 6-min walking test at discharge. Results In total 257 patients with DHF were included, with a mean age of 67 ± 11 years, 84% (n = 205) had a reduced ejection fraction and the hospital stay was 16 ± 10 days. At discharge, patients in the intervention group walked further compared to the control group (278 ± 117m vs 219 ± 115m, p < 0.01) and this difference stayed significant after correcting for confounders (p < 0.01). A significant difference was found favoring the exercise group in functional independence (96 ± 7 vs 93 ± 12, p = 0.02) and dyspnea associated to ADL (13 ± 5 vs 17 ± 7, p < 0.01) and these differences persisted after correcting for baseline values and confounders (functional independence p < 0.01; dyspnea associated with ADL p = 0.02). Conclusion The ERIC-HF program is safe, feasible, and effective in increasing functional exercise tolerance and functional independence in hospitalized patients admitted due to DHF.
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Affiliation(s)
- Bruno Delgado
- Centro Hospitalar Universitário do Porto, Instituto de Ciências Biomédicas Abel Salazar
| | - André Novo
- 386399Instituto Politécnico de Bragança, CINTESIS:NursID, Portugal
| | - Ivo Lopes
- Centro Hospitalar Universitário do Porto
| | | | | | | | - Bárbara Gomes
- 112123Escola Superior de Enfermagem do Porto, CINTESIS:NursID, Portugal
| | - Erika Froelicher
- Department of Physiological Nursing, School of Nursing and Department of Epidemiology & Biostatistics, School of Medicine, University of California San Francisco, USA
| | - Leonie Klompstra
- Departement of Social and Welfare Studies, Linköping University, Linköping, Sweden
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Schneider AM, Mucharraz C, Denyer S, Brown NM. Prolonged hospital stay after arthroplasty for geriatric femoral neck fractures is associated with increased early mortality risk after discharge. J Clin Orthop Trauma 2022; 26:101785. [PMID: 35211374 PMCID: PMC8844821 DOI: 10.1016/j.jcot.2022.101785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/25/2022] [Accepted: 01/30/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Recent studies show increasing mortality rates of geriatric femoral neck fracture patients with delays in operative treatment greater than 48 hours from injury. A less extensively studied area in this population is the effect of length of inpatient hospital stay (LOS) on outcomes. The purpose of this study was to determine the association of LOS after arthroplasty for geriatric femoral neck fractures with 30-day mortality risk. METHODS This study is a retrospective review using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), a nationally validated, outcomes-based database incorporating data from over 700 geographically diverse medical centers. It included 9005 patients, 65 years of age or older, who underwent either hemiarthroplasty or total hip arthroplasty for a femoral neck fracture between 2011 and 2018. Using multivariate analysis, risk of 30-day mortality based on surgery-to-discharge time was determined, expressed as odds ratios (OR) with 95% confidence intervals (CI). RESULTS After controlling for sex, BMI, age, surgical procedure, American Society of Anesthesiologists (ASA) classification, and discharge location, the risk of mortality after discharge was increased with longer post-surgical length of stay [OR 2.5, P < .001]. CONCLUSION Prolonged LOS after arthroplasty for geriatric femoral neck fractures is associated with increased 30-day mortality risk. Efforts made to target and mitigate modifiable risk factors responsible for delaying discharge may improve early outcomes in this population.
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Affiliation(s)
- Andrew M. Schneider
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, 2160 S. First Ave, Maywood, IL, 60153, USA
| | - Carlos Mucharraz
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, 2160 S. First Ave, Maywood, IL, 60153, USA
| | - Steven Denyer
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, 2160 S. First Ave, Maywood, IL, 60153, USA
| | - Nicholas M. Brown
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, 2160 S. First Ave, Maywood, IL, 60153, USA
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Clinical impact of functional independent measure (FIM) on 180-day readmission and mortality in elderly patients hospitalized with acute decompensated heart failure. Heart Vessels 2021; 36:1536-1541. [PMID: 33834270 DOI: 10.1007/s00380-021-01841-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/19/2021] [Indexed: 10/21/2022]
Abstract
Activities of daily living (ADL) are important prognostic factors for heart failure. The functional independent measure (FIM) has emerged as a comprehensive valid measure of ADL from both physical and cognitive perspectives. This study aimed to investigate the prognostic impact of the FIM score on clinical outcomes in hospitalized patients with acute decompensated heart failure (ADHF). We retrospectively analyzed 473 ADHF patients, with available pre-discharge FIM scores, admitted to our institution between May 2018 and May 2020. Primary outcome measures, defined as a composite of 180-day all-cause deaths and readmissions, were compared among three tertiles. The median FIM score was 102 (interquartile range: 85-115). Tertile 1 corresponded to an FIM score > 111 (n = 154), Tertile 2 to that of 90-111 (n = 167), and Tertile 3 to that of < 90 (n = 152). During follow-up, 28 deaths and 114 readmissions occurred. Patients with lower FIM scores were associated with a graded increase in the risk of primary outcome measure (p = 0.001). Even after multivariable adjustment, the results remained significant [Tertile 1 vs 3; adjusted hazard ratio: 3.28 (95% confidence interval: 1.72-6.56), p < 0.001; Tertile 2 vs 3; 2.32 (1.27-4.47), p = 0.006]. FIM scores were significantly associated with readmission or death within 180 days of discharge in hospitalized ADHF patients.
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Wan CS, Reijnierse EM, Maier AB. Risk Factors of Readmissions in Geriatric Rehabilitation Patients: RESORT. Arch Phys Med Rehabil 2021; 102:1524-1532. [PMID: 33607077 DOI: 10.1016/j.apmr.2021.01.082] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 01/16/2021] [Accepted: 01/19/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To evaluate the risk factors associated with 30- and 90-day hospital readmissions in geriatric rehabilitation inpatients. DESIGN Observational, prospective longitudinal inception cohort. SETTING Tertiary hospital in Victoria, Australia. PARTICIPANTS Geriatric rehabilitation inpatients of the REStORing Health of Acutely Unwell AdulTs (RESORT) cohort evalutated by a comprehensive geriatric assessment including potential readmission risk factors (ie, demographic, social support, lifestyle, functional performance, quality of life, morbidity, length of stay in an acute ward). Of 693 inpatients, 11 died during geriatric rehabilitation. The mean age of the remaining 682 inpatients was 82.2±7.8 years, and 56.7% were women. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Thirty- and 90-day readmissions after discharge from geriatric inpatient rehabilitation. RESULTS The 30- and 90-day unplanned all-cause readmission rates were 11.6% and 25.2%, respectively. Risk factors for 30- and 90-day readmissions were as follows: did not receive tertiary education, lower quality of life, higher Charlson Comorbidity Index and Cumulative Illness Rating Scale (CIRS) scores, and a higher number of medications used in the univariable models. Formal care was associated with increased risk for 90-day readmissions. In multivariable models, CIRS score was a significant risk factor for 30-day readmissions, whereas high fear of falling and CIRS score were significant risk factors for 90-day readmissions. CONCLUSIONS High fear of falling and CIRS score were independent risk factors for readmission in geriatric rehabilitation inpatients. These variables should be included in hospital readmission risk prediction model developments for geriatric rehabilitation inpatients.
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Affiliation(s)
- Ching S Wan
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Esmee M Reijnierse
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia; Department of Human Movement Sciences, @AgeAmsterdam, Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands
| | - Andrea B Maier
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia; Department of Human Movement Sciences, @AgeAmsterdam, Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands; Healthy Longevity Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Centre for Healthy Longevity, @AgeSingapore, National University Health System, Singapore.
