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Mohammadi R, Jain S, Namin AT, Scholem Heller M, Palacholla R, Kamarthi S, Wallace B. Predicting Unplanned Readmissions Following a Hip or Knee Arthroplasty: Retrospective Observational Study. JMIR Med Inform 2020; 8:e19761. [PMID: 33245283 PMCID: PMC7732713 DOI: 10.2196/19761] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 09/08/2020] [Accepted: 09/13/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Total joint replacements are high-volume and high-cost procedures that should be monitored for cost and quality control. Models that can identify patients at high risk of readmission might help reduce costs by suggesting who should be enrolled in preventive care programs. Previous models for risk prediction have relied on structured data of patients rather than clinical notes in electronic health records (EHRs). The former approach requires manual feature extraction by domain experts, which may limit the applicability of these models. OBJECTIVE This study aims to develop and evaluate a machine learning model for predicting the risk of 30-day readmission following knee and hip arthroplasty procedures. The input data for these models come from raw EHRs. We empirically demonstrate that unstructured free-text notes contain a reasonably predictive signal for this task. METHODS We performed a retrospective analysis of data from 7174 patients at Partners Healthcare collected between 2006 and 2016. These data were split into train, validation, and test sets. These data sets were used to build, validate, and test models to predict unplanned readmission within 30 days of hospital discharge. The proposed models made predictions on the basis of clinical notes, obviating the need for performing manual feature extraction by domain and machine learning experts. The notes that served as model inputs were written by physicians, nurses, pathologists, and others who diagnose and treat patients and may have their own predictions, even if these are not recorded. RESULTS The proposed models output readmission risk scores (propensities) for each patient. The best models (as selected on a development set) yielded an area under the receiver operating characteristic curve of 0.846 (95% CI 82.75-87.11) for hip and 0.822 (95% CI 80.94-86.22) for knee surgery, indicating reasonable discriminative ability. CONCLUSIONS Machine learning models can predict which patients are at a high risk of readmission within 30 days following hip and knee arthroplasty procedures on the basis of notes in EHRs with reasonable discriminative power. Following further validation and empirical demonstration that the models realize predictive performance above that which clinical judgment may provide, such models may be used to build an automated decision support tool to help caretakers identify at-risk patients.
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Affiliation(s)
| | - Sarthak Jain
- Northeastern University, Boston, MA, United States
| | - Amir T Namin
- Northeastern University, Boston, MA, United States
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Loyd C, Markland AD, Zhang Y, Fowler M, Harper S, Wright NC, Carter CS, Buford TW, Smith CH, Kennedy R, Brown CJ. Prevalence of Hospital-Associated Disability in Older Adults: A Meta-analysis. J Am Med Dir Assoc 2020; 21:455-461.e5. [PMID: 31734122 PMCID: PMC7469431 DOI: 10.1016/j.jamda.2019.09.015] [Citation(s) in RCA: 146] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 09/03/2019] [Accepted: 09/23/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Hospital-associated disability (HAD), defined as loss of independence in activities of daily living (ADL) following acute hospitalization, is observed among older adults. The study objective is to determine overall prevalence of HAD among older adults hospitalized in acute care, and to assess the impact of study initiation year in moderation of prevalence. DESIGN Meta-analysis of data collected from randomized trials, quasi-experimental, and prospective cohort studies. English-language searches to identify included studies were completed February 2018 and updated May 2018 of electronic databases and reference lists of studies and reviews. Included studies were human subjects investigations that measured ADL ≥2 time points before or during and after hospitalization and reported prevalence of ADL decline among older adults. SETTING Acute care hospital units. PARTICIPANTS Adults aged ≥65 years hospitalized in medical-surgical acute care; total sample size across all included studies was 7375. METHODS Independence in ADL was assessed using the Katz Index of Independence in Activities of Daily Living and Barthel Index of Independence in Activities of Daily Living. RESULTS Random effects meta-analysis across included studies identified combined prevalence of HAD as 30% (95% CI 24%, 33%; P < .001). The effect of study initiation year on the prevalence rate was minimal. A large amount of heterogeneity was observed between studies, which may be due in part to nonstandardized measurement of ADL impairment or other methodological differences. CONCLUSIONS AND IMPLICATIONS Hospitalization in acute care poses a significant risk to functional independence of older adults, and this risk is unchanged despite shorter lengths of stay. The evidence supports the continued need for hospital-based programs that provide assessment of functional ability and identification of at-risk older adults in order to better treat and prevent HAD.
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Affiliation(s)
- Christine Loyd
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, UAB School of Medicine, University of Alabama at Birmingham, Birmingham, AL; Birmingham/Atlanta Veterans Affairs Geriatric Research, Education, and Clinical Center, Birmingham Veterans Affairs Medical Center, Birmingham, AL
| | - Alayne D Markland
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, UAB School of Medicine, University of Alabama at Birmingham, Birmingham, AL; Birmingham/Atlanta Veterans Affairs Geriatric Research, Education, and Clinical Center, Birmingham Veterans Affairs Medical Center, Birmingham, AL.
| | - Yue Zhang
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, UAB School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Mackenzie Fowler
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
| | - Sara Harper
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, UAB School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Nicole C Wright
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
| | - Christy S Carter
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, UAB School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Thomas W Buford
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, UAB School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Catherine H Smith
- Lister Hill Library of the Health Sciences, University of Alabama at Birmingham, Birmingham, AL
| | - Richard Kennedy
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, UAB School of Medicine, University of Alabama at Birmingham, Birmingham, AL; Birmingham/Atlanta Veterans Affairs Geriatric Research, Education, and Clinical Center, Birmingham Veterans Affairs Medical Center, Birmingham, AL
| | - Cynthia J Brown
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, UAB School of Medicine, University of Alabama at Birmingham, Birmingham, AL; Birmingham/Atlanta Veterans Affairs Geriatric Research, Education, and Clinical Center, Birmingham Veterans Affairs Medical Center, Birmingham, AL
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Hofmeister M, Khadaroo RG, Holroyd-Leduc J, Padwal R, Wagg A, Warkentin L, Clement F. Cost-effectiveness Analysis of the Elder-Friendly Approaches to the Surgical Environment (EASE) Intervention for Emergency Abdominal Surgical Care of Adults Aged 65 Years and Older. JAMA Netw Open 2020; 3:e202034. [PMID: 32242905 PMCID: PMC7125431 DOI: 10.1001/jamanetworkopen.2020.2034] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The Elder-Friendly Approaches to the Surgical Environment (EASE) initiative is a novel approach to acute surgical care for elderly patients. OBJECTIVE To determine the cost-effectiveness of EASE. DESIGN, SETTING, AND PARTICIPANTS An economic evaluation from the perspective of the health care system was conducted as part of the controlled before-and-after EASE study at 2 tertiary care centers, the University of Alberta Hospital and Foothills Medical Centre. Participants included elderly adults (aged ≥65 years) admitted for emergency abdominal surgery between 2014 and 2017. Data were analyzed from April 2018 to February 2019. MAIN OUTCOMES AND MEASURES Data were captured at both control and intervention sites before and after implementation of the EASE intervention. Resource use was captured over 6 months of follow-up and was converted to costs. Utility was measured with the EuroQol Five-Dimensions Three-Levels instrument at 6 weeks and 6 months of follow-up. The differences-in-differences method was used to estimate the association of the intervention with cost and quality-adjusted life-years. For a subset of participants, self-reported out-of-pocket health care costs were collected using the Resource Use Inventory at 6 months. RESULTS A total of 675 participants were included (mean [SD] age, 75.3 [7.9] years; 333 women [49.3%]), 289 in the intervention group and 386 in the control group. The mean (SD) cost per control participant was $36 995 ($44 169) before EASE and $35 032 ($43 611) after EASE (all costs are shown in 2018 Canadian dollars). The mean (SD) cost per intervention participant was $56 143 ($74 039) before EASE and $39 001 ($59 854) after EASE. Controlling for age, sex, and Clinical Frailty Score, the EASE intervention was associated with a mean (SE) cost reduction of 23.5% (12.5%) (P = .02). The change in quality-adjusted life-years observed associated with the intervention was not statistically significant (mean [SE], 0.00001 [0.0001] quality-adjusted life-year; P = .72). The Resource Use Inventory was collected for 331 participants. The mean (SE) odds ratio for having 0 out-of-pocket expenses because of the intervention, compared with having expenses greater than 0, was 15.77 (3.37) (P = .02). Among participants with Resource Use Inventory costs greater than 0, EASE was not associated with a change in spending (mean [SE] reduction associated with EASE, 19.1% [45.2%]; P = .57). CONCLUSIONS AND RELEVANCE This study suggests that the EASE intervention was associated with a reduction in costs and no change in quality-adjusted life-years. In locations that lack capacity to implement this intervention, costs to increase capacity should be weighed against the estimated costs avoided.
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Affiliation(s)
- Mark Hofmeister
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | | | - Jayna Holroyd-Leduc
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Raj Padwal
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Adrian Wagg
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Lindsey Warkentin
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Fiona Clement
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
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Holroyd-Leduc J, Harris C, Hamid JS, Ewusie JE, Quirk J, Osiowy K, Moore JE, Khan S, Liu B, Straus SE. Scaling-up implementation in community hospitals: a multisite interrupted time series design of the Mobilization of Vulnerable Elders (MOVE) program in Alberta. BMC Geriatr 2019; 19:288. [PMID: 31653204 PMCID: PMC6815022 DOI: 10.1186/s12877-019-1311-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 10/10/2019] [Indexed: 12/21/2022] Open
Abstract
Background As the population ages, older hospitalized patients are at increased risk for hospital-acquired morbidity. The Mobilization of Vulnerable Elders (MOVE) program is an evidence-informed early mobilization intervention that was previously evaluated in Ontario, Canada. The program was effective at improving mobilization rates and decreasing length of stay in academic hospitals. The aim of this study was to scale-up the program and conduct a replication study evaluating the impact of the evidence-informed mobilization intervention on various units in community hospitals within a different Canadian province. Methods The MOVE program was tailored to the local context at four community hospitals in Alberta, Canada. The study population was patients aged 65 years and older who were admitted to medicine, surgery, rehabilitation and intensive care units between July 2015 and July 2016. The primary outcome was patient mobilization measured by conducting visual audits twice a week, three times a day. The secondary outcomes included hospital length of stay obtained from hospital administrative data, and perceptions of the intervention assessed through a qualitative assessment. Using an interrupted time series design, the intervention was evaluated over three time periods (pre-intervention, during, and post-intervention). Results A total of 3601 patients [mean age 80.1 years (SD = 8.4 years)] were included in the overall analysis. There was a significant increase in mobilization at the end of the intervention period compared to pre-intervention, with 6% more patients out of bed (95% confidence interval (CI) 1, 11; p-value = 0.0173). A decreasing trend in median length of stay was observed, where patients on average stayed an estimated 3.59 fewer days (95%CI -15.06, 7.88) during the intervention compared to pre-intervention period. Conclusions MOVE is a low-cost, effective and adaptable intervention that improves mobilization in older hospitalized patients. This intervention has been replicated and scaled up across various units and hospital settings.
