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Ling T, Basic D, Tcharkhedian E, Campisi J, Pringle B, Khoo A. Care in the Community: A COVID-19 initiative to reduce hospital re-presentations among community-dwelling people. Australas J Ageing 2024. [PMID: 39007519 DOI: 10.1111/ajag.13356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 05/12/2024] [Accepted: 06/11/2024] [Indexed: 07/16/2024]
Abstract
OBJECTIVE The COVID-19 pandemic has had a substantial impact on the utilisation of hospital and emergency department (ED) services. We examined the effect of a rapid response service on hospital re-presentations among people discharged from the ED and short-stay wards at a tertiary referral hospital. METHODS This retrospective cohort study compared 112 patients who completed the Care in the Community program with 112 randomly selected controls. Both cases and controls were discharged from hospital between September 2020 and June 2021. Intervention patients were evaluated by a multidisciplinary team, who implemented a goal-directed program of up to 4-weeks duration. Logistic regression, negative binomial regression and Cox proportional hazards regression were used to evaluate outcomes at 28 days and at 6 months. RESULTS The median time between referral and the first home visit was 3.9 days. In adjusted analyses, the intervention reduced hospital re-presentations at 28 days (odds ratio: .40, 95% confidence interval (CI): .17-.94) and lengthened the time to the first hospital re-presentation (hazard ratio: .59, 95% CI: .38-.92). Although the intervention did not reduce the total number of hospital re-presentations at 6 months (adjusted incidence rate ratio: .73, 95% CI: .49-1.08), it reduced total time spent in hospital by 303 days (582 vs. 885). CONCLUSIONS This study is among the first to investigate the effect of a community-based intervention on hospital re-presentations during the COVID-19 pandemic. It provides evidence that a sustainable 4-week intervention is associated with reduced hospital re-presentations and time spent in hospital.
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Affiliation(s)
- Tammy Ling
- Department of Geriatric Medicine, Liverpool Hospital, Sydney, New South Wales, Australia
| | - David Basic
- Department of Geriatric Medicine, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Elise Tcharkhedian
- Department of Physiotherapy, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Josephine Campisi
- Department of Occupational Therapy, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Bernadette Pringle
- Aged Care Services Emergency Team, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Angela Khoo
- Department of Geriatric Medicine, Liverpool Hospital, Sydney, New South Wales, Australia
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Pietrantonio F, Florczak M, Kuhn S, Kärberg K, Leung T, Said Criado I, Sikorski S, Ruggeri M, Signorini A, Rosiello F, Drago C, Vinci A, Barreto V, Montano N, Dicker D, Gomez Huelgas R. Applications to augment patient care for Internal Medicine specialists: a position paper from the EFIM working group on telemedicine, innovative technologies & digital health. Front Public Health 2024; 12:1370555. [PMID: 39005984 PMCID: PMC11239350 DOI: 10.3389/fpubh.2024.1370555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 05/24/2024] [Indexed: 07/16/2024] Open
Abstract
Telemedicine applications present virtually limitless prospects for innovating and enhancing established and new models of patient care in the field of Internal Medicine. Although there is a wide range of innovative technological solutions in Europe, there are overarching elements associated with such technologies when applied to the practices of Internal Medicine specialists. The European Federation of Internal Medicine (EFIM) strongly advocates for active leadership and influence from the Internal Medicine societies and specialist physicians across Europe in the development and application of telemedicine and digital technologies in healthcare. This position paper's conclusions were drawn via Delphi method, which was developed collaboratively from July 2021 to December 2023. The panel, consisting of experts in clinical medicine, public health, health economics and statistics, assessed various aspects related to telemedicine. Participants assigned scores on a Likert scale reflecting perceived value and potential risks. The findings were consolidated in a comprehensive checklist aligning with relevant literature and a SWOT analysis. Specifically, key issues that need to be addressed include promoting the professional development of e-health competencies in the healthcare and medical workforce, using educational campaigns to promote digital literacy among patients and caregivers, designing and implementing telemedicine applications tailored to local conditions and needs and considering the ethical and legal contexts under which these applications are employed. Importantly, there is currently no consensus on care models or standardized protocols among European Internal Medicine specialists regarding the utilization of telemedicine. This position paper aims to outline the opportunities and challenges associated with the application of telemedicine in Internal Medical practice in Europe.
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Affiliation(s)
- F Pietrantonio
- Medical Area Department, Internal Medicine Unit, Castelli Hospital, Rome, Italy
- Saint Camillus International University of Health Sciences