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Austin EJ, Neukirch J, Ong TD, Simpson L, Berger GN, Keller CS, Flum DR, Giusti E, Azen J, Davidson GH. Development and Implementation of a Complex Health System Intervention Targeting Transitions of Care from Hospital to Post-acute Care. J Gen Intern Med 2021; 36:358-365. [PMID: 32869191 PMCID: PMC7878619 DOI: 10.1007/s11606-020-06140-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 08/12/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Failure of effective transitions of care following hospitalization can lead to excess days in the hospital, readmissions, and adverse events. Evidence identifies both patient and system factors that influence poor care transitions, yet health systems struggle to translate evidence into complex interventions that have a meaningful impact on care transitions. OBJECTIVE We report on our experience developing, pilot testing, and evaluating a complex intervention (Addressing Complex Transitions program, or ACT program) that aims to improve care transitions for complex patients. DESIGN Following the Medical Research Council (MRC) framework, we engaged in iterative, stakeholder-driven work to develop a complex care intervention, assess feasibility and pilot methods, evaluate the intervention in practice, and facilitate ongoing implementation monitoring and dissemination. PARTICIPANTS Patients receiving care from UW Medicine's health system including 4 hospitals and 20-site Post-Acute Care network. INTERVENTION Literature review and prospective data collection activities informed ACT program design. ACT program components include a tailored risk calculator that provides real-time scoring of transitions of care risk factors, a multidisciplinary team with the capacity to address complex barriers to safe transitions, and enhanced discharge workflows to improve care transitions for complex patients. KEY MEASURES Program evaluation metrics included estimated hospital days saved and program acceptance by care team members. KEY RESULTS During the 6-month pilot, 565 patients were screened and 97 enrolled in the ACT program. An estimated 664 hospital days were saved for the index admission of ACT program participants. Analysis of pre/post-hospital utilization for ACT program participants showed an estimated 3227 fewer hospital days after ACT program enrollment. CONCLUSIONS Health systems need to address increasingly difficult challenges in care delivery. The use of evidence-based frameworks, such as the MRC framework, can guide systems to design complex interventions that respond to their local context and stakeholder needs.
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Affiliation(s)
- Elizabeth J. Austin
- Surgical Outcomes Research Center, University of Washington , Seattle, WA USA
- Department of Surgery, University of Washington, Seattle, WA USA
| | - Jen Neukirch
- UW Medicine Post-Acute Care, University of Washington, Seattle, WA USA
| | - Thuan D. Ong
- UW Medicine Post-Acute Care, University of Washington, Seattle, WA USA
- Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, WA USA
| | - Louise Simpson
- UW Medicine Post-Acute Care, University of Washington, Seattle, WA USA
| | - Gabrielle N. Berger
- Division of General Internal Medicine, University of Washington, Seattle, WA USA
| | - Carolyn Sy Keller
- Division of General Internal Medicine, University of Washington, Seattle, WA USA
| | - David R Flum
- Surgical Outcomes Research Center, University of Washington , Seattle, WA USA
- Department of Surgery, University of Washington, Seattle, WA USA
| | - Elaine Giusti
- Center for Clinical Excellence, University of Washington, Seattle, WA USA
| | - Jennifer Azen
- Division of General Internal Medicine, University of Washington, Seattle, WA USA
| | - Giana H. Davidson
- Surgical Outcomes Research Center, University of Washington , Seattle, WA USA
- Department of Surgery, University of Washington, Seattle, WA USA
- UW Medicine Post-Acute Care, University of Washington, Seattle, WA USA
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Provencher V, D'Amours M, Menear M, Obradovic N, Veillette N, Sirois MJ, Kergoat MJ. Understanding the positive outcomes of discharge planning interventions for older adults hospitalized following a fall: a realist synthesis. BMC Geriatr 2021; 21:84. [PMID: 33514326 PMCID: PMC7844968 DOI: 10.1186/s12877-020-01980-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 12/21/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Older adults hospitalized following a fall often encounter preventable adverse events when transitioning from hospital to home. Discharge planning interventions developed to prevent these events do not all produce the expected effects to the same extent. This realist synthesis aimed to better understand when, where, for whom, why and how the components of these interventions produce positive outcomes. METHODS Nine indexed databases were searched to identify scientific papers and grey literature on discharge planning interventions for older adults (65+) hospitalized following a fall. Manual searches were also conducted. Documents were selected based on relevance and rigor. Two reviewers extracted and compiled data regarding intervention components, contextual factors, underlying mechanisms and positive outcomes. Preliminary theories were then formulated based on an iterative synthesis process. RESULTS Twenty-one documents were included in the synthesis. Four Intervention-Context-Mechanism-Outcome configurations were developed as preliminary theories, based on the following intervention components: 1) Increase two-way communication between healthcare providers and patients/caregivers using a family-centered approach; 2) Foster interprofessional communication within and across healthcare settings through both standardized and unofficial information exchange; 3) Provide patients/caregivers with individually tailored fall prevention education; and 4) Designate a coordinator to manage discharge planning. These components should be implemented from patient admission to return home and be supported at the organizational level (contexts) to trigger knowledge, understanding and trust of patients/caregivers, adjusted expectations, reduced family stress, and sustained engagement of families and professionals (mechanisms). These optimal conditions improve patient satisfaction, recovery, functional status and continuity of care, and reduce hospital readmissions and fall risk (outcomes). CONCLUSIONS Since transitions are critical points with potential communication gaps, coordinated interventions are vital to support a safe return home for older adults hospitalized following a fall. Considering the organizational challenges, simple tools such as pictograms and drawings, combined with computer-based communication channels, may optimize discharge interventions based on frail patients' needs, habits and values. Empirically testing our preliminary theories will help to develop effective interventions throughout the continuum of transitional care to enhance patients' health and reduce the economic burden of avoidable care.
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Affiliation(s)
- Véronique Provencher
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada.
- Research Centre on Aging, Sherbrooke, QC, Canada.
| | | | - Matthew Menear
- Department of Family Medicine and Emergency Medicine, Laval University, Québec, Canada
- Centre de recherche sur les soins et les services de première ligne, Université Laval, Québec, Canada
| | - Natasa Obradovic
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
- Research Centre on Aging, Sherbrooke, QC, Canada
| | - Nathalie Veillette
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Marie-Josée Sirois
- Department of Rehabilitation, Faculty of Medicine, Université Laval, Québec, Canada
| | - Marie-Jeanne Kergoat
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
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Pilot of the Patient Concerns Inventory - Ward Discharge in Patients following major reconstructive surgery for head and neck cancer. Br J Oral Maxillofac Surg 2020; 59:425-432. [PMID: 33789810 PMCID: PMC7441974 DOI: 10.1016/j.bjoms.2020.08.080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 08/12/2020] [Indexed: 11/25/2022]
Abstract
Planning discharge from hospital following microvascular free-tissue surgery can be complex and challenging. Planning involves the patient, carers and multiple health professionals. Poor communication and expectations can delay discharge or give a suboptimal discharge process. It was hypothesised that prompt-list modelled along the principals of the Patient Concerns Inventory (PCI) could be help in discharge planning. The aim of this study was to define the items and format of a PCI-Ward Discharge (PCI-WD) and undertake a small pilot. Items appropriate for the PCI-WD were formulated through discussion with patients, carers, ward staff, Head and Neck Clinical Nurse Specialists, and clinicians. The pilot took place over 3 months from December 2019 through February 2020. Audit approval was given by the hospital Audit Department. The PCI-WD comprises 43 items. Items from existing PCIs for use at diagnosis and follow-up consultations were reduced in number and 38 new or modified items added; 6 treatment related, 5 social care and social well-being, 4 psychological, emotional and spiritual well-being, 7 physical and functional well-being and 16 discharge related. The pilot involved 14 free-tissue transfer patients, 7 male, 7 female, with age range 57 to 87 and average age 72. Eight PCI-WD were returned. PCI-WD items identified most frequently were ‘surgery site other than head/neck’, ‘when do I come back to hospital’, ‘dental check-up/oral health care’ and ‘diet/eating’. Early findings suggest that PCI-WD could be a useful tool in aiding the discharge process. Further evaluation is required.
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Abstract
The quality of discharge teaching is statistically linked to decreased readmission rates. Nursing most often bears the major responsibility of patient and caregiver teaching. Currently, discharge teaching is complicated by problems including time constraints, patient and caregiver overload, and coexisting comorbidities that add complexity to the patient's care needs at home. Not only are readmissions a preventable cost, more importantly, but they also are a negative patient experience signifying to our patients that they are unable to optimally care for themselves or that their disease or healing is not something they can care for alone. The following is a review of Agency for Healthcare Research and Quality's IDEAL discharge process, common problems in discharge teaching, and nursing's responsibilities with assessing a patient and his or her caregiver for discharge readiness. IDEAL is a structured discharge process with tools to help healthcare organizations improve their discharge process to decrease readmissions rates.