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Affiliation(s)
- Jayna Holroyd-Leduc
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada. .,Specialized Geriatric Services, Alberta Health Services, Calgary, Canada.
| | - Charmalee Harris
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Jemila S Hamid
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Joycelyne E Ewusie
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Jacquelyn Quirk
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Public Health Ontario, Toronto, Ontario, Canada
| | - Karen Osiowy
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Julia E Moore
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Sobia Khan
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Barbara Liu
- Regional Geriatric Program of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sharon E Straus
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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McComb A, Warkentin LM, McNeely ML, Khadaroo RG. Development of a reconditioning program for elderly abdominal surgery patients: the Elder-friendly Approaches to the Surgical Environment-BEdside reconditioning for Functional ImprovemenTs (EASE-BE FIT) pilot study. World J Emerg Surg 2018; 13:21. [PMID: 29942346 PMCID: PMC5963094 DOI: 10.1186/s13017-018-0180-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 04/13/2018] [Indexed: 02/06/2023] Open
Abstract
Background Elderly individuals who are hospitalized due to emergency abdominal surgery spend over 80% of their recovery time in bed, resulting in early and rapid muscle loss. As these elderly individuals have a lower physiological reserve, the impact of muscle wasting on function may be profound. The objectives of this study are to (1) create an independently led post-surgical reconditioning program and (2) pilot its implementation, while assessing the feasibility and safety of the program. Methods The BE FIT program was generated with hospital rehabilitation staff to target lower limb strength, balance, and endurance. This pilot study was assessed using a sequential before and after trial, with a cohort of patients aged ≥ 65 years enrolled in the Elder-friendly Approaches to the Surgical Environment (EASE) study. Change in 30-s sit-to-stand performance between postoperative day 2 and discharge was compared between Usual Care pre- and post-BE FIT participants. Results A total of 66 patients participated in the sub-study, 33 Usual Care and 33 BE FIT. Mean (SD) age was 76.2 (8.78); 44 (67%) were female, with 11 (17%) reporting mild/moderate frailty on the CHSA Clinical Frailty Scale. BE FIT participants had a median of three rehab days and self-reported completing an average of 83% of the exercises. The adjusted between group difference showed that the BE FIT patients were able to complete more stands than the Usual Care (1.9 stands (0.94), p = 0.05). There were no reported adverse events. Conclusion The reconditioning program was shown to be safe and feasible within the hospital setting for the elderly emergency abdominal surgery patients. More rigorous assessment is needed to confirm this effectiveness and to better assess patient adherence to self-directed exercise. Trial registration Registration #NCT02233153 through ClinicalTrials.gov. Registered September 8, 2014.
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Affiliation(s)
- Alyssa McComb
- 1Faculty of Rehabilitation Medicine, University of Alberta, 1-38 Corbett Hall, 8205-114 St NW Edmonton, Edmonton, Alberta T6G 2G4 Canada
| | | | - Margaret L McNeely
- 1Faculty of Rehabilitation Medicine, University of Alberta, 1-38 Corbett Hall, 8205-114 St NW Edmonton, Edmonton, Alberta T6G 2G4 Canada
| | - Rachel G Khadaroo
- 2Department of Surgery, University of Alberta, Edmonton, Alberta Canada.,3Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta Canada
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Effectiveness of multicomponent interventions on incidence of delirium in hospitalized older patients with hip fracture: a systematic review. Int Psychogeriatr 2018; 30:481-492. [PMID: 29295719 DOI: 10.1017/s1041610217002782] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
UNLABELLED ABSTRACTBackground:Delirium is the most frequent complication among the hospitalized elderly with hip fracture. Although, delirium is associated with longer hospital stay, higher mortality rates, worse functional outcomes, and higher institutionalization rates yet health service planners have hugely ignored its existence. This review aims to identify the effectiveness of multicomponent interventions to prevent delirium in hospitalized elderly patients with hip fracture. METHODS This review includes experimental, non-experimental, and observational studies. Electronic searches were conducted in MEDLINE, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials, Embase, and Web of science. RESULTS After inclusion and exclusion criteria were applied, nine full text articles were included in the review. The studies reported the following effect on delirium: We pooled data regarding incidence of delirium from the three RCTs. The effect was in favor of the intervention group (odds ratio 0.64, 95% CI 0.46-0.87). All three RCTs reported that duration of delirium was shorter in the intervention group than in the usual care group (mean 2.9 vs. 3.1 days, median 3 vs. 4 days, median 5.0 vs. 10.2 days). Four other studies reported on the duration of delirium with Milisen and colleagues reported shorter duration of delirium within the intervention group. Four studies reported on severity of delirium with two research groups reporting significant results. CONCLUSION Early engagement of multidisciplinary staff who addresses the risk factors of delirium as soon as the patient presents to the acute care environment is the key element of a successful delirium prevention program. Once delirium had developed, the multicomponent interventions did not appear to make a difference to the duration or severity of delirium.
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Calero-García MJ, Ortega AR, Navarro E, Calero MD. Relationship between hospitalization and functional and cognitive impairment in hospitalized older adults patients. Aging Ment Health 2017; 21:1164-1170. [PMID: 27564919 DOI: 10.1080/13607863.2016.1220917] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To study changes in the cognitive status and dependency of patients aged over 65 years during hospitalization for bone fracture and how these changes relate to the total number of days of admission and absolute rest during hospitalization. Along with cognitive decline, musculoskeletal disorders are considered key factors in this patient population. As well as requiring hospital admission and/or surgical treatment, fractures increase the risk factors that contribute to disability and dependency in older adults. METHOD A longitudinal case-series study with repeated follow-up assessments was conducted. The sample consisted of 259 older adults. The following tests were administered: Barthel index, Lawton-Brody's scale, Phototest, and informant questionnaire on cognitive decline in the elderly. RESULTS The main variable which fosters functional dependency, cognitive decline, and functional loss and diminishes functional gain (both in the hospital and at home) is the number of days of bed rest during hospitalization. CONCLUSIONS The present study reveals that the greater impact on levels of functional dependency and cognitive decline comes from the patient's days of bed rest in hospital, rather than the total days of hospitalization. These findings could be taken into consideration when discussing post-discharge functional recovery.
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Affiliation(s)
| | - Ana Raquel Ortega
- b Department of Psychology , University of Jaén , Campus Las Lagunillas, Jaén , Spain
| | - Elena Navarro
- c Department of Personality, Evaluation and Psychological Treatment , Campus Universitario de Cartuja , Granada , Spain
| | - María Dolores Calero
- c Department of Personality, Evaluation and Psychological Treatment , Campus Universitario de Cartuja , Granada , Spain
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Applegate WB, Ouslander JG. Journal of the American Geriatrics Society
: Evolving Strategies and Processes. J Am Geriatr Soc 2017. [DOI: 10.1111/jgs.14951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Chang A, Singh N, Boyd L, Lawson C. Strategies to Improve Radiographic Practices for Patients With Alzheimer's Disease: A Systematic Review. J Med Imaging Radiat Sci 2016; 47:362-366. [PMID: 31047262 DOI: 10.1016/j.jmir.2016.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 08/22/2016] [Accepted: 09/14/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Alzheimer's disease (AD) patients are one of the highest health care service users globally. In the context of radiography, there are many AD patients who undergo imaging procedures for common age-related conditions. However, there is currently no literature on how radiographers can effectively manage such patients in imaging situations. METHODOLOGY This review examined the literature regarding the interaction between Alzheimer's patients and other health care professionals (eg, nurses) and the strategies that have been used to improve patient compliance and accommodate functional decline. FINDINGS Many strategies relating to care of patients with AD are long term, and cannot be applied in a radiographic setting, where patients may only present once. Transferrable strategies for a radiographic setting include the support of carers during the examination process, a reduction in noise and use of calming music, and allowing the patient to personalize the examination room by bringing a photograph or an item of comfort. CONCLUSION These simple strategies can reduce the level of anxiety experienced by AD patients, reduce typical behavioral symptoms of agitation, aggression and discomfort, and increase patient cooperation and responsiveness.
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Affiliation(s)
- Angie Chang
- Warringal Radiology MIA, Heidelberg, Victoria, Australia
| | - Nabita Singh
- Department of Medical Imaging and Radiation Sciences, Monash University, Melbourne, Victoria, Australia
| | - Lori Boyd
- Department of Medical Imaging and Radiation Sciences, Monash University, Melbourne, Victoria, Australia
| | - Celeste Lawson
- Professional Communication Program, School of Education and the Arts, Central Queensland University, Rockhampton, Queensland, Australia.
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de Morton NA, Keating JL, Jeffs K. The effect of exercise on outcomes for older acute medical inpatients compared with control or alternative treatments: a systematic review of randomized controlled trials. Clin Rehabil 2016; 21:3-16. [PMID: 17213236 DOI: 10.1177/0269215506071313] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To determine the effect of exercise interventions for acutely hospitalized older medical patients on functional status and hospital outcomes. Data sources: MEDLINE, CINAHL, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PEDro, Current Contents and Sports Discus were searched until February 2006. Additional studies were identified through reference and citation tracking and contacting authors of eligible trials. Review methods: Eligible studies were prospective randomized or pseudor and omized controlled trials comparing exercise for medical inpatients to alternate or no treatment controls. Of 3138 potentially relevant articles screened by two independent reviewers, seven randomized controlled trials and two pseudorandomized controlled trials were included. Two independent reviewers extracted data relating to patient and hospital outcomes and assessed the method quality. Results: Pooled analysis of multidisciplinary interventions that included exercise indicated a significant increase in the proportion of patients discharged to home at hospital discharge (relative risk 1.08; 95% confidence interval (CI) 1.03 –1.14) and a small but important reduction in acute hospital length of stay (weighted mean difference – / 1.08 days; 95% CI – / 1.93 to – / 0.22) and total hospital costs (weighted mean difference – / US$280; 95% CI – / $493 to – / $65) compared with usual care. Pooled analysis of exercise intervention trials found no effect on the proportion of patients discharged to home or acute hospital length of stay. The effect of exercise on functional outcome measures is unclear. There was no influence of exercise intervention on adverse events. Conclusions: Multidisciplinary intervention that includes exercise improves patient and hospital outcomes for acutely hospitalized older medical patients.