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Tamblyn R, Abrahamowicz M, Buckeridge DL, Bustillo M, Forster AJ, Girard N, Habib B, Hanley J, Huang A, Kurteva S, Lee TC, Meguerditchian AN, Moraga T, Motulsky A, Petrella L, Weir DL, Winslade N. Effect of an Electronic Medication Reconciliation Intervention on Adverse Drug Events: A Cluster Randomized Trial. JAMA Netw Open 2019; 2:e1910756. [PMID: 31539073 PMCID: PMC6755531 DOI: 10.1001/jamanetworkopen.2019.10756] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Adverse drug events (ADEs) account for up to 16% of emergency department (ED) visits and 7% of hospital admissions. Medication reconciliation is required for hospital accreditation because it can reduce medication discrepancies, but there is no evidence that reducing discrepancies reduces ADEs or other adverse outcomes. OBJECTIVE To evaluate whether electronic medication reconciliation reduces ADEs, medication discrepancies, and other adverse outcomes compared with usual care. DESIGN, SETTING, AND PARTICIPANTS This cluster randomized trial involved 3491 patients who were discharged from 2 medical units and 2 surgical units at the McGill University Health Centre, Montreal, Quebec, Canada, between October 2014 and November 2016. Data analysis took place from July 2017 to July 2019. INTERVENTION The RightRx intervention electronically retrieved community drugs from the provincial insurer and aligned them with in-hospital drugs to facilitate reconciliation and communication at care transitions. MAIN OUTCOMES AND MEASURES The primary outcome was ADEs in 30 days after discharge. Secondary outcomes included medication discrepancies, ED visits, hospital readmissions, and a composite outcome of ED visits, readmissions, and death up to 90 days after discharge. RESULTS Of 4656 eligible patients, 3567 (76.6%) consented to participate (2060 [57.8%] men; mean [SD] age, 69.8 [14.9] years). Overall, 76 patients died during the hospital stay, so 3491 patients were included in the analysis. There was no significant difference in the risk of ADEs between intervention and control groups (76 [4.6%] vs 73 [4.0%]; OR, 0.97; 95% CI, 0.33-1.48), ED visits (433 [26.2%] vs 488 [26.6%]; OR, 0.83; 95% CI, 0.36-1.42), hospital readmission (170 [10.3%] vs 261 [14.2%]; OR, 0.22; 95% CI, 0.06-1.14), or the composite outcome (447 [27.0%] vs 506 [27.6%]; OR, 0.75; 95% CI, 0.34-1.27) at 30 days. Medication discrepancies were significantly reduced in the intervention group compared with the control group (437 [26.4%] vs 1029 [56.0%]; OR, 0.24; 95% CI, 0.12-0.57). Changes made to community medications (OR, 1.05; 95% CI, 1.01-1.10) and new medications (OR, 1.09; 95% CI, 1.01-1.18) were significant risk factors for ADEs. CONCLUSIONS AND RELEVANCE Electronic medication reconciliation reduced medication discrepancies but did not reduce ADEs or other adverse outcomes. Hospital accreditation should focus on interventions that reduce the risk of adverse events for patients with multiple changes to community medications. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01179867.
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Affiliation(s)
- Robyn Tamblyn
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- Clinical and Health Informatics Research Group, McGill University, Montreal, Quebec, Canada
- Department of Medicine, McGill University Health Center, Montreal, Quebec, Canada
| | - Michal Abrahamowicz
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - David L. Buckeridge
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- Clinical and Health Informatics Research Group, McGill University, Montreal, Quebec, Canada
| | - Melissa Bustillo
- Clinical and Health Informatics Research Group, McGill University, Montreal, Quebec, Canada
| | | | - Nadyne Girard
- Clinical and Health Informatics Research Group, McGill University, Montreal, Quebec, Canada
| | - Bettina Habib
- Clinical and Health Informatics Research Group, McGill University, Montreal, Quebec, Canada
| | - James Hanley
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Allen Huang
- Division of Geriatric Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Siyana Kurteva
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Todd C. Lee
- Department of Medicine, McGill University Health Center, Montreal, Quebec, Canada
- McGill University Health Centre, Montreal, Quebec, Canada
| | - Ari N. Meguerditchian
- Clinical and Health Informatics Research Group, McGill University, Montreal, Quebec, Canada
- Department of Medicine, McGill University Health Center, Montreal, Quebec, Canada
- McGill University Health Centre, Montreal, Quebec, Canada
| | - Teresa Moraga
- Clinical and Health Informatics Research Group, McGill University, Montreal, Quebec, Canada
| | - Aude Motulsky
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal, School of Public Health, University of Montreal, Montreal, Quebec, Canada
| | - Lina Petrella
- McGill University Health Centre, Montreal, Quebec, Canada
| | - Daniala L. Weir
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Nancy Winslade
- Clinical and Health Informatics Research Group, McGill University, Montreal, Quebec, Canada
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Braun T, Grüneberg C, Süßmilch K, Wiessmeier M, Schwenk I, Eggert S, Machleit-Ebner A, Harras I, Thiel C. An augmented prescribed exercise program (APEP) to improve mobility of older acute medical patients - a randomized, controlled pilot and feasibility trial. BMC Geriatr 2019; 19:240. [PMID: 31470815 PMCID: PMC6716827 DOI: 10.1186/s12877-019-1246-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 08/12/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND There is inconclusive evidence for the effectiveness of additional exercise in older hospital patients. The aims of this study were (1) to assess the feasibility of an augmented prescribed exercise program (APEP) in older acute medical patients and (2) to measure the potential effects of APEP on mobility capacity in order to assess the feasibility of a large full-scale study. METHODS We conducted a single-center, prospective, parallel-group, single-blinded, randomized (1:1) controlled pilot and feasibility trial. Participants were recruited from acute geriatric wards of a general hospital. Key inclusion criteria were: age ≥ 65 years and walking ability. Key exclusion criteria were severe cognitive impairment and medical restriction for physical exercise interventions. Both groups received usual care, including physiotherapy. Intervention group participants were scheduled for additional exercise sessions (20-30 min, 4-5x/week). Feasibility of the trial design was assessed along pre-defined criteria for process, resources and management. Feasibility of the APEP intervention was analyzed by means of adherence, compliance and safety. Outcomes were measured at baseline and prior to hospital discharge. The primary outcome was mobility capacity (de Morton Mobility Index; DEMMI). Secondary outcomes were walking ability, physical endurance, fear of falling, frailty and length of stay. RESULTS Thirty-five participants were recruited (recruitment rate 20.3%). We lost 7 participants to follow-up (retention rate: 80%). Intervention group participants (n = 17) each participated in 5.3 ± 2.2 additional exercise sessions (mean duration: 23.2 ± 4.0 min; mean adherence rate 78% ± 26%). No severe adverse events occurred during study assessments or APEP sessions. There were no statistically significant differences in mean change scores in any outcome measure. A sample of 124 participants would be required to detect a difference of 4 DEMMI points (ES = 0.45) with a power of 80%. CONCLUSIONS This small feasibility RCT indicates that an APEP intervention may be safe and feasible in older acute medical patients. APEP may possibly induce small to moderate effects on mobility, but the clinical relevance of these effects may be limited. These results inform the planning of a larger-scale phase III study. TRIAL REGISTRATION German Clinical Trials Register ( DRKS00011262 ). Registered 27 October 2016.
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Affiliation(s)
- Tobias Braun
- Department of Applied Health Sciences, Division of Physiotherapy, Hochschule für Gesundheit (University of Applied Sciences), Gesundheitscampus 6-8, 44801 Bochum, Germany
| | - Christian Grüneberg
- Department of Applied Health Sciences, Division of Physiotherapy, Hochschule für Gesundheit (University of Applied Sciences), Gesundheitscampus 6-8, 44801 Bochum, Germany
| | - Kirsten Süßmilch
- Department of Applied Health Sciences, Division of Physiotherapy, Hochschule für Gesundheit (University of Applied Sciences), Gesundheitscampus 6-8, 44801 Bochum, Germany
- Evangelische Krankenhausgemeinschaft Herne/Castrop-Rauxel gGmbH, Division of Physiotherapy, Castrop-Rauxel, Germany
| | - Max Wiessmeier
- Department of Applied Health Sciences, Division of Physiotherapy, Hochschule für Gesundheit (University of Applied Sciences), Gesundheitscampus 6-8, 44801 Bochum, Germany
| | - Isabel Schwenk
- Department of Applied Health Sciences, Division of Physiotherapy, Hochschule für Gesundheit (University of Applied Sciences), Gesundheitscampus 6-8, 44801 Bochum, Germany
| | - Sarah Eggert
- Department of Applied Health Sciences, Division of Physiotherapy, Hochschule für Gesundheit (University of Applied Sciences), Gesundheitscampus 6-8, 44801 Bochum, Germany
| | - Annika Machleit-Ebner
- Evangelische Krankenhausgemeinschaft Herne/Castrop-Rauxel gGmbH, Clinical Trials Center, Wiescherstraße 24, 44623 Herne, Germany
| | - Irene Harras
- Evangelische Krankenhausgemeinschaft Herne/Castrop-Rauxel gGmbH, Therapeutic management, Wiescherstraße 24, 44623 Herne, Germany
| | - Christian Thiel
- Department of Applied Health Sciences, Division of Physiotherapy, Hochschule für Gesundheit (University of Applied Sciences), Gesundheitscampus 6-8, 44801 Bochum, Germany
- Ruhr-University Bochum, Faculty of Sports Science, Training and Exercise Science, Bochum, Germany
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Krause O, Glaubitz S, Hager K, Schleef T, Wiese B, Junius-Walker U. Post-discharge adjustment of medication in geriatric patients : A prospective cohort study. Z Gerontol Geriatr 2019; 53:663-670. [PMID: 31440831 DOI: 10.1007/s00391-019-01601-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 08/05/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Little is known to what extent general practitioners (GP) change hospital discharge medications in older patients. OBJECTIVE This prospective cohort study aimed to analyze medication changes at the interface between hospital and community in terms of quality, quantity and type of drugs. METHODS A total of 121 out of 248 consecutively enrolled patients admitted to an acute geriatric hospital unit participated in the study. Medication regimens were recorded at admission and discharge and 4 weeks after hospital discharge the general practitioners in charge were contacted to provide the current medication charts. Changes in the extent of polypharmacy, in the type of drugs using anatomical therapeutic chemical classification (ATC) codes and potentially inappropriate medications (PIM) were analyzed. RESULTS Medication charts could be obtained for 98 participants in primary care. Only 21% of these patients remained on the original discharge medication. Overall, the average number of medications rose from hospital admission (6.58 SD ± 3.45) to discharge (6.96 SD ± 3.49) and again post-discharge in general practice (7.22 SD ± 3.68). The rates of patients on excessive polypharmacy (≥10 drugs) and on PIM were only temporarily reduced during hospital stay. The GPs stopped anti-infective drugs (ATC-J) and prescribed more antirheumatic drugs (ATC-M). Although no significant net changes occurred in other ATC groups, a substantial number of drugs were interchanged regarding the subgroups. CONCLUSION The study found that GPs extensively adjusted geriatric discharge medications. Whereas some changes may be necessary due to alterations in patients' state of health, a thorough communication between hospital doctors and GPs may level off different prescribing cultures and contribute to consistency in medication across sectors.
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Affiliation(s)
- Olaf Krause
- Center for Medicine of the Elderly, DIAKOVERE Henriettenstift, Schwemannstr. 19, 30559, Hannover, Germany. .,Institute for General Practice, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Stefanie Glaubitz
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.,Department of Neurology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Klaus Hager
- Center for Medicine of the Elderly, DIAKOVERE Henriettenstift, Schwemannstr. 19, 30559, Hannover, Germany
| | - Tanja Schleef
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Birgitt Wiese
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Ulrike Junius-Walker
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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Flaks-Manov N, Topaz M, Hoshen M, Balicer RD, Shadmi E. Identifying patients at highest-risk: the best timing to apply a readmission predictive model. BMC Med Inform Decis Mak 2019; 19:118. [PMID: 31242886 PMCID: PMC6595564 DOI: 10.1186/s12911-019-0836-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 06/06/2019] [Indexed: 11/21/2022] Open
Abstract
Background Most of readmission prediction models are implemented at the time of patient discharge. However, interventions which include an early in-hospital component are critical in reducing readmissions and improving patient outcomes. Thus, at-discharge high-risk identification may be too late for effective intervention. Nonetheless, the tradeoff between early versus at-discharge prediction and the optimal timing of the risk prediction model application remains to be determined. We examined a high-risk patient selection process with readmission prediction models using data available at two time points: at admission and at the time of hospital discharge. Methods An historical prospective study of hospitalized adults (≥65 years) discharged alive from internal medicine units in Clalit’s (the largest integrated payer-provider health fund in Israel) general hospitals in 2015. The outcome was all-cause 30-day emergency readmissions to any internal medicine ward at any hospital. We used the previously validated Preadmission Readmission Detection Model (PREADM) and developed a new model incorporating PREADM with hospital data (PREADM-H). We compared the percentage of overlap between the models and calculated the positive predictive value (PPV) for the subgroups identified by each model separately and by both models. Results The final cohort included 35,156 index hospital admissions. The PREADM-H model included 17 variables with a C-statistic of 0.68 (95% CI: 0.67–0.70) and PPV of 43.0% in the highest-risk categories. Of patients categorized by the PREADM-H in the highest-risk decile, 78% were classified similarly by the PREADM. The 22% (n = 229) classified by the PREADM-H at the highest decile, but not by the PREADM, had a PPV of 37%. Conversely, those classified by the PREADM into the highest decile but not by the PREADM-H (n = 218) had a PPV of 31%. Conclusions The timing of readmission risk prediction makes a difference in terms of the population identified at each prediction time point – at-admission or at-discharge. Our findings suggest that readmission risk identification should incorporate a two time-point approach in which preadmission data is used to identify high-risk patients as early as possible during the index admission and an “all-hospital” model is applied at discharge to identify those that incur risk during the hospital stay.
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Affiliation(s)
- Natalie Flaks-Manov
- Clalit Research Institute, Clalit Health Services, Shoham 2, Ramat Gan, Israel
| | - Maxim Topaz
- Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, 31905, Haifa, Israel
| | - Moshe Hoshen
- Clalit Research Institute, Clalit Health Services, Shoham 2, Ramat Gan, Israel
| | - Ran D Balicer
- Clalit Research Institute, Clalit Health Services, Shoham 2, Ramat Gan, Israel.,Department of Epidemiology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Efrat Shadmi
- Clalit Research Institute, Clalit Health Services, Shoham 2, Ramat Gan, Israel. .,Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, 31905, Haifa, Israel.
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Pudalov LR, Swogger MT, Wittink M. Towards integrated medical and mental healthcare in the inpatient setting: what is the role of psychology? Int Rev Psychiatry 2018; 30:210-223. [PMID: 30821187 DOI: 10.1080/09540261.2018.1552125] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Integrated medical and psychiatric hospital units hold great promise for improving the value and quality of care for patients with severe mental illness and concomitant acute medical needs. It is important to explore the utility of providing a range of multidisciplinary inpatient services to meet patients' complex needs. Within this context, services typically provided by psychologists have received little research attention. To address this gap in the literature, this study assessed inpatient clinicians' perceptions of the need for specific behavioural services on a medical psychiatric unit, exploring their overlap with established psychological services. Results indicate the potential utility of specific psychological services, including psychological assessments, direct psychosocial interventions, and psychoeducational training. While reimbursement and billing barriers still exist for psychologists to be routinely incorporated into hospital settings, the movement towards value-based care could provide the opportunity to think about the value added. Embedding evidence-based psychological services has the potential to promote high quality, well-rounded care that aligns with the established mission of multidisciplinary teamwork on integrated medical and psychiatric inpatient units.
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Affiliation(s)
- Lauren R Pudalov
- a Chronic Pain Rehabilitation Program and Bariatric & Metabolic Institute, Cleveland Clinic , Cleveland , OH , USA
| | - Marc T Swogger
- b Department of Psychiatry, University of Rochester School of Medicine and Dentistry , Rochester , NY , USA
| | - Marsha Wittink
- c Departments of Family Medicine and Psychiatry, University of Rochester School of Medicine and Dentistry , Rochester , NY , USA
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Goh KS, Low SKM, Zhang D, Png GK, Lin H, Ang WST, Lim JKH. Mortality predictors in an acute care geriatric unit in Singapore. PROCEEDINGS OF SINGAPORE HEALTHCARE 2018. [DOI: 10.1177/2010105818762915] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Aim: Admission to an acute care geriatric unit may lead to adverse outcomes. It is therefore important to identify high-risk patients early so that appropriate management can be instituted to prevent or delay onset of adverse events. The aim of this study is to evaluate one-year mortality and its associated risk factors among hospitalized patients. Methods: This is a retrospective cohort study on consecutive patients admitted to an acute geriatric ward in a Singapore hospital from March to April 2013.Demographic and clinical information was collected from patient medical records. Linkage with death records from a national registry was performed. Results: Of the 196 patients assessed, 4.6%, 20.9% and 35.7% died during admission, within six months post-admission and within one year post-admission respectively. Pneumonia and cardiovascular diseases accounted for most of the death cases. In the multivariable logistic regression adjusted by age and gender, abbreviated mental test (AMT) score, admission for falls and depression were found to be significantly associated with death within one year post-admission. In the analysis stratified by gender, AMT score and depression were found to be significantly associated with death in males whereas AMT score and admission for falls were significantly associated with death in females. Conclusions: This study offers significant insight into mortality trends and risk factors for clinicians, hence guiding them in individualizing their management plan for acutely ill geriatric patients. Predicting long-term prognosis will enhance rehabilitation goal-setting and advance care-planning.