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Siddiqi N, Harrison JK, Clegg A, Teale EA, Young J, Taylor J, Simpkins SA. Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev 2016; 3:CD005563. [PMID: 26967259 PMCID: PMC10431752 DOI: 10.1002/14651858.cd005563.pub3] [Citation(s) in RCA: 173] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Delirium is a common mental disorder, which is distressing and has serious adverse outcomes in hospitalised patients. Prevention of delirium is desirable from the perspective of patients and carers, and healthcare providers. It is currently unclear, however, whether interventions for preventing delirium are effective. OBJECTIVES To assess the effectiveness of interventions for preventing delirium in hospitalised non-Intensive Care Unit (ICU) patients. SEARCH METHODS We searched ALOIS - the Cochrane Dementia and Cognitive Improvement Group's Specialized Register on 4 December 2015 for all randomised studies on preventing delirium. We also searched MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), Central (The Cochrane Library), CINAHL (EBSCOhost), LILACS (BIREME), Web of Science core collection (ISI Web of Science), ClinicalTrials.gov and the WHO meta register of trials, ICTRP. SELECTION CRITERIA We included randomised controlled trials (RCTs) of single and multi- component non-pharmacological and pharmacological interventions for preventing delirium in hospitalised non-ICU patients. DATA COLLECTION AND ANALYSIS Two review authors examined titles and abstracts of citations identified by the search for eligibility and extracted data independently, with any disagreements settled by consensus. The primary outcome was incidence of delirium; secondary outcomes included duration and severity of delirium, institutional care at discharge, quality of life and healthcare costs. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes; and between group mean differences and standard deviations for continuous outcomes. MAIN RESULTS We included 39 trials that recruited 16,082 participants, assessing 22 different interventions or comparisons. Fourteen trials were placebo-controlled, 15 evaluated a delirium prevention intervention against usual care, and 10 compared two different interventions. Thirty-two studies were conducted in patients undergoing surgery, the majority in orthopaedic settings. Seven studies were conducted in general medical or geriatric medicine settings.We found multi-component interventions reduced the incidence of delirium compared to usual care (RR 0.69, 95% CI 0.59 to 0.81; seven studies; 1950 participants; moderate-quality evidence). Effect sizes were similar in medical (RR 0.63, 95% CI 0.43 to 0.92; four studies; 1365 participants) and surgical settings (RR 0.71, 95% CI 0.59 to 0.85; three studies; 585 participants). In the subgroup of patients with pre-existing dementia, the effect of multi-component interventions remains uncertain (RR 0.90, 95% CI 0.59 to 1.36; one study, 50 participants; low-quality evidence).There is no clear evidence that cholinesterase inhibitors are effective in preventing delirium compared to placebo (RR 0.68, 95% CI, 0.17 to 2.62; two studies, 113 participants; very low-quality evidence).Three trials provide no clear evidence of an effect of antipsychotic medications as a group on the incidence of delirium (RR 0.73, 95% CI, 0.33 to 1.59; 916 participants; very low-quality evidence). In a pre-planned subgroup analysis there was no evidence for effectiveness of a typical antipsychotic (haloperidol) (RR 1.05, 95% CI 0.69 to 1.60; two studies; 516 participants, low-quality evidence). However, delirium incidence was lower (RR 0.36, 95% CI 0.24 to 0.52; one study; 400 participants, moderate-quality evidence) for patients treated with an atypical antipsychotic (olanzapine) compared to placebo (moderate-quality evidence).There is no clear evidence that melatonin or melatonin agonists reduce delirium incidence compared to placebo (RR 0.41, 95% CI 0.09 to 1.89; three studies, 529 participants; low-quality evidence).There is moderate-quality evidence that Bispectral Index (BIS)-guided anaesthesia reduces the incidence of delirium compared to BIS-blinded anaesthesia or clinical judgement (RR 0.71, 95% CI 0.60 to 0.85; two studies; 2057 participants).It is not possible to generate robust evidence statements for a range of additional pharmacological and anaesthetic interventions due to small numbers of trials, of variable methodological quality. AUTHORS' CONCLUSIONS There is strong evidence supporting multi-component interventions to prevent delirium in hospitalised patients. There is no clear evidence that cholinesterase inhibitors, antipsychotic medication or melatonin reduce the incidence of delirium. Using the Bispectral Index to monitor and control depth of anaesthesia reduces the incidence of postoperative delirium. The role of drugs and other anaesthetic techniques to prevent delirium remains uncertain.
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Affiliation(s)
- Najma Siddiqi
- University of YorkDepartment of Health SciencesHeslingtonYorkNorth YorkshireUKY010 5DD
| | - Jennifer K Harrison
- University of EdinburghCentre for Cognitive Ageing and Cognitive Epidemiology and the Alzheimer Scotland Dementia Research CentreDepartment of Geriatric Medicine, The Royal Infirmary of Edinburgh, Room S164251 Little France CrescentEdinburghUKEH16 4SB
| | - Andrew Clegg
- University of LeedsAcademic Unit of Elderly Care and RehabilitationBradford Institute for Health ResearchBradfordUKBD9 6RJ
| | - Elizabeth A Teale
- University of LeedsAcademic Unit of Elderly Care and RehabilitationBradford Institute for Health ResearchBradfordUKBD9 6RJ
| | - John Young
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust/University of LeedsAcademic Unit of Elderly Care and RehabilitationBradfordUK
| | - James Taylor
- Bradford Teaching Hospitals NHS Foundation TrustDepartment of AnaesthesiaBradfordUKBD9 6RJ
| | - Samantha A Simpkins
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust/University of LeedsAcademic Unit of Elderly Care and RehabilitationBradfordUK
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Deschodt M, Claes V, Van Grootven B, Van den Heede K, Flamaing J, Boland B, Milisen K. Structure and processes of interdisciplinary geriatric consultation teams in acute care hospitals: A scoping review. Int J Nurs Stud 2016; 55:98-114. [DOI: 10.1016/j.ijnurstu.2015.09.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 09/02/2015] [Accepted: 09/25/2015] [Indexed: 01/16/2023]
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Parsons J, Mathieson S, Jull A, Parsons M. Does vibration training reduce the fall risk profile of frail older people admitted to a rehabilitation facility? A randomised controlled trial. Disabil Rehabil 2015; 38:1082-8. [PMID: 26693802 DOI: 10.3109/09638288.2015.1103793] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To determine the effect of Vibration Training (VT) on functional ability and falls risk among a group of frail older people admitted to an inpatient rehabilitation unit in a regional hospital in New Zealand. METHOD A randomized controlled trial of 56 participants (mean 82.01 years in the intervention group and 81.76 years in the control group). VT targeting lower limb muscles with a frequency 30-50 Hz occurred three times per week until discharge. Amplitude progressively increased from 2 to 5 mm to allow the programme to be individually tailored to the participant. The control group received usual care physiotherapy sessions. Outcome measures were: Physiological profile assessment (PPA); and Functional Independence measure (FIM) and Modified Falls Efficacy Scale (MFES). RESULTS There was a statistically significant difference observed between the two groups in terms of FIM score (F = 5.09, p = 0.03) and MFES (F = 3.52, p = 0.007) but no difference was observed in terms of PPA scores (F = 0.96, p = 0.36). CONCLUSIONS Among older people admitted to an inpatient rehabilitation facility there may be some beneficial effect to the use of VT in conjunction with usual care physiotherapy in terms of improved functional ability. The study design and the small dosage of VT provided may have precluded any change in falls risk among participants. IMPLICATIONS FOR REHABILITATION Vibration training (VT) may assist in reducing the risk of falling among at risk older people. Current pressures on health systems (ageing population, reduced hospital length of stay) necessitate the development of innovative strategies to maximise the rehabilitation potential of older people. Among older people admitted to an inpatient rehabilitation facility there may be some beneficial effect to the use of vibration training in conjunction with usual care physiotherapy in terms of improved functional ability.
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Affiliation(s)
- J Parsons
- a School of Nursing, Faculty of Medical and Health Sciences, The University of Auckland , New Zealand.,b Institute of Healthy Ageing, Waikato District Health Board , Hamilton , New Zealand
| | - S Mathieson
- a School of Nursing, Faculty of Medical and Health Sciences, The University of Auckland , New Zealand.,b Institute of Healthy Ageing, Waikato District Health Board , Hamilton , New Zealand
| | - A Jull
- a School of Nursing, Faculty of Medical and Health Sciences, The University of Auckland , New Zealand
| | - M Parsons
- a School of Nursing, Faculty of Medical and Health Sciences, The University of Auckland , New Zealand.,b Institute of Healthy Ageing, Waikato District Health Board , Hamilton , New Zealand
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Khadaroo RG, Padwal RS, Wagg AS, Clement F, Warkentin LM, Holroyd-Leduc J. Optimizing senior's surgical care - Elder-friendly Approaches to the Surgical Environment (EASE) study: rationale and objectives. BMC Health Serv Res 2015; 15:338. [PMID: 26293153 PMCID: PMC4546177 DOI: 10.1186/s12913-015-1001-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Accepted: 08/11/2015] [Indexed: 01/08/2023] Open
Abstract
Background It is estimated that seniors (≥65 years old) account for >50 % of acute inpatient hospital days and are presenting for surgical evaluation of acute illness in increasing numbers. Unfortunately, conventional acute care models rarely take into account needs of the elderly population. The failure to consider these special needs have resulted in poor outcomes, longer lengths of hospital stay and have likely increased the need for institutional care. Acute Care for the Elderly models on medical wards have demonstrated decreased cost, length of hospital stay, readmissions and improved cognition, function and patient/staff satisfaction. We hypothesize that specific Elder-friendly Approaches to the Surgical Environment (EASE) interventions will similarly improve health outcomes in a cost-effective manner. Methods/design Prospective, before-after study with a concurrent control group. Four cohorts of 140 consecutively-screened older patients (≥65 years old) will be enrolled (560 patients in total). The EASE interventions involves co-locating all older surgical patients on a single unit, involving an interdisciplinary care team (including a geriatric specialist) in the development of individual care plans, implementing evidence-informed elder-friendly practices, use of a reconditioning program, and optimizing discharge planning. Subjects will be followed via chart review for their hospital stay, and will then complete in-person or telephone interviews at 6 weeks and 6 months after discharge. Measured outcomes include clinical (postoperative major in-hospital complication or death [primary composite outcome]; death or readmission within 30-days of initial discharge; length of hospital stay), humanistic (quality of life; functional, cognitive, and nutritional status) and economic (health care resource utilization and costs) endpoints. Within-site mean change scores will be computed for the composite primary outcome and the overall covariate-adjusted between-site pre-post difference will be the dependent variable analyzed using generalized linear mixed model procedures including adjustment for clustering. Discussion Our findings will generate new knowledge on outcomes from acute surgical care in older patients and validate a novel elder-friendly surgical model including assessment of both clinical and economic benefits. If effective, we expect the EASE initiatives to be generalizable to other surgical centres. Trial registration Clinicaltrials.govidentifier:NCT02233153
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Affiliation(s)
- Rachel G Khadaroo
- Department of Surgery, University of Alberta, Edmonton, AB, Canada. .,2D3.77 Walter C. Mackenzie Health Sciences Centre, 8440-112th Street, Edmonton, T6G 2B7, AB, Canada.
| | - Raj S Padwal
- Department of Medicine, University of Alberta, Edmonton, AB, Canada. .,Alberta Diabetes Institute, Edmonton, AB, Canada.
| | - Adrian S Wagg
- Department of Medicine, University of Alberta, Edmonton, AB, Canada. .,Alberta Seniors Health Strategic Clinical Network, Calgary, AB, Canada.
| | - Fiona Clement
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | | | - Jayna Holroyd-Leduc
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada. .,Alberta Seniors Health Strategic Clinical Network, Calgary, AB, Canada.