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Affiliation(s)
| | | | - Di Zhang
- Changi General Hospital, Singapore
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20
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Schreiber N, Powell T, O'Dowd MA. Who Should Decide? Residence Capacity Evaluation of a Cognitively-Impaired Older Adult Requesting an “Unsafe” Discharge to Home. PSYCHOSOMATICS 2018; 59:612-617. [DOI: 10.1016/j.psym.2018.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 03/07/2018] [Accepted: 03/19/2018] [Indexed: 11/30/2022]
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Hughes LD, Witham MD. Causes and correlates of 30 day and 180 day readmission following discharge from a Medicine for the Elderly Rehabilitation unit. BMC Geriatr 2018; 18:197. [PMID: 30153802 PMCID: PMC6114496 DOI: 10.1186/s12877-018-0883-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 08/15/2018] [Indexed: 12/16/2022] Open
Abstract
Background Recently hospitalized patients experience a period of generalized risk of adverse health events. This study examined reasons for, and predictors of, readmission to acute care facilities within 30 and 180 days of discharge from an inpatient rehabilitation unit for older people. Methods Routinely collected, linked clinical data on admissions to a single inpatient rehabilitation facility over a 13-year period were analysed. Data were available regarding demographics, comorbid disease, admission and discharge Barthel scores, length of hospital stay, and number of medications on discharge. Discharge diagnoses for the index admission and readmissions were available from hospital episode statistics. Univariate and multivariate Cox regression analyses were performed to identify baseline factors that predicted 30 and 180-day readmission. Results A total of 3984 patients were included in the analysis. The cohort had a mean age of 84.1 years (SD 7.4), and 39.7% were male. Overall, 5.6% (n = 222) and 23.2% (n = 926) of the patients were readmitted within 30 days and 180 days of discharge respectively. For patients readmitted to hospital, 26.6% and 21.1% of patients were readmitted with the same condition as their initial admission at 30 days and 180 respectively. For patients readmitted within 30 days, 13.5% (n = 30) were readmitted with the same condition with the most common diagnoses associated with readmission being chest infection, falls/immobility and stroke. For patients readmitted within 180 days, 12.4% (n = 115) of patients were readmitted with the same condition as the index condition with the most common diagnoses associated with readmission being falls/immobility, cancer and chest infections. In multivariable Cox regression analyses, older age, male sex, length of stay and heart failure predicted 30 or 180-day readmission. In addition, discharge from hospital to patients own home predicted 30-day readmission, whereas diagnoses of cancer, previous myocardial infarction or chronic obstructive pulmonary disease predicted 180-day readmission. Conclusion Most readmissions of older people after discharge from inpatient rehabilitation occurred for different reasons to the original hospital admission. Patterns of predictors for early and late readmission differed, suggesting the need for different mitigation strategies.
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Affiliation(s)
- Lloyd D Hughes
- GP Registrar, Primary Care Directorate, NHS Education for Scotland, Edinburgh, UK
| | - Miles D Witham
- Ageing and Health, University of Dundee, Ninewells Hospital, Dundee, UK.
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Hodgins MJ, Logan SM, Fraser JM, Buck DM, Stack BD. Clinical utility of scores on the Blaylock Risk Assessment Screen (BRASS): An analysis of administrative data. Appl Nurs Res 2018; 41:36-40. [PMID: 29853211 DOI: 10.1016/j.apnr.2018.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 02/07/2018] [Accepted: 03/02/2018] [Indexed: 12/01/2022]
Abstract
PURPOSE Project was undertaken to examine the utility of the Blaylock Risk Assessment Screen (BRASS) in identifying patients who may experience discharge complications as indicated by longer hospital stays or readmission within 30-days of a discharge to home. BACKGROUND Before measures can be put in place to facilitate discharge planning and to prevent unplanned readmission by recently discharged patients, those at risk of such events must be identified. METHODS Project involved an analysis of 13-months of administrative data from one tertiary care hospital. Utility of the BRASS was examined in terms of its sensitivity and specificity as well as its positive and negative predictive values. RESULTS Majority (83%) of hospital discharges were to home. Approximately 7% of patients experienced at least one readmission within 30-days of being discharged to home. Using scores of 10 or higher as an indicator of risk, BRASS exhibited a high degree of specificity suggesting it is useful for 'ruling in' those who have the outcomes-of-interest. However low sensitivity indicates many who experienced the outcomes were incorrectly classified by the BRASS as low risk. The low positive predictive value for 30-day readmission also suggests many who were classified by the BRASS as being 'at risk' were not readmitted. CONCLUSION The observed rate of 30-day readmission is likely conservative as the analysis involved data from only one acute care facility. One explanation for the low positive predictive value for 30-day readmission is that completion of the BRASS on admission enabled the implementation of preventive measures.
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Affiliation(s)
- Marilyn J Hodgins
- Faculty of Nursing, University of New Brunswick Fredericton, 208 MacLaggan Hall, 33 Dineen Drive, Fredericton, New Brunswick E3B 5A3, Canada.
| | | | | | | | - Bridget D Stack
- SJRH Family & Internal Medicine, and Palliative Care, Canada
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Storeng SH, Sund ER, Krokstad S. Factors associated with basic and instrumental activities of daily living in elderly participants of a population-based survey: the Nord-Trøndelag Health Study, Norway. BMJ Open 2018; 8:e018942. [PMID: 29530908 PMCID: PMC5857703 DOI: 10.1136/bmjopen-2017-018942] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To investigate factors associated with the need for assistance in basic and instrumental activities of daily living in Norwegian elderly. DESIGN Prospective cohort study. SETTING The Nord-Trøndelag Health Study (HUNT), a large population-based health survey in Norway. PARTICIPANTS 5050 individuals aged 60-69 years old at baseline in HUNT2 (1995-1997) who also participated in HUNT3 (2006-2008) were included in the study. 676/693 individuals were excluded in the analyses due to missing outcomes. OUTCOMES Needing assistance in one or more basic or instrumental activities of daily living reported in HUNT3. RESULTS In adjusted multinomial logistic regression analyses, poor self-rated health and depression were the strongest risk factors for needing assistance in one or more basic activities of daily living in HUNT3, with ORs of 2.13 (1.35 to 3.38) and 1.58 (0.91 to 2.73). Poor self-rated health and poor life satisfaction were the strongest risk factors for needing assistance in one or more instrumental activities of daily living in HUNT3, with ORs of 2.30 (1.93 to 2.74) and 2.29 (1.86 to 2.81), respectively. Excessive sitting time, short or prolonged sleeping time, and physical inactivity seemed to be the most important lifestyle risk factors for basic/instrumental activities of daily living (ADL/IADL) disability. The studied factors were, in general, greater risk factors for mortality during follow-up than for ADL/IADL disability. Smoking was the strongest risk factor for mortality during follow-up and non-participation in HUNT3. Smoking and low social participation were the strongest risk factors for non-participation in HUNT3. CONCLUSIONS Subjective health perception, life satisfaction and depression were the strongest risk factors for needing assistance in one or more basic/instrumental activities of daily living later in life. These factors could be possible targets for prevention purposes.