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Hartgerink JM, Cramm JM, Bakker TJ, Mackenbach JP, Nieboer AP. The importance of older patients' experiences with care delivery for their quality of life after hospitalization. BMC Health Serv Res 2015; 15:311. [PMID: 26253521 PMCID: PMC4529729 DOI: 10.1186/s12913-015-0982-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 07/29/2015] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Older patients' experiences with care delivery may be important for their quality of life over time. Evidence is however lacking. Therefore, this study aims to identify the longitudinal relationship between older patients' experiences with hospital care, perceived quality of integrated care and quality of life after hospitalization. METHODS Our longitudinal research was based on a pilot study of older people who had recently been admitted to a hospital. In the pilot study, all patients (≥ 65 years of age) who were admitted to the Vlietland hospital between June and October 2010 were asked to participate, which led to the inclusion of 500 older patients at baseline. A total of 291 patients (58% response rate) were interviewed 3 months after admission. Measures included quality of life, patients' perceptions of quality of integrated care delivery and patients' experiences with hospital care. We used descriptive statistics, correlations, and multilevel analyses. RESULTS Being married (p ≤ 0.05), patients' experiences with hospital care, perceived quality of integrated care delivery (both p ≤ 0.01), and quality of life within 48 h of hospital admission (p ≤ 0.001) significantly correlated with quality of life 3 months after hospital admission. After controlling for background characteristics, multilevel analysis indicated a longitudinal relationship between patients' experiences with hospital care (p ≤ 0.05), perceived quality of integrated care delivery (p ≤ 0.01) and patients' quality of life 3 months after hospitalization. CONCLUSIONS This study found a longitudinal relationship between patients' perceived quality of integrated care delivery, experiences with hospital care and quality of life of older patients after hospitalization. These results underscore the importance of enhancing older patients' experiences with care delivery.
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Affiliation(s)
- Jacqueline M Hartgerink
- Institute of Health Policy & Management (iBMG), Erasmus University, Rotterdam, The Netherlands.
| | - Jane M Cramm
- Institute of Health Policy & Management (iBMG), Erasmus University, Rotterdam, The Netherlands.
| | | | | | - Anna P Nieboer
- Institute of Health Policy & Management (iBMG), Erasmus University, Rotterdam, The Netherlands.
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Abstract
OBJECTIVE To review how disability can develop in older adults with critical illness and to explore ways to reduce long-term disability following critical illness. DATA SOURCES We searched PubMed, CINAHL, Web of Science and Google Scholar for studies reporting disability outcomes (i.e., activities of daily living, instrumental activities of daily living, and mobility activities) and/or cognitive outcomes among patients treated in an ICU who were 65 years or older. We also reviewed the bibliographies of relevant citations to identify additional citations. STUDY SELECTION We identified 19 studies evaluating disability outcomes in critically ill patients who were 65 years and older. DATA EXTRACTION Descriptive epidemiologic data on disability after critical illness. DATA SYNTHESIS Newly acquired disability in activities of daily living, instrumental activities of daily living, and mobility activities was commonplace among older adults who survived a critical illness. Incident dementia and less severe cognitive impairment were also highly prevalent. Factors related to the acute critical illness, ICU practices, such as heavy sedation, physical restraints, and immobility, as well as aging physiology, and coexisting geriatric conditions can combine to result in these poor outcomes. CONCLUSIONS Older adults who survive critical illness have physical and cognitive declines resulting in disability at greater rates than hospitalized, noncritically ill and community dwelling older adults. Interventions derived from widely available geriatric care models in use outside of the ICU, which address modifiable risk factors including immobility and delirium, are associated with improved functional and cognitive outcomes and can be used to complement ICU-focused models such as the ABCDEs.
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Griffiths P, Bridges J, Sheldon H, Thompson R. The role of the dementia specialist nurse in acute care: a scoping review. J Clin Nurs 2014; 24:1394-405. [DOI: 10.1111/jocn.12717] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Peter Griffiths
- Faculty of Health Sciences; University of Southampton; Southampton and National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (Wessex); UK
| | - Jackie Bridges
- Faculty of Health Sciences; University of Southampton; Southampton and National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (Wessex); UK
| | | | - Rachel Thompson
- Royal College of Nursing and Admiral Nurse; Dementia UK
- Royal College of Nursing; London UK
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Osuna-Pozo CM, Ortiz-Alonso J, Vidán M, Ferreira G, Serra-Rexach JA. [Review of functional impairment associated with acute illness in the elderly]. Rev Esp Geriatr Gerontol 2014; 49:77-89. [PMID: 24529877 DOI: 10.1016/j.regg.2013.08.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 07/29/2013] [Accepted: 08/01/2013] [Indexed: 06/03/2023]
Abstract
Hospitalization is a risk for elderly population, with a high probability of having adverse events. The most important one is functional impairment, due to its high prevalence and the serious impact it has on the quality of life. The main risk factors for functional decline associated with hospitalization are, age, immobility, cognitive impairment, and functional status prior to admission. It is necessary to detect patients at risk in order to implement the necessary actions to prevent this deterioration, with physical exercise and multidisciplinary geriatric care being the most important.
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Affiliation(s)
| | - Javier Ortiz-Alonso
- Servicio de Geriatría, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - Maite Vidán
- Servicio de Geriatría, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - Guillermo Ferreira
- Servicio de Geriatría, Hospital General Universitario Gregorio Marañón, Madrid, España
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Thorpe O, Kumar S, Johnston K. Barriers to and enablers of physical activity in patients with COPD following a hospital admission: a qualitative study. Int J Chron Obstruct Pulmon Dis 2014; 9:115-28. [PMID: 24489465 PMCID: PMC3904833 DOI: 10.2147/copd.s54457] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) is characterized by a persistent blockage of airflow, prompting episodes of shortness of breath, commonly leading to hospitalization. Hospitalization may lead to a decline in physical activity following discharge. Physical activity has been shown to improve symptoms of COPD and reduce readmissions, and to decrease morbidity and mortality. This study aims to explore, from the perspectives of people with COPD, the barriers to and enablers of participation in physical activity following hospitalization for COPD. Methods This study had a qualitative descriptive design and included semistructured interviews with 28 adult COPD patients who had been admitted to hospital with a primary diagnosis of exacerbation of COPD. Results A plethora of barriers to but fewer enablers of participation in physical activity and pulmonary rehabilitation were identified for this cohort of people. The main barriers identified were health-related (comorbidities, COPD symptoms, and physical injury or illness) environment-related (weather, transport, and finance), and self-related. The main enabling factors reported were access to health professionals and equipment, social support, routine and extracurricular activities, personal goals and motivation, and the effect of physical activity and “feeling better”. Conclusion This research provides a snapshot of the barriers to and enablers of physical activity and pulmonary rehabilitation in people with COPD. It is evident that there are significant barriers which hinder the ability of people with COPD to undertake and continue participation in physical activity and pulmonary rehabilitation. While there are some enablers that may counter these barriers, it is clear that health professionals dealing with people suffering from COPD need to actively recognize and address barriers to physical activity and pulmonary rehabilitation. Hospital admission may create an opportunity for implementation of interventions promoting physical activity (such as referral to pulmonary rehabilitation), which may assist in reducing hospital readmission, as well as decreasing morbidity and mortality.
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Affiliation(s)
- Olivia Thorpe
- International Centre for Allied Health Evidence, The Samson Institute for Health Research, School of Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Saravana Kumar
- International Centre for Allied Health Evidence, The Samson Institute for Health Research, School of Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Kylie Johnston
- International Centre for Allied Health Evidence, The Samson Institute for Health Research, School of Health Sciences, University of South Australia, Adelaide, SA, Australia
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Hartgerink JM, Cramm JM, van Wijngaarden JDH, Bakker TJEM, Mackenbach JP, Nieboer AP. A framework for understanding outcomes of integrated care programs for the hospitalised elderly. Int J Integr Care 2013; 13:e047. [PMID: 24363635 PMCID: PMC3860580 DOI: 10.5334/ijic.1063] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Revised: 08/27/2013] [Accepted: 09/04/2013] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Integrated care has emerged as a new strategy to enhance the quality of care for hospitalised elderly. Current models do not provide insight into the mechanisms underlying integrated care delivery. Therefore, we developed a framework to identify the underlying mechanisms of integrated care delivery. We should understand how they operate and interact, so that integrated care programmes can enhance the quality of care and eventually patient outcomes. THEORY AND METHODS Interprofessional collaboration among professionals is considered to be critical in integrated care delivery due to many interdependent work requirements. A review of integrated care components brings to light a distinction between the cognitive and behavioural components of interprofessional collaboration. RESULTS Effective integrated care programmes combine the interacting components of care delivery. These components affect professionals' cognitions and behaviour, which in turn affect quality of care. Insight is gained into how these components alter the way care is delivered through mechanisms such as combining individual knowledge and actively seeking new information. CONCLUSION We expect that insight into the cognitive and behavioural mechanisms will contribute to the understanding of integrated care programmes. The framework can be used to identify the underlying mechanisms of integrated care responsible for producing favourable outcomes, allowing comparisons across programmes.
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Affiliation(s)
- Jacqueline M Hartgerink
- Department of Social Medical Sciences, Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Jane M Cramm
- Department of Social Medical Sciences, Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Jeroen D H van Wijngaarden
- Department of Health Service and Management of Organizations, Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | - Johan P Mackenbach
- Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Anna P Nieboer
- Department of Social Medical Sciences, Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
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Guerra RO, Oliveira BS, Alvarado BE, Curcio CL, Rejeski WJ, Marsh AP, Ip EH, Barnard RT, Guralnik JM, Zunzunegui MV. Validity and applicability of a video-based animated tool to assess mobility in elderly Latin American populations. Geriatr Gerontol Int 2013; 14:864-73. [PMID: 24666718 DOI: 10.1111/ggi.12180] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2013] [Indexed: 11/30/2022]
Abstract
AIM To assess the reliability and the validity of Portuguese- and Spanish-translated versions of the video-based short-form Mobility Assessment Tool in assessing self-reported mobility, and to provide evidence for the applicability of these videos in elderly Latin American populations as a complement to physical performance measures. METHODS The sample consisted of 300 elderly participants (150 from Brazil, 150 from Colombia) recruited at neighborhood social centers. Mobility was assessed with the Mobility Assessment Tool, and compared with the Short Physical Performance Battery score and self-reported functional limitations. Reliability was calculated using intraclass correlation coefficients. Multiple linear regression analyses were used to assess associations among mobility assessment tools and health, and sociodemographic variables. RESULTS A significant gradient of increasing Mobility Assessment Tool score with better physical function was observed for both self-reported and objective measures, and in each city. Associations between self-reported mobility and health were strong, and significant. Mobility Assessment Tool scores were lower in women at both sites. Intraclass correlation coefficients of the Mobility Assessment Tool were 0.94 (95% confidence interval 0.90-0.97) in Brazil and 0.81 (95% confidence interval 0.66-0.91) in Colombia. Mobility Assessment Tool scores were lower in Manizales than in Natal after adjustment by Short Physical Performance Battery, self-rated health and sex. CONCLUSIONS These results provide evidence for high reliability and good validity of the Mobility Assessment Tool in its Spanish and Portuguese versions used in Latin American populations. In addition, the Mobility Assessment Tool can detect mobility differences related to environmental features that cannot be captured by objective performance measures.
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Hartgerink JM, Cramm JM, Bakker TJEM, van Eijsden AM, Mackenbach JP, Nieboer AP. The importance of multidisciplinary teamwork and team climate for relational coordination among teams delivering care to older patients. J Adv Nurs 2013; 70:791-9. [PMID: 23980594 PMCID: PMC4282281 DOI: 10.1111/jan.12233] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2013] [Indexed: 11/30/2022]
Abstract
Aim To identify predictors of relational coordination among professionals delivering care to older patients. Background Relational coordination is known to enhance quality of care in hospitals. The underlying mechanisms, however, remain poorly understood. Design This cross-sectional study was part of a larger evaluation study examining the opportunity to prevent loss of function in older patients due to hospitalization in the Netherlands. Methods This study was performed in spring 2010 among team members delivering care to older hospitalized patients (192 respondents; 44% response rate) in one hospital. Relational coordination was measured by the Relational Coordination survey; team climate by the Team Climate Inventory and questions were asked about participation in multidisciplinary team meetings and disciplines represented in these meetings. To account for the hierarchical structure, a multilevel analysis was performed. Results Correlation analysis revealed a positive relationship among being female, being a nurse and relational coordination; medical specialists showed a negative relationship. The number of disciplines represented during multidisciplinary team meetings and team climate were positively related with relational coordination. The multilevel analysis showed a positive relationship between the number of disciplines represented during multidisciplinary team meetings and team climate with relational coordination. Conclusions The enhancement of team climate and attendance of diverse professionals during multidisciplinary team meetings are expected to improve relational coordination. Furthermore, this study underscores the importance of enhancing relational coordination between medical specialists and other professionals.
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Affiliation(s)
- J M Hartgerink
- Department of Social Medical Sciences, Institute of Health Policy and Management, Erasmus University Rotterdam, The Netherlands
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Liu B, Almaawiy U, Moore JE, Chan WH, Straus SE. Evaluation of a multisite educational intervention to improve mobilization of older patients in hospital: protocol for mobilization of vulnerable elders in Ontario (MOVE ON). Implement Sci 2013; 8:76. [PMID: 23822563 PMCID: PMC3704763 DOI: 10.1186/1748-5908-8-76] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 06/28/2013] [Indexed: 01/29/2023] Open
Abstract
Background Functional decline is a common adverse outcome of hospitalization in older people. Often, this decline is not related to the illness that precipitated admission, but to the process of care delivered in hospital. The association between immobility and adverse consequences is well established, yet older inpatients spend significant amounts of time supine in bed. We aim to implement and evaluate the impact of an evidence-based strategy to promote early mobilization and prevent functional decline in older patients admitted to university-affiliated acute care hospitals in Ontario, Canada. We will implement a multi-component educational intervention to support a change in practice to enhance mobilization of older patients. Methods/design Implementation of our early mobilization strategy is guided by the Knowledge to Action Cycle. Through focus groups with frontline staff, we will identify barriers and facilitators to early mobilization. We will tailor the intervention at each site to the identified barriers and facilitators, focusing on the following key messages: to complete a mobility assessment and care plan within 24 hours of the decision to admit patients aged 65 years and older; to achieve mobilization at least 3 times per day; and, to ensure that mobilization is scaled and progressive. The primary outcome, number of patients observed out of bed, will be documented three times per day (in the morning, at lunch and in the afternoon), two days each week. This data collection will occur over 3 phases: pre-implementation (10 weeks), implementation (8 weeks), and post-implementation (20 weeks). Discussion This is the first large, multisite study to evaluate the impact of a multi-component knowledge translation strategy on rates of mobilization of older patients in hospital. Our implementation is framed by the Knowledge to Action Cycle, and the intervention is being adapted to the local context. These unique features render our intervention approach more generalizable to multiple practice settings. Contextualization of the intervention has also facilitated engagement of participants from multiple hospitals. Upon completion of this study, we will better understand the barriers and facilitators to implementing an early mobilization strategy across a spectrum of hospitals, as well as the impact of a mobilization strategy.
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Borges RC, Carvalho CRF. Physical activity in daily life in Brazilian COPD patients during and after exacerbation. COPD 2013; 9:596-602. [PMID: 23244169 DOI: 10.3109/15412555.2012.705364] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Although hospitalization is recognized as an important cause of reduction in physical activity in daily life (PADL) in COPD, there is only one study evaluating this effect, and it was performed in European COPD patients who have a lower PADL than that of South American COPD patients. OBJECTIVES To investigate the effect of hospitalization due to acute exacerbation of PADL in Brazilian COPD patients and to evaluate the factors that determines the physical activity levels during hospitalization and after discharge. METHODS PADL was quantified using a 3-axis accelerometer on the 3rd day of hospitalization and 1 month after discharge in Brazilian COPD patients who were hospitalized due to disease exacerbation. Six-minute walking distance (6MWD), lower limb strength and pulmonary function were also evaluated. RESULTS A total of 20 patients completed the study. During hospitalization, patients spent most of the time (87%) lying down or sitting; however, 1 month after they were walking >40 min/day. In addition, patients with prior hospitalization had a lower level of physical activity compared to those without a previous history of hospitalization. The time spent walking during hospitalization was significantly explained by the quadriceps strength (r(2) = 0.29; p < 0.05), while 1 month after, the time spent walking was only significantly explained by the 6MWD (r(2) = 0.51; p = 0.02). CONCLUSIONS Brazilian COPD patients are inactive during hospitalization but become active 1 month after discharge. Previously hospitalized are more inactive both during and after exacerbation. The quadriceps strength and 6MWD explain the physical activity levels during hospitalization and at home, respectively.
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Affiliation(s)
- Rodrigo Cerqueira Borges
- Physical Therapy Department, School of Medicine, University of São Paulo, São Paulo, São Paulo, Brazil
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Lundström M, Edlund A, Lundström G, Gustafson Y. Reorganization of Nursing and Medical Care to Reduce the Incidence of Postoperative Delirium and Improve Rehabilitation Outcome in Elderly Patients Treated for Femoral Neck Fractures. Scand J Caring Sci 2013. [DOI: 10.1111/j.1471-6712.1999.tb00539.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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A randomized controlled trial to determine the effect of a model of restorative home care on physical function and social support among older people. Arch Phys Med Rehabil 2013; 94:1015-22. [PMID: 23416219 DOI: 10.1016/j.apmr.2013.02.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Revised: 01/22/2013] [Accepted: 02/04/2013] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine the impact of a restorative model of home care on social support and physical function among community-dwelling older people. DESIGN Cluster-randomized controlled trial. SETTING Home care in an urban area. PARTICIPANTS Participants (N=205) were randomly assigned to an intervention group (n=108; mean age, 79.1y; 71.3% women; 81.5% New Zealand European [NZE]; 50.8% residing in areas of the highest levels of social deprivation) or a usual care group (n=97; mean age, 76.9y; 60.8% women; 73.2% NZE; 53.5% in the highest levels of social deprivation). INTERVENTION Participants randomly assigned to the intervention group completed a goal facilitation tool with a needs assessor to determine their needs and to establish the aims for the episode of care. Services were structured according to the principles of restorative home care (independence focused with individually tailored activity programs). Usual care participants received a standard needs assessment that informed the delivery of home care services. MAIN OUTCOME MEASURES Short Physical Performance Battery (SPPB), Dukes Social Support Index (DSSI). RESULTS There was greater change over time in physical function (measured by SPPB: F=8.30, P=.003) but no associated increase in social support (as determined by DSSI: F=2.58, P=.09). CONCLUSIONS Significant improvements in physical function were observed after a period of restorative home care services. The absence of an associated change in social support may have been the result of a combination of factors, including the threshold of physical function required for community ambulation, the low rate of allied health service provision, and the time required to reestablish social ties. The findings contribute to a greater understanding of factors necessary to refocus home-based services to emphasize improvements in physical function and independence.
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Travers C, Byrne GJ, Pachana NA, Klein K, Gray L. Validation of the interRAI Cognitive Performance Scale against independent clinical diagnosis and the Mini-Mental State Examination in older hospitalized patients. J Nutr Health Aging 2013; 17:435-9. [PMID: 23636544 DOI: 10.1007/s12603-012-0439-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the diagnostic accuracy of the interRAI Acute Care (AC) Cognitive Performance Scale (CPS2) and the Mini-Mental State Examination (MMSE), against independent clinical diagnosis for detecting dementia in older hospitalized patients. DESIGN, SETTING, AND PARTICIPANTS The study was part of a prospective observational cohort study of patients aged ≥70 years admitted to four acute hospitals in Queensland, Australia, between 2008 and 2010. Recruitment was consecutive and patients expected to remain in hospital for ≥48 hours were eligible to participate. Data for 462 patients were available for this study. MEASUREMENTS Trained research nurses completed comprehensive geriatric assessments and administered the interRAI AC and MMSE to patients. Two physicians independently reviewed patients' medical records and assessments to establish the diagnosis of dementia. Indicators of diagnostic accuracy included sensitivity, specificity, predictive values, likelihood ratios and areas under receiver (AUC) operating characteristic curves. RESULTS 85 patients (18.4%) were considered to have dementia according to independent clinical diagnosis. The sensitivity of the CPS2 [0.68 (95%CI: 0.58-0.77)] was not statistically different to the MMSE [0.75 (0.64-0.83)] in predicting physician diagnosed dementia. The AUCs for the 2 instruments were also not statistically different: CPS2 AUC = 0.83 (95%CI: 0.78-0.89) and MMSE AUC = 0.87 (95%CI: 0.83-0.91), while the CPS2 demonstrated higher specificity [0.92 95%CI: 0.89-0.95)] than the MMSE [0.82 (0.77-0.85)]. Agreement between the CPS2 and clinical diagnosis was substantial (87.4%; κ=0.61). CONCLUSION The CPS2 appears to be a reliable screening tool for assessing cognitive impairment in acutely unwell older hospitalized patients. These findings add to the growing body of evidence supporting the utility of the interRAI AC, within which the CPS2 is embedded. The interRAI AC offers the advantage of being able to accurately screen for both dementia and delirium without the need to use additional assessments, thus increasing assessment efficiency.
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Affiliation(s)
- C Travers
- Centre for Research in Geriatric Medicine, The University of Queensland, Level 2, Building 33, The Princess Alexandra Hospital, Ipswich Rd., Woolloongabba Q 4102, Australia.
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Parsons JGM, Parsons MJG. The effect of a designated tool on person-centred goal identification and service planning among older people receiving homecare in New Zealand. HEALTH & SOCIAL CARE IN THE COMMUNITY 2012; 20:653-62. [PMID: 22812380 DOI: 10.1111/j.1365-2524.2012.01081.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
This study sought to determine the ability of a designated tool developed to identify client-directed goals in a sample of older people referred for homecare. A retrospective pre/post-intervention design was used and a total of 360 older people in an urban centre in New Zealand were included in the analysis. All clients receiving services at the time of data collection (July 2007) who were referred for service provision between July 2003 and the implementation in January 2007 of a restorative model of homecare were included in the analysis. The restorative model of homecare included a designated goal-facilitation tool [Towards Achieving Realistic Goal in Elders Tool (TARGET)]. Prior to the use of TARGET, participants had a goal recorded for their home-care episode in 31 cases (8.6%), whereas following the implementation of TARGET, goals were recorded in 339 cases (94.2%). At a quarterly review, eight clients (2.2%) achieved their goal prior to TARGET, whereas 172 clients (47.8%) fully achieved their goal when TARGET was utilised. Within the sample, multinomial logistic regression showed that the use of TARGET significantly improved goal attainment. Furthermore, moderate-to-severe cognitive impairment significantly reduced the successful attainment of goals. The study highlighted the importance of a designated tool for facilitating older people to set goals that are then used in developing support plans to structure services to assist them in the home. The need for alternative strategies for goal setting for people with significant cognitive impairment was highlighted. This study, in attempting to determine the effect of a goal-facilitation tool as a driver for quality improvement in homecare, had an observational comparative design, this being the most pragmatic option to assess the feasibility of TARGET prior to further work being undertaken. The results do show that in this sample of older people receiving homecare, the use of TARGET led to a greater proportion of goal identification, higher rates of goal attainment and a more diverse range of categories of goals than traditional non-structured methods of goal setting.