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Affiliation(s)
- Siri Høivik Storeng
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Erik R Sund
- Department of Public Health and Nursing, HUNT Research Centre, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Levanger, Norway
- Faculty of Nursing and Health Sciences, Nord University, Levanger, Norway
| | - Steinar Krokstad
- Department of Public Health and Nursing, HUNT Research Centre, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Levanger, Norway
- Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
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El Morabet N, Uitvlugt EB, van den Bemt BJ, van den Bemt PM, Janssen MJ, Karapinar-Çarkit F. Prevalence and Preventability of Drug-Related Hospital Readmissions: A Systematic Review. J Am Geriatr Soc 2018; 66:602-608. [DOI: 10.1111/jgs.15244] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Najla El Morabet
- Department of Hospital Pharmacy; OLVG; Amsterdam The Netherlands
| | | | - Bart J.F. van den Bemt
- Department of Pharmacy; SintMaartenskliniek; Nijmegen The Netherlands
- Department of Pharmacy; Radboud University Medical Centre; Nijmegen The Netherlands
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Schwab C, Korb-Savoldelli V, Escudie JB, Fernandez C, Durieux P, Saint-Jean O, Sabatier B. Iatrogenic risk factors associated with hospital readmission of elderly patients: A matched case-control study using a clinical data warehouse. J Clin Pharm Ther 2018; 43:393-400. [PMID: 29446115 DOI: 10.1111/jcpt.12670] [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: 11/30/2017] [Accepted: 01/09/2018] [Indexed: 12/29/2022]
Abstract
WHAT IS KNOWN Hospital readmission within 30 days of patient discharge has become a standard to judge the quality of hospitalizations. It is estimated that 14% of the elderly, people over 75 years old or those over 65 with comorbidities, are at risk of readmission, of which 23% are avoidable. It may be possible to identify elderly patients at risk of readmission and implement steps to reduce avoidable readmissions. OBJECTIVE The aim of this study was to identify iatrogenic risk factors for readmission. The secondary objective was to evaluate the rate of drug-related readmissions (DRRs) among all readmissions and compare it to the rate of readmissions for other reasons. METHODS We conducted a retrospective, matched, case-control study to identify non-demographic risk factors for avoidable readmission, specifically DRRs. The study included patients hospitalized between 1 September 2014 and 31 October 2015 in an 800-bed university hospital. We included patients aged 75 and over. Cases consisted of patients readmitted to the emergency department within 30 days of initial discharge. Controls did not return to the emergency department within 30 days. Cases and controls were matched on sex and age because they are known as readmissions risk factors. After comparison of the mean or percentage between cases and controls for each variable, we conducted a conditional logistic regression. RESULTS The risk factors identified were an emergency admission at the index hospitalization, returning home after discharge, a history of unplanned readmissions and prescription of nervous system drugs. Otherwise, 11.4% of the readmissions were DRRs, of which 30% were caused by an overdose of antihypertensive. The number of drugs at readmission was higher, and potentially inappropriate medications were more widely prescribed for DRRs than for readmissions for other reasons. WHAT IS NEW AND CONCLUSION In this matched case-control retrospective study, after controlling for gender and age, we identified the typical profile of elderly patients at risk of readmission. These patients had an unplanned admission at the index hospitalization and prescribed nervous system drugs at discharge from the index admission; they have a history of unplanned readmission within 30 days and return home after discharge.
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Affiliation(s)
- C Schwab
- INSERM UMR 1138, Equipe 22, Centre de Recherche des Cordeliers, Universités Paris, Paris, France.,Service Pharmacie, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - V Korb-Savoldelli
- Service Pharmacie, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France.,Université Paris-Sud, Faculté de Pharmacie, Châtenay-Malabry, France
| | - J B Escudie
- INSERM UMR 1138, Equipe 22, Centre de Recherche des Cordeliers, Universités Paris, Paris, France.,Département de Santé Publique et Informatique Médicale, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - C Fernandez
- Université Paris-Sud, Faculté de Pharmacie, Châtenay-Malabry, France.,Service de Pharmacie, Hôpital Saint-Antoine, Assistance Publique - Hôpitaux de Paris, Paris, France.,Sorbonne Universités, UPMC Univ Paris 06, UMR-S 1136, Institut Pierre Louis D'Epidémiologie et de Santé Publique, Paris, France
| | - P Durieux
- INSERM UMR 1138, Equipe 22, Centre de Recherche des Cordeliers, Universités Paris, Paris, France.,Département de Santé Publique et Informatique Médicale, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - O Saint-Jean
- Faculté de Médecine, Université Paris-Descartes, Paris, France.,Service de Gériatrie, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - B Sabatier
- INSERM UMR 1138, Equipe 22, Centre de Recherche des Cordeliers, Universités Paris, Paris, France.,Service Pharmacie, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France
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Patient Education and Discharge Planning to Prevent Functional Decline in the Older Adult. Gastroenterol Nurs 2017; 40:272-278. [PMID: 28746112 DOI: 10.1097/sga.0000000000000238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The population in the United States is aging, and persons older than 65 years account for over 50% of healthcare costs. Preventing functional decline in older adults through patient education and optimal discharge planning is one way we can succeed in decreasing healthcare costs, readmissions, and mortality in this population. The aim of this article is to present viable healthcare policy options to prevent or minimize functional decline in the older adult, regardless of what health-related facility the person enters. Policy objectives include mandating functional screening tests on all persons 65 years and older, addressing functional status as a required element of discharge planning, tracking and reporting patient outcomes, and utilizing advanced practice nurses to the full extent of their education and scope of practice. Three policy options are presented, analyzed, and compared. The summary concludes with a recommended policy option.
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Shinan-Altman S, Ayalon L. If I am not for myself, who is for me? The experiences of older migrant home care recipients during their hospitalization. Aging Ment Health 2017; 21:182-189. [PMID: 28121476 DOI: 10.1080/13607863.2015.1093604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Hospitalization is a major risk for older adults; therefore, it is crucial to provide the appropriate treatment during hospitalization. This study examined hospitalized older adults' perceptions regarding three groups of treatment providers: nursing staff, family members, migrant home care workers. METHOD Qualitative interviews were conducted with 17 hospitalized older adults. Data were gathered by in-depth interviews. Content analysis included open coding, axial coding and integration of the main findings using constant comparisons. RESULTS Three themes emerged: (1) 'What is my worth?' This theme was focused on the participants' perceptions of themselves as helpless and dependent on others. (2) 'What would I do without them?' This theme referred to the perception of the migrant home care workers and nursing staff as essential. It meant immense gratitude, but also a sense of dependency on paid caregivers. (3) 'They have their own busy life.' This theme concerned participants' low treatment expectations from their family members due to their perception of their family members as having multiple obligations. CONCLUSION Hospitalized older adults prefer to turn to paid caregivers rather than to their families. Findings are discussed in light of the tension between formal and informal care in countries that are transitioning from traditional family values to modern values, placing the care of older adults by paid caregivers.
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Affiliation(s)
- Shiri Shinan-Altman
- a Louis and Gabi Weisfeld School of Social Work , Bar Ilan University , Ramat-Gan , Israel
| | - Liat Ayalon
- a Louis and Gabi Weisfeld School of Social Work , Bar Ilan University , Ramat-Gan , Israel
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28
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Umegaki H, Asai A, Kanda S, Maeda K, Shimojima T, Nomura H, Kuzuya M. Risk Factors for the Discontinuation of Home Medical Care among Low-functioning Older Patients. J Nutr Health Aging 2016; 20:453-7. [PMID: 26999247 DOI: 10.1007/s12603-015-0606-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Older patients receiving home medical care often have declining functional status and multiple disease conditions. It is important to identify the risk factors for care transition events in this population in order to avoid preventable transitions. In the present study, therefore, we investigated the factors associated with discontinuation of home medical care as a potentially preventable care transition event in older patients. METHODS Baseline data for participants in the Observational study of Nagoya Elderly with HOme MEdical (ONEHOME) study and data on the mortality, institutionalization, or hospitalisation of the study participants during a 2-year follow-up period were used. Discontinuation of home care was defined as admission to a hospital for any reason, institutionalization, or death. Univariate and multivariate Cox hazard models were used to assess the association of each of the factors with the discontinuation of home care during the observational period. The covariates included in the multivariate analysis were those significantly associated with the discontinuation of home care at the level of P<0.05 in the univariate analysis. RESULTS The univariate Cox hazard model revealed that a low hemoglobin level (< 11g/dL), low serum albumin level (< 3g/dL), higher Charlson Comorbidity Index score, and low Mini Nutritional Assessment Short Form score (< 7) were significantly associated with the discontinuation of home care. A multivariate Cox hazard model including these four factors demonstrated that all four were independently associated with home-care discontinuation. CONCLUSIONS The present results demonstrated that anemia, hypoalbuminemia, malnourishment, and the presence of serious comorbidities were associated with the discontinuation of home medical care among low-functioning older patients.
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Affiliation(s)
- H Umegaki
- Hiroyuki Umegaki, Nagoya University Graduate School of Medicine, Department of Community Healthcare and Geriatrics, 65 Tsuruma-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan, Phone: +81-52-744-2364; Fax: +81-52-744-2371; Email address:
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29
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LaManna JB, Bushy A, Norris AE, Chase SK. Early and Intermediate Hospital-to-Home Transition Outcomes of Older Adults Diagnosed With Diabetes. DIABETES EDUCATOR 2015; 42:72-86. [DOI: 10.1177/0145721715620020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Purpose The purpose of this study was to identify factors affecting early and intermediate hospital-to home transition outcomes of older adults with preexisting diabetes mellitus. Methods A mixed-methods design was used. A sample of 96 hospitalized older adults with a prior diagnosis of diabetes were recruited within 4 hours of discharge. Data reflective of general health status, diabetes status, perceived discharge readiness (Readiness for Hospital Discharge Scale), hospitalization, and anticipated postdischarge support were gathered upon enrollment. Transition outcome data including unplanned care encounter occurrences, perceived transition quality (Care Transition Measure-15), and postdischarge difficulty (scale and free responses to the Post-Discharge Coping Difficulty Scale [PDCDS]) were obtained by telephone interview 7 and 30 days after discharge. Three unique, dichotomous variables were created from recurrent subthemes that emerged during content analysis of free-response data and were used in statistical testing. Binary logistic regression was performed to identify predictive factors for an unplanned care encounter within 30 days of discharge. Results Multimorbidity was prevalent in participants. Difficulties managing medications, blood glucose, and chronic illnesses other than diabetes were common problems. Higher PDCDS scores 7 and 30 days following discharge and difficulty managing a nondiabetes chronic health problem were predictive of an unplanned care encounter within 30 days of discharge. Conclusions Multimorbidity complicates home recovery of older adults with diabetes. Diabetes adds complexity to hospital-to-home care transitions. Transition difficulties predict higher risk for an unplanned care encounter. More intensive follow-up of older adults with diabetes during the first month following discharge is recommended.
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Affiliation(s)
- Jacqueline B. LaManna
- University of Central Florida College of Nursing, Orlando, Florida (Dr LaManna, Dr Bushy)
- University of Miami School of Nursing and Health Studies, Miami, Florida (Dr Norris)
- University of Central Florida College of Nursing, Orlando, Florida (Dr Chase)
| | - Angeline Bushy
- University of Central Florida College of Nursing, Orlando, Florida (Dr LaManna, Dr Bushy)
- University of Miami School of Nursing and Health Studies, Miami, Florida (Dr Norris)
- University of Central Florida College of Nursing, Orlando, Florida (Dr Chase)
| | - Anne E. Norris
- University of Central Florida College of Nursing, Orlando, Florida (Dr LaManna, Dr Bushy)
- University of Miami School of Nursing and Health Studies, Miami, Florida (Dr Norris)
- University of Central Florida College of Nursing, Orlando, Florida (Dr Chase)
| | - Susan K. Chase
- University of Central Florida College of Nursing, Orlando, Florida (Dr LaManna, Dr Bushy)
- University of Miami School of Nursing and Health Studies, Miami, Florida (Dr Norris)
- University of Central Florida College of Nursing, Orlando, Florida (Dr Chase)
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Braet A, Weltens C, Sermeus W, Vleugels A. Risk factors for unplanned hospital re-admissions: a secondary data analysis of hospital discharge summaries. J Eval Clin Pract 2015; 21:560-6. [PMID: 25756358 DOI: 10.1111/jep.12320] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/09/2014] [Indexed: 12/19/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES To identify patient groups at risk for unplanned hospital re-admissions and risk factors for re-admission. METHOD We analysed the Belgian Hospital Discharge Dataset including data from 1 130 491 patients discharged in 2008. Patient and hospital factors contributing to re-admission rate were analysed using a multivariable model for logistic regression. RESULTS The overall unplanned re-admission rate was 5.2%. Cardiovascular and pulmonary diagnoses were the most common reasons for re-admission. We found that 10.4% of all re-admissions were due to complications. A high number of previous emergency department (ED) visits proved to be a predictor for re-admission [odds ratio (OR) for patients with at least four ED visits in the past 6 months 4.65; 95% confidence interval (CI) 4.25-5.08]. Patients discharged on Friday (OR 1.05; 95% CI 1.01-1.08) and patients with a long length of stay (OR 1.19; 95% CI 1.15-1.23) also had a higher risk for re-admission. Patients with short lengths of stay were not at risk for re-admission (OR 0.99; 95% CI 0.95-1.02). CONCLUSIONS Actions to reduce re-admissions can be targeted to patient groups at risk, and should be aimed at the caring for chronic cardiovascular or pulmonary diseases, preventing complications and multiple ED visits, and ensuring continuity of care after discharge, especially for patients discharged on Friday.
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Affiliation(s)
- Anja Braet
- Department of Public Health and Primary Care, KU Leuven-University of Leuven, Leuven, Belgium.,Medical Department, az Sint-Blasius, Dendermonde, Belgium
| | - Caroline Weltens
- Flemish Hospital Network, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Walter Sermeus
- Public Health, KU Leuven-University of Leuven, Leuven, Belgium
| | - Arthur Vleugels
- Public Health, KU Leuven-University of Leuven, Leuven, Belgium
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Abstract
SummaryThe majority of hospital in-patients are older people, and many of these are at increased risk of readmission, which can be an adverse outcome for the patient. Currently there is poor understanding as to how best to reduce the risk of readmission. We searched MEDLINE, EMBASE and the Cochrane library for high quality review articles about readmissions. Each review was quality assessed by two reviewers. Grouped data and evidence from original papers is cited with 95% confidence intervals when possible. Nine review studies of sufficient quality were included. Two addressed risk factors for readmission, which included: age, poor functional status prior to admission, length of stay during the index admission, depression, cognitive impairment, malnutrition, social support and social networks/support. The seven other reviews addressed interventions to reduce readmission, which included: discharge planning, post-discharge support, post-discharge case management, and nutritional supplementation. It is possible to identify older people at risk of readmission using well-established risk factors; discharge planning, post-discharge support and nutritional interventions appear to be effective in reducing readmission. Combined interventions appear to be more effective than isolated interventions.
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Impact of discharge planning decision support on time to readmission among older adult medical patients. Prof Case Manag 2015; 19:29-38. [PMID: 24300427 DOI: 10.1097/01.pcama.0000438971.79801.7a] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF THE STUDY Hospital clinicians are overwhelmed with the volume of patients churning through the health care systems. The study purpose was to determine whether alerting case managers about high-risk patients by supplying decision support results in better discharge plans as evidenced by time to first hospital readmission. PRIMARY PRACTICE SETTING Four medical units at one urban, university medical center. METHODOLOGY AND SAMPLE A quasi-experimental study including a usual care and experimental phase with hospitalized English-speaking patients aged 55 years and older. The intervention included using an evidence-based screening tool, the Discharge Decision Support System (D2S2), that supports clinicians' discharge referral decision making by identifying high-risk patients upon admission who need a referral for post-acute care. The usual care phase included collection of the D2S2 information, but not sharing the information with case managers. The experimental phase included data collection and then sharing the results with the case managers. The study compared time to readmission between index discharge date and 30 and 60 days in patients in both groups (usual care vs. experimental). RESULTS After sharing the D2S2 results, the percentage of referral or high-risk patients readmitted by 30 and 60 days decreased by 6% and 9%, respectively, representing a 26% relative reduction in readmissions for both periods. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE Supplying decision support to identify high-risk patients recommended for postacute referral is associated with better discharge plans as evidenced by an increase in time to first hospital readmission. The tool supplies standardized information upon admission allowing more time to work with high-risk admissions.