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Affiliation(s)
- John G M Parsons
- School of Nursing, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.
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Hartgerink JM, Cramm JM, Bakker TJEM, van Eijsden RAM, Mackenbach JP, Nieboer AP. The importance of relational coordination for integrated care delivery to older patients in the hospital. J Nurs Manag 2012; 22:248-56. [PMID: 24576117 DOI: 10.1111/j.1365-2834.2012.01481.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2012] [Indexed: 12/29/2022]
Abstract
AIM This study investigated relational coordination among professionals providing healthcare to hospitalized older patients and assessed its impact on integrated care delivery. BACKGROUND Previous studies have shown that relational coordination is positively associated with the delivery of acute, emergency and trauma care. The effect of relational coordination in integrated care delivery to hospitalized older patients remains unknown. METHODS This cross-sectional study was part of an examination of integrated care delivery to hospitalized older patients. Data were collected using questionnaires distributed to hospital professionals (192 respondents; 44% response rate). RESULTS After controlling for demographic variables, regression analyses showed that relational coordination was positively related to integrated care delivery (β = 0.20; P ≤ 0.05). Relational coordination was lower among professionals in the same discipline, and higher between nurses and others than between medical specialists and others. Relational coordination and integrated care delivery were significantly higher in geriatrics than in other units (both P ≤ 0.001). CONCLUSIONS The enhancement of relational coordination among healthcare professionals is positively associated with integrated care delivery to older patients. IMPLICATIONS FOR NURSING MANAGEMENT Relational coordination should be improved between medical specialists and others and higher levels of relational coordination and integrated care delivery should be achieved in all hospital units.
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Parke B, Hunter KF, Bostrom AM, Chambers T, Manraj C. Identifying modifiable factors to improve quality for older adults in hospital: a scoping review. Int J Older People Nurs 2012; 9:8-24. [PMID: 23067226 DOI: 10.1111/opn.12007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Accepted: 07/26/2012] [Indexed: 01/20/2023]
Abstract
BACKGROUND Traditional ways of viewing hospitalisation do not always recognise how elements within the hospital environment contribute to disability. Four theoretical dimensions of older adult-hospital environment fit have been proposed in previous research on elder-friendly hospitals: social climate, physical design, care systems and processes, policies and procedures; however, modifiable factors for each dimension are not yet identified. DESIGN Exploratory iterative design guided by Arksey and O'Malley (2005, International Journal of Social Research Methodology 8, 19) scoping review methodology. METHOD We undertook a scoping review of primary research related to hospitalised community-dwelling older adults. Keys search terms and criteria were used to identify relevant articles with modifiable factors extracted from articles meeting study criteria. RESULTS A total of 66 studies were included and evaluated for modifiable factor mapping. We were able to map all 66 studies to the four dimensions. The majority of included studies described care systems and processes, with little relating to social climate, physical design and policies and procedures. Thirty-nine potentially modifiable factors were identified and mapped to the theoretical dimensions according to four overarching themes: models of care; assessment of potential geriatric issues; targeting care to a specific clinical issue and supporting transitions home themes. CONCLUSION The dimensions of older adult-hospital fit help us to organise key features of an elder-friendly hospital and identify potentially modifiable factors. Although it makes intuitive sense to cluster and organise according to the dimensions to help with understanding, this tells us little about the synergy of interactions and hierarchical relationships. Our results highlight the importance of competent gerontological nursing in care for hospitalised older adults and the need for further understanding of the older adult and family as a unit of care. IMPLICATIONS FOR PRACTICE Registered nurses have a leadership role to ensure safe quality care for older people in hospital. This leadership role can be framed in interventions that focus on fixing the fit between what older people need and what the hospital environment provides. Modifiable factors for improvement are within the scope and competency of the registered nurse.
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Affiliation(s)
- Belinda Parke
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
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Implementation of inpatient geriatric consultation teams and geriatric resource nurses in acute hospitals: A national survey study. Int J Nurs Stud 2012; 49:842-9. [DOI: 10.1016/j.ijnurstu.2011.11.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Revised: 11/23/2011] [Accepted: 11/28/2011] [Indexed: 11/20/2022]
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Reid WD, Yamabayashi C, Goodridge D, Chung F, Hunt MA, Marciniuk DD, Brooks D, Chen YW, Hoens AM, Camp PG. Exercise prescription for hospitalized people with chronic obstructive pulmonary disease and comorbidities: a synthesis of systematic reviews. Int J Chron Obstruct Pulmon Dis 2012; 7:297-320. [PMID: 22665994 PMCID: PMC3363140 DOI: 10.2147/copd.s29750] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION The prescription of physical activity for hospitalized patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) can be complicated by the presence of comorbidities. The current research aimed to synthesize the relevant literature on the benefits of exercise for people with multimorbidities who experience an AECOPD, and ask: What are the parameters and outcomes of exercise in AECOPD and in conditions that are common comorbidities as reported by systematic reviews (SRs)? METHODS An SR was performed using the Cochrane Collaboration protocol. Nine electronic databases were searched up to July 2011. Articles were included if they (1) described participants with AECOPD, chronic obstructive pulmonary disease (COPD), or one of eleven common comorbidities, (2) were an SR, (3) examined aerobic training (AT), resistance training (RT), balance training (BT), or a combination thereof, (4) included at least one outcome of fitness, and (5) compared exercise training versus control/sham. RESULTS This synthesis examined 58 SRs of exercise training in people with AECOPD, COPD, or eleven chronic conditions commonly associated with COPD. Meta-analyses of endurance (aerobic or exercise capacity, 6-minute walk distance--6MWD) were shown to significantly improve in most conditions (except osteoarthritis, osteoporosis, and depression), whereas strength was shown to improve in five of the 13 conditions searched: COPD, older adults, heart failure, ischemic heart disease, and diabetes. Several studies of different conditions also reported improvements in quality of life, function, and control or prevention outcomes. Meta-analyses also demonstrate that exercise training decreases the risk of mortality in older adults, and those with COPD or ischemic heart disease. The most common types of training were AT and RT. BT and functional training were commonly applied in older adults. The quality of the SRs for most conditions was moderate to excellent (>65%) as evaluated by AMSTAR scores. CONCLUSION In summary, this synthesis showed evidence of significant benefits from exercise training in AECOPD, COPD, and conditions that are common comorbidities. A broader approach to exercise and activity prescription in pulmonary rehabilitation may induce therapeutic benefits to ameliorate clinical sequelae associated with AECOPD and comorbidities such as the inclusion of BT and functional training.
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Affiliation(s)
- W Darlene Reid
- Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada.
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Parsons J, Rouse P, Robinson EM, Sheridan N, Connolly MJ. Goal setting as a feature of homecare services for older people: does it make a difference? Age Ageing 2012; 41:24-9. [PMID: 21896558 DOI: 10.1093/ageing/afr118] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Health services delivered in an older person's home are often implemented at a critical juncture in an individual's functional status. Although homecare has potential to improve this situation, it often focuses on treating disease and 'taking care' of the patient rather than promoting independence. The aim of restorative homecare is to change the philosophy from one where delivery of care may create dependency to provision of care which maximises independence, self-esteem, self-image and quality of life, and reduces the care required. AIMS To assess impact of a designated goal facilitation tool on health-related quality of life (HRQoL), social support and physical function among community-dwelling older people referred for homecare. METHODS A total of 205 participants [mean age 79.1 years, 71.3% female (intervention group) and 76.9 years with 60.8% female (control group)] were cluster randomised to an intervention or control assessor. The intervention arm involved participants completing a goal facilitation tool with assessors. This established rehabilitation aims. Control participants received a standard needs assessment. Clients from both groups were then referred to a homecare organisation for service delivery. RESULTS There was greater change over time in HRQoL [measured by Short Form 36 Survey (SF-36)] in the intervention group (P = 0.0001). There was a marked variation across homecare providers in types of services provided (P < 0.001). Identification of a goal did not predict completion of a formalised review of participants' needs by the homecare organisation. CONCLUSIONS Use of a goal facilitation tool in assessment of an older person's needs on referral for homecare leads to significant improvements in HRQoL. This may be through a higher proportion of individualised activities tailored to a successful identification of the person's goals. The findings contribute to greater understanding of factors necessary to implement improvements in homecare services for older people.
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Affiliation(s)
- John Parsons
- School of Nursing, The University of Auckland, ECOM House Ferncroft St Grafton, Auckland 1150, New Zealand.
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Variability in measuring (instrumental) activities of daily living functioning and functional decline in hospitalized older medical patients: a systematic review. J Clin Epidemiol 2011; 64:619-27. [DOI: 10.1016/j.jclinepi.2010.07.005] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Revised: 06/11/2010] [Accepted: 07/23/2010] [Indexed: 11/22/2022]
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Abstract
RÉSUMÉStimuler l'autonomie chez les gens de plus de 65 ans, dont plus de 80 pour cent éprouvent des troubles médicaux, constitue un défi de taille pour le personnel des politiques, les planificateurs de programme et les prestateurs de services, qui doivent prendre en considération les aspects physiques, sociaux et psychologiques de l'autonomie. Cet article présente une analyse bibliographique systématique et une synthèse rigoureuse de 65 rapports de recherche détaillés sélectionnés à partir de 238 études publicées sur les approches de soins favorisant la promotion de l'autonomie des personnes àgées. Cet article témoigne en faveur des programmes d'exercices et de promotion de la santé pour toutes les personnes âgées, ainsi que de la gestion à domicile des soins de santé et des programmes de prévention des chutes pour les aîné(e)s frêles. De plus, les conclusions soulignent l'importance d'accorder plus d'attention aux politiques sur les appareils accessoires fonctionnels et le besoin d'avoir plus de recherches sur l'efficacité des programmes de santé publique, sur les stratégies de promotion de soins médicaux préventifs et sur les facteurs psychosociaux qui influent sur l'auto-efficacité des personnes âgées.
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Mudge AM, O'Rourke P, Denaro CP. Timing and risk factors for functional changes associated with medical hospitalization in older patients. J Gerontol A Biol Sci Med Sci 2010; 65:866-72. [PMID: 20494952 DOI: 10.1093/gerona/glq069] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Older medical patients often experience a decline in function associated with hospitalization. Some of this decline is already established at hospital admission, whereas some occurs during hospitalization. Objectives of this study were to separately describe pre-hospital and in-hospital functional changes in older Australian medical patients and to identify risk factors associated with these functional changes. METHODS Secondary analysis of data from a prospective controlled trial conducted in general medical units of an Australian tertiary teaching hospital. Participants were 615 consecutive patients aged 65 years or older admitted under a general medical unit for more than 2 days, discharged alive, and not fully dependent at pre-admission baseline. Activities of daily living measured 2 weeks before admission, at admission, and at discharge were used to calculate rates of pre-hospital and in-hospital decline and of in-hospital recovery to pre-admission function. Potential predictors including age, sex, diagnosis, illness severity, pre-admission function, pre-admission supports, and documented "geriatric syndromes" (dementia, falls, malnutrition) were investigated for each functional change outcome using multiple logistic regression models. RESULTS Sixty-four percent of participants had pre-hospital functional decline; only 42% of these had recovered to pre-admission function by hospital discharge. Only 7% had in-hospital decline. The different functional change variables had distinct patterns of predictors. CONCLUSIONS Most decline occurred prior to hospitalization and was associated with common indicators of poor outcomes in hospitalized elders. In-hospital decline was uncommon, suggesting that in-hospital recovery may be a more appropriate intervention target.
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Affiliation(s)
- Alison M Mudge
- University of Queensland School of Medicine, Brisbane, Australia.
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Impact of a Nurse-Driven Mobility Protocol on Functional Decline in Hospitalized Older Adults. J Nurs Care Qual 2009; 24:325-31. [DOI: 10.1097/ncq.0b013e3181a4f79b] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Zwarenstein M, Goldman J, Reeves S. Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2009:CD000072. [PMID: 19588316 DOI: 10.1002/14651858.cd000072.pub2] [Citation(s) in RCA: 437] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Poor interprofessional collaboration (IPC) can negatively affect the delivery of health services and patient care. Interventions that address IPC problems have the potential to improve professional practice and healthcare outcomes. OBJECTIVES To assess the impact of practice-based interventions designed to change IPC, compared to no intervention or to an alternate intervention, on one or more of the following primary outcomes: patient satisfaction and/or the effectiveness and efficiency of the health care provided. Secondary outcomes include the degree of IPC achieved. SEARCH STRATEGY We searched the Cochrane Effective Practice and Organisation of Care Group Specialised Register (2000-2007), MEDLINE (1950-2007) and CINAHL (1982-2007). We also handsearched the Journal of Interprofessional Care (1999 to 2007) and reference lists of the five included studies. SELECTION CRITERIA Randomised controlled trials of practice-based IPC interventions that reported changes in objectively-measured or self-reported (by use of a validated instrument) patient/client outcomes and/or health status outcomes and/or healthcare process outcomes and/or measures of IPC. DATA COLLECTION AND ANALYSIS At least two of the three reviewers independently assessed the eligibility of each potentially relevant study. One author extracted data from and assessed risk of bias of included studies, consulting with the other authors when necessary. A meta-analysis of study outcomes was not possible given the small number of included studies and their heterogeneity in relation to clinical settings, interventions and outcome measures. Consequently, we summarised the study data and presented the results in a narrative format. MAIN RESULTS Five studies met the inclusion criteria; two studies examined interprofessional rounds, two studies examined interprofessional meetings, and one study examined externally facilitated interprofessional audit. One study on daily interdisciplinary rounds in inpatient medical wards at an acute care hospital showed a positive impact on length of stay and total charges, but another study on daily interdisciplinary rounds in a community hospital telemetry ward found no impact on length of stay. Monthly multidisciplinary team meetings improved prescribing of psychotropic drugs in nursing homes. Videoconferencing compared to audioconferencing multidisciplinary case conferences showed mixed results; there was a decreased number of case conferences per patient and shorter length of treatment, but no differences in occasions of service or the length of the conference. There was also no difference between the groups in the number of communications between health professionals recorded in the notes. Multidisciplinary meetings with an external facilitator, who used strategies to encourage collaborative working, was associated with increased audit activity and reported improvements to care. AUTHORS' CONCLUSIONS In this updated review, we found five studies (four new studies) that met the inclusion criteria. The review suggests that practice-based IPC interventions can improve healthcare processes and outcomes, but due to the limitations in terms of the small number of studies, sample sizes, problems with conceptualising and measuring collaboration, and heterogeneity of interventions and settings, it is difficult to draw generalisable inferences about the key elements of IPC and its effectiveness. More rigorous, cluster randomised studies with an explicit focus on IPC and its measurement, are needed to provide better evidence of the impact of practice-based IPC interventions on professional practice and healthcare outcomes. These studies should include qualitative methods to provide insight into how the interventions affect collaboration and how improved collaboration contributes to changes in outcomes.
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Affiliation(s)
- Merrick Zwarenstein
- Continuing Education, University of Toronto, Senior Scientist, Institute for Clinical Evaluative Sciences, Room G1 06, 1075 Bayview Ave, Toronto, ON, Canada, M4N 3M5
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[Functional decline during hospitalization in elderly patients. Benefits of admission to the geriatrics service]. Rev Esp Geriatr Gerontol 2008; 43:133-8. [PMID: 18682129 DOI: 10.1016/s0211-139x(08)71172-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION In some elderly individuals, hospital admission for acute illness represents a possible loss of autonomy not always related to the reason for hospitalization. The importance of this problem and the possible existence of differences among services are not sufficiently well known. OBJECTIVE To compare the incidence of functional decline and associated risk factors during hospitalization between an acute care geriatric unit (GU) and an internal medicine (IM) ward. MATERIAL AND METHODS We performed a prospective, cohort study. Sociodemographic characteristics, comorbidity, cause of admission, severity, use of several hospital practices, mortality rate and functional decline were analyzed. Functional decline was defined as the loss of independence to perform at least one of the basic activities of daily living with respect to preadmission status. The influence of the admitting service was evaluated by a multiple logistic regression model. RESULTS A total of 379 patients were included (140 in the GU and 239 in IM). Compared with IM, patients in the GU were older (87 vs 81.5; P< .001), had a greater prevalence of dementia and visual alterations and worse previous functional status. The proportion of patients who spent > 48 hours in bed and who received nocturnal medication was lower in the GU. The functional decline rate was greater in IM than in the GU (60.2% vs 48%; P=.04). Length of hospital stay was similar in both groups (7.7 vs 8.1 days; P=.37). Functional decline was associated with age, delirium, lack of mobilization, bed rest for > 48 h, psychotropic drugs, nocturnal medication and physical restraints. In the multivariate analysis, admission to IM was associated with a greater risk of functional decline. CONCLUSIONS Functional decline during hospitalization for acute diseases is frequent among frail patients. Many modifiable clinical practices are associated with this complication. In patients at risk of delirium, admission to geriatric wards may be associated with less functional deterioration than admission to internal medicine wards.
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Podrazik PM, Whelan CT. Acute hospital care for the elderly patient: its impact on clinical and hospital systems of care. Med Clin North Am 2008; 92:387-406, ix. [PMID: 18298985 DOI: 10.1016/j.mcna.2007.11.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
A significant portion of hospital care involves elderly patients who have frequent and severe disease presentations, higher risk of iatrogenic injury during hospitalization, and greater baseline vulnerability. These risks frequently result in longer and more frequent hospitalizations. The frailty and complication rates of the elderly population underscore the importance of hospital-based programs of education and screening for cognitive and functional impairments to determine risk and needed additional care and services during hospitalization and at discharge. In addition, physicians are needed to take the lead in instituting programs of prevention and improving the systems of care. It is such a multi-tiered approach, with interventions in the areas of education, screening, prevention, and systems of care improvements, that is needed to improve the clinical care and outcomes of the hospitalized elderly patient.
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Affiliation(s)
- Paula M Podrazik
- Section of Geriatrics, Department of Medicine, University of Chicago, IL 60637, USA.
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Badger N, Mullis S, Butler K, Tucker D. Pharmacist’s intervention for older hospitalized patients. Am J Health Syst Pharm 2007; 64:1794-6. [PMID: 17724358 DOI: 10.2146/ajhp070074] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- NaaDede Badger
- Department of Pharmacy, Piedmont Hospital, Atlanta, GA 30309, USA.
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Naylor MD. Advancing the science in the measurement of health care quality influenced by nurses. Med Care Res Rev 2007; 64:144S-69S. [PMID: 17406016 DOI: 10.1177/1077558707299257] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
A robust set of quality measures is essential to provide consumers with a vehicleto evaluate nurses' contributions to the care of hospitalized patients, providers, and systems with a set of nursing processes and outcomes to guide quality improvement, and insurers with indicators to reward hospitals for high quality nursing services. The processes employed by the Nursing Care Performance Measures Steering Committee convened by the National Quality Forum (NQF) in 2004 resulted in the endorsement of 15 indicators of health care quality influenced by nurses and contributed to the identification of significant gaps in measurement and priority areas for future research. This critical review of the state of the science related to health care processes and outcomes that reflect nurses' contributions to the quality of care for hospitalized patients is intended to push the boundaries in the measurement of nursing performance. Specific recommendations for future research and measure development are presented.
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Affiliation(s)
- Mary D Naylor
- University of Pennsylvania, School of Nursing, Philadelphia, Pennsylvania, USA
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Abstract
AIMS The aim of this study was to determine the association between the common geriatric syndromes and predefined adverse outcomes of hospitalization and to identify the most important independent predictors of adverse outcomes using information gained within 24 h of admission in older general medical patients. METHODS A prospective longitudinal cohort study of patients aged > or =75 years admitted to the rapid assessment medical unit in a teaching hospital was carried out. The role of geriatric syndromes in predicting outcomes was examined in univariate and multivariate models. The outcome measures were (i) length of hospital stay (LOS) of 28 days or more, (ii) institutionalization or change in residential care status to a more dependent category at discharge or during 3 months post-discharge, (iii) unplanned readmissions during 3 months and (iv) mortality in hospital or 3 months post-discharge. RESULTS The presence of geriatric syndromes was significantly associated with increased LOS and institutionalization or change in residential care status to a more dependent category. The factors most predictive of these outcomes were impaired pre-admission functional status in activities of daily living, recurrent falls, urinary incontinence and supported living arrangements. The geriatric syndromes appeared less important in predicting unplanned readmission and death. CONCLUSION The presence of geriatric syndromes in older general medical patients is an important determinant of adverse outcomes of hospitalization, particularly of LOS and admission to residential care. The predictors most useful for screening patients for these outcomes, within 24 h of admission, appear to be the presence of certain pre-existing geriatric syndromes before admission.
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Affiliation(s)
- M Anpalahan
- Western Hospital, Melbourne, Victoria, Australia.
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Siddiqi N, Stockdale R, Britton AM, Holmes J. Interventions for preventing delirium in hospitalised patients. Cochrane Database Syst Rev 2007:CD005563. [PMID: 17443600 DOI: 10.1002/14651858.cd005563.pub2] [Citation(s) in RCA: 136] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Delirium is a common mental disorder with serious adverse outcomes in hospitalised patients. It is associated with increases in mortality, physical morbidity, length of hospital stay, institutionalisation and costs to healthcare providers. A range of risk factors has been implicated in its aetiology, including aspects of the routine care and environment in hospitals. Prevention of delirium is clearly desirable from patients' and carers' perspectives, and to reduce hospital costs. Yet it is currently unclear whether interventions for prevention of delirium are effective, whether they can be successfully delivered in all environments, and whether different interventions are necessary for different groups of patients. OBJECTIVES Our primary objective was to determine the effectiveness of interventions designed to prevent delirium in hospitalised patients. We also aimed to highlight the quality and quantity of research evidence to prevent delirium in these settings. SEARCH STRATEGY We searched the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 28th September, 2005. As the searches in MEDLINE, EMBASE, CINAHL and PsycINFO for the Specialized Register would not necessarily have picked up all delirium prevention trials, these databases were searched again on 28th October, 2005. We also examined reference lists of retrieved articles, reviews and books. Experts in this field were contacted and the Internet searched for further references and to locate unpublished trials. SELECTION CRITERIA Randomised controlled trials evaluating any interventions to prevent delirium in hospitalised patients. DATA COLLECTION AND ANALYSIS Data collection and quality assessment were performed by three reviewers independently and agreement reached by consensus. MAIN RESULTS Six studies with a total of 833 participants were identified for inclusion. All were conducted in surgical settings, five in orthopaedic surgery and one in patients undergoing resection for gastric or colon cancer. Only one study of 126 hip fracture patients comparing proactive geriatric consultation with usual care was sufficiently powered to detect a difference in the primary outcome, incident delirium. Total cumulative delirium incidence during admission was reduced in the intervention group (OR 0.48 [95% CI 0.23, 0.98]; RR 0.64 [95% CI 0.37, 0.98]), suggesting a 'number needed to treat' of 5.6 patients to prevent one case. The intervention was particularly effective in preventing severe delirium. In logistic regression analyses adjusting for pre fracture dementia and Activities of Daily Living impairment, there was no reduction in effect size, OR 0.6, but this no longer remained significant [95% CI 0.3,1.3]. There was no effect on the duration of delirium episodes, length of hospital stay, and cognitive status or institutionalisation at discharge. There was also no significant difference in cumulative delirium incidence between treatment and control groups in a sub-group of 50 patients with dementia (RR 0.9 [95% CI 0.59, 1.36]). In another trial of low dose haloperidol prophylaxis, there was no difference in delirium incidence but the severity and duration of a delirium episode, and length of hospital stay were all reduced. We identified no completed studies in hospitalised medical, care of the elderly, general surgery, cancer or intensive care patients. In outcomes, no studies examined for death, use of psychotropic medication, activities of daily living, psychological morbidity, quality of life, carers or staff psychological morbidity, cost of intervention and cost to health care services. Outcomes were only reported up to discharge, with no studies reporting medium or longer-term effects. AUTHORS' CONCLUSIONS Research evidence on effectiveness of interventions to prevent delirium is sparse. Based on a single study, a programme of proactive geriatric consultation may reduce delirium incidence and severity in patients undergoing surgery for hip fracture. Prophylactic low dose haloperidol may reduce severity and duration of delirium episodes and shorten length of hospital admission in hip surgery. Further studies of delirium prevention are needed.
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Affiliation(s)
- N Siddiqi
- University of Leeds, Academic Unit Psychiatry and Behavioural Sciences, 15 Hyde Terrace, Leeds, UK, LS2 9LT.
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Michaud L, Büla C, Berney A, Camus V, Voellinger R, Stiefel F, Burnand B. Delirium: guidelines for general hospitals. J Psychosom Res 2007; 62:371-83. [PMID: 17324689 DOI: 10.1016/j.jpsychores.2006.10.004] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2006] [Revised: 09/25/2006] [Accepted: 10/03/2006] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Delirium is highly prevalent in general hospitals but remains underrecognized and undertreated despite its association with increased morbidity, mortality, and health services utilization. To enhance its management, we developed guidelines covering all aspects, from risk factor identification to preventive, diagnostic, and therapeutic interventions in adult patients. METHODS Guidelines, systematic reviews, randomized controlled trials (RCT), and cohort studies were systematically searched and evaluated. Based on a synthesis of retrieved high-quality documents, recommendation items were submitted to a multidisciplinary expert panel. Experts scored the appropriateness of recommendation items, using an evidence-based, explicit, multidisciplinary panel approach. Each recommendation was graded according to this process' results. RESULTS Rated recommendations were mostly supported by a low level of evidence (1.3% RCT and systematic reviews, 14.3% nonrandomized trials vs. 84.4% observational studies or expert opinions). Nevertheless, 71.1% of recommendations were considered appropriate by the experts. Prevention of delirium and its nonpharmacological management should be fostered. Haloperidol remains the first-choice drug, whereas the role of atypical antipsychotics is still uncertain. CONCLUSIONS While many topics addressed in these guidelines have not yet been adequately studied, an explicit panel and evidence-based approach allowed the proposal of comprehensive recommendations for the prevention and management of delirium in general hospitals.
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Affiliation(s)
- Laurent Michaud
- Clinical Epidemiology Center, Institute of Social and Preventive Medicine, University Hospital, Lausanne, Switzerland
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Abstract
BACKGROUND A high incidence of functional decline (deterioration in physical or cognitive function) during hospitalisation of older adults is reported. The role of exercise in preventing these deconditioning effects is unclear. OBJECTIVES To determine the effect of exercise interventions for acutely hospitalised older medical patients on functional status, adverse events and hospital outcomes. SEARCH STRATEGY We searched MEDLINE (1966-Feb 2006), CINAHL (1982-Feb 2006), EMBASE (1988 to Feb 2006), Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2006), PEDro (1929- Feb 2006), Current Contents (1993- Feb 2006) and Sports Discus (1830-Feb 2006). The Journal of the American Geriatrics Society was hand searched. Additional studies were identified through reference and citation tracking, personal communications with a content expert and contacting authors of eligible trials. There was no language restriction. SELECTION CRITERIA Eligible studies were prospective randomised controlled trials (RCT) or prospective controlled clinical trials (CCT) comparing exercise for acutely hospitalised older medical patients to usual care or no treatment controls. DATA COLLECTION AND ANALYSIS Two independent reviewers extracted data relating to patient and hospital outcomes and assessed the method quality of included studies. Data were pooled in meta-analysis using the relative risk (RR) and absolute risk reduction (ARR) for dichotomous outcomes and the standardised mean difference (SMD) or the weighted mean difference (WMD) for continuous outcomes. MAIN RESULTS Of 3138 potentially relevant articles screened, 7 randomised controlled trials and 2 controlled clinical trials were included. The effect of exercise on functional outcome measures is unclear. No intervention effect was found on adverse events. Pooled analysis of multidisciplinary interventions that included exercise indicated a small significant increase in the proportion of patients discharged to home at hospital discharge (Relative Risk 1.08, 95% CI 1.03 to 1.14 and Numbers Needed to Treat 16, 95% CI 11 to 43) and a small but important reduction in acute hospital length of stay (weighted mean difference, -1.08 days, 95% CI -1.93 to -0.22) and total hospital costs (weighted mean difference, -US$278.65, 95% CI -491.85 to -65.44) compared to usual care. Pooled analysis of exercise intervention trials found no effect on the proportion of patients discharged to home or acute hospital length of stay. AUTHORS' CONCLUSIONS There is 'silver' level evidence (www.cochranemsk.org) that multidisciplinary intervention that includes exercise may increase the proportion of patients discharged to home and reduce length and cost of hospital stay for acutely hospitalised older medical patients.
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Affiliation(s)
- N A de Morton
- Monash University, School of Primary Health Care, Faculty of Medicine, Nursing and Health Sciences, Peninsula Campus, PO Box 527, Frankston, Victoria, Australia, 3199.
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Jayadevappa R, Chhatre S, Weiner M, Raziano DB. Health resource utilization and medical care cost of acute care elderly unit patients. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2006; 9:186-92. [PMID: 16689713 DOI: 10.1111/j.1524-4733.2006.00099.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
OBJECTIVE In this study we compared the readmissions, medical care cost, and health resource utilization (HRU) of acute care elderly (ACE) unit patients and usual medical care patients. METHODS Retrospective case-control design was used. Patients admitted to ACE unit (n = 680) between 1999 and 2002 with primary admitting diagnosis of pneumonia, congestive heart failure, or urinary tract infection were randomly selected from the health-care system's administrative database. Equal number controls (n = 680) were selected from usual medical care services and were matched by DRG, age, ethnicity, and Charlson comorbidity score. Data on HRU, annual number of admissions before and after index admission, length of stay (LOS), and medical care cost were obtained. Bootstrap, t-test, and Wilcoxon test were used to compare cost, LOS, and number of readmissions between ACE and non-ACE unit. Multivariate log-linear and Poisson regressions were used to assess the impact of ACE unit on incremental cost and number of readmissions, respectively. RESULTS Mean LOS was 1 day shorter for ACE unit (4.9 vs. 5.9 P = 0.01). Mean cost of ACE unit was 9.7% lower than that of non-ACE unit (Dollars 13,586 vs. Dollars 15,040, P = 0.012). Both groups had similar costs of pharmacy, diagnostic and therapeutic procedures. Multiple log-linear and Poisson regression models indicated that ACE unit patients had 21% lower cost and 11% lower annual readmissions. CONCLUSIONS Our results confirm the hypotheses that ACE unit patients have lower medical care cost, shorter LOS, and fewer readmissions. Thus, ACE unit may be a beneficial model for improved inpatient care of elderly.
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Tucker D, Bechtel G, Quartana C, Badger N, Werner D, Ford I, Connelly L. The OASIS Program: Redesigning Hospital Care for Older Adults. Geriatr Nurs 2006; 27:112-7. [PMID: 16638482 DOI: 10.1016/j.gerinurse.2006.02.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
A major factor in poor outcomes for hospitalized older adults is the health care delivery system. If acute care is not designed to address their altered response to illness and treatments, functional needs, and psychosocial issues, they are at significant risk for hospital-acquired complications and loss of functionality. Each health system should develop its own acute geriatric care program based on its resources and a plan for geriatric competency for all its health care workers. The OASIS pilot was created by taking elements from programs around the country that have succeeded in reengineering care for older adults. This pilot addressed the acute care of older patients scattered across 2 medical units in a 500+ bed community hospital. Outcomes demonstrated that coordinated, geriatric specific care had a positive, measurable impact on the quality of care, costs, and provided geriatric support to physicians and hospital staff.
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Affiliation(s)
- Dee Tucker
- Gerontological Nursing in the Sixty Plus Older Adult Services, Piedmont Hospital, Atlanta, Georgia, USA
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Pitta F, Troosters T, Probst VS, Spruit MA, Decramer M, Gosselink R. Physical Activity and Hospitalization for Exacerbation of COPD. Chest 2006; 129:536-44. [PMID: 16537849 DOI: 10.1378/chest.129.3.536] [Citation(s) in RCA: 443] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Acute exacerbations (AEs) have a negative impact on various aspects of the progression of COPD, but objective and detailed data on the impact of hospitalizations for an AE on physical activity are not available. Objective and measurements: We aimed to investigate physical activity using an activity monitor (DynaPort; McRoberts; the Hague, the Netherlands), pulmonary function, muscle force, 6-min walking distance, and arterial blood gas levels in 17 patients (mean age, 69 +/- 9 years [+/- SD]; body mass index, 24 +/- 5 kg/m(2)) at the beginning and end of a hospitalization period for an AE and 1 month after discharge. RESULTS Time spent on weight-bearing activities (walking and standing) was markedly low both at day 2 and day 7 of hospitalization (median, 7%; interquartile range [IQR], 3 to 18% of the time during the day; and median, 9%; IQR, 7 to 21%, respectively) and 1 month after discharge (median, 19% [IQR, 10 to 34%]; Friedman test, p = 0.13). Time spent on weight-bearing activities was positively correlated to quadriceps force at the end of the hospitalization period (r = 0.47; p = 0.048). Patients with hospitalization for an AE in the previous year had an even lower activity level when compared to those without a recent hospitalization. In addition, patients with a lower activity level at 1 month after discharge were more likely to be readmitted in the following year. CONCLUSIONS Patients with COPD are markedly inactive during and after hospitalization for an AE. Efforts to enhance physical activity should be among the aims of the disease management during and following the AE periods.
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Affiliation(s)
- Fabio Pitta
- Respiratory Rehabilitation and Respiratory Division, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium
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