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Son YJ, You MA. Transitional Care for Older Adults with Chronic Illnesses as a Vulnerable Population: Theoretical Framework and Future Directions in Nursing. J Korean Acad Nurs 2015; 45:919-27. [DOI: 10.4040/jkan.2015.45.6.919] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 11/22/2015] [Accepted: 11/27/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Youn-Jung Son
- Red Cross College of Nursing, Chung-Ang University, Seoul, Korea
| | - Mi-Ae You
- College of Nursing, Institute of Nursing Science, Ajou University, Suwon, Korea
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Abstract
The estimated cost for hospital readmissions in 2011 was more than $41 billion, but the costs to patients in terms of quality of life are immeasurable. The purpose of this study was to determine if there are variables available to nurses at the time of the patient's admission that could be predictive of a 30-day hospital readmission. Logistic regression was used in a stepwise approach to determine the variable combinations most predictive for 30-day readmission. Thirty-two variables were found to be significantly predictive of 30-day readmissions from the more than 1400 examined.
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Li J, Halaszynski TM. Regional anesthesia for acute pain management in elderly patients. World J Anesthesiol 2014; 3:82-95. [DOI: 10.5313/wja.v3.i1.82] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 08/24/2013] [Accepted: 09/17/2013] [Indexed: 02/06/2023] Open
Abstract
Normal aging is a process that involves loss of functional reserve of most organ systems of the human body, most significantly: cardiovascular, pulmonary, renal and nervous systems. Advancements in both surgery and anesthesia have made it possible to operate more safely on the elderly population and those older patients with multiple severe co-morbidities that were not routinely possible in the recent past. Regional anesthesiologist have proven to be instrumental in this regard as regional anesthetic/analgesic techniques may now permit surgeons to operate on the elderly who were not ideal surgical candidates or unable to tolerate general anesthesia. In addition, regional techniques provide alternatives that may optimize acute pain control and reduce the incidence of devastating side effects during the perioperative period such as: myocardial infarction, pulmonary embolism, pneumonia, and also increases the opportunity to allow for early ambulation and shorter hospital stays. These anesthetic options now provide the elderly patient with better medical care alternatives, but also can show a significant financial impact on health care system resources. Further understanding on aging molecular biology, physiology and pathophysiology, together with technical improvements of regional anesthetic techniques will continue to make it safer and more efficacious to operate on the elderly population with evidence of reduced morbidity and mortality. Although there is only anecdotal evidence that regional anesthesia (RA) improves survival, there is little doubt that RA plays an important role in perioperative optimization of pain control and decreases pain management complications as well as a reduction in healthcare costs. Beyond traditional operating rooms, elderly patients may increasingly benefit from RA and acute pain management in Emergency Rooms, medical clinics and even within a patient’s home. Therefore, the focus of this review is directed toward geriatric patients and beneficial effects of RA on outcomes in the elderly.
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Nilsson A, Lindkvist M, Rasmussen BH, Edvardsson D. Measuring levels of person-centeredness in acute care of older people with cognitive impairment: evaluation of the POPAC scale. BMC Health Serv Res 2013; 13:327. [PMID: 23958295 PMCID: PMC3751919 DOI: 10.1186/1472-6963-13-327] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 08/13/2013] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Person-centeredness is increasingly advocated in the literature as a gold-standard, best practice concept in health services for older people. This concept describes care that incorporates individual and multidimensional needs, personal biography, subjectivity and interpersonal relationships. However, acute in-patient hospital services have a long-standing biomedical tradition that may contrast with person-centred care. Since few tools exist that enable measurements of the extent to which acute in-patient hospital services are perceived as being person-centred, this study aimed to translate the English version of the Person-centred care of older people with cognitive impairment in acute care scale (POPAC) to Swedish, and evaluate its psychometric properties in a sample of acute hospital staff. METHODS The 15-item POPAC was translated, back-translated and culturally adjusted, and distributed to a cross-sectional sample of Swedish acute care staff (n = 293). Item performance was evaluated through assessment of item means, internal consistency by Cronbach's alpha on total and on subscale levels; temporal stability was assessed through Pearson's product correlation and intra-class correlation between test and retest scores. Confirmatory factor analysis was used to explore model fit. RESULTS The results indicate that the Swedish version POPAC provides a tentatively construct-valid and reliable contribution to measuring the extent to which acute in-patient hospital services have processes and procedures that can facilitate person-centred care of older patients with cognitive impairment. However, some questions remain regarding the dimensionality of POPAC. CONCLUSIONS POPAC provides a valuable contribution to the quest of improving acute care for older patients with cognitive impairment by enabling measures and subsequent accumulation of internationally comparable data for research and practice development purposes. POPAC can be used to highlight strengths and areas for improvements in care practice for older patients, and to illuminate aspects that risk being overlooked in busy acute hospital settings.
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Affiliation(s)
- Anita Nilsson
- Department of Nursing, Umeå University, Umeå, Sweden
| | | | | | - David Edvardsson
- Department of Nursing, Umeå University, Umeå, Sweden
- School of Nursing and Midwifery, La Trobe University, Melbourne, Australia
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Takahashi PY, Sauver JLS, Olson TC, Huber JM, Cha SS, Ebbert JO. Association between underweight and hospitalization, emergency room visits, and mortality among patients in community medical homes. Risk Manag Healthc Policy 2013; 6:1-6. [PMID: 23378790 PMCID: PMC3559084 DOI: 10.2147/rmhp.s39976] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background In older adults, underweight (body mass index [BMI] <18.5) has been associated with increased mortality. This increased mortality risk may be associated with increased health care utilization. We evaluated the relationship between underweight and hospitalization, emergency room visits, and mortality. Methods An analysis of a retrospective cohort study was conducted at a multisite academic primary care medical practice in Minnesota. The patients were ≥60 years of age, impaneled within primary care on January 1, 2011, and had a BMI measurement recorded between January 1, 2011, and December 31, 2011. Individuals were excluded if they refused review of their medical record. The primary measurement was BMI, which was categorized as underweight (BMI < 18.5) or normal and obese (BMI ≥ 18.5). The outcomes were hospitalization, emergency room visits, and mortality in the 2011 calendar year. Associations between underweight and each outcome were calculated using logistic regression. Interactions between underweight and gender were assessed in the logistic regression models. The final results were adjusted for age, gender, comorbid health conditions, and single living status. Results The final cohort included 21,019 patients, of whom 220 (1%) were underweight. Underweight patients had a higher likelihood of hospitalization compared with patients with higher BMI (adjusted odds ratio [OR] 1.64; 95% confidence interval [CI] 1.21–2.22). Underweight patients were also more likely to visit the emergency room (adjusted OR 1.70; 95% CI 1.28–2.25) or to die (adjusted OR 3.64; 95% CI 2.33–5.69). Men with a BMI < 18.5 compared with those having a BMI ≥ 18.5 had the highest odds of hospitalization (OR 3.45; 95% CI 1.59–7.48). Conclusion Underweight older adults, especially men, have higher odds of hospitalization, emergency room visits, and mortality. Future work on underweight might involve improving weight status, which may reduce the risk of hospitalization, emergency room visits, and mortality.
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Affiliation(s)
- Paul Y Takahashi
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
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Transitional care programs: who is left behind? A systematic review. Int J Integr Care 2012; 12:e132. [PMID: 23593046 PMCID: PMC3601531 DOI: 10.5334/ijic.805] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Revised: 05/15/2012] [Accepted: 05/20/2012] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Older adults are at risk of rehospitalization if their care transitions from hospital-to-home are not properly managed. The objective of this review was to determine if older patient populations recruited for randomized controlled trials of transitional care interventions represented those at greatest risk of rehospitalization following discharge. Relevant risk factors examined were cognitive impairment, depression, polypharmacy, comorbidity, length of stay, advanced non-malignant diseases, and available social support. DESIGN Systematic review. SETTING Hospital to home. PARTICIPANTS Older hospitalized adults. MEASUREMENTS For inclusion, articles were required to focus on hospital-to-home transitions with a self-care component, have components occurring both before and after discharge, and a randomized controlled trial design. Articles were excluded if participants had a mean age under 55 years, or if interventions focused on developmental disabilities, youth, addictions, or case management, or were solely primary-care based. RESULTS Following title, abstract, and full review by two authors, 17 articles met inclusion criteria. Risk factors for rehospitalization were often listed either as exclusion criteria or were not reported at baseline by the studies. One study included patients with all identified risk factors for rehospitalization. CONCLUSIONS These data suggest that published studies of transitional care interventions do not often include older adults at highest risk of rehospitalization, raising concerns about the generalizability of their results. Studies are needed that evaluate interventions that explicitly address the needs and characteristics of these patients.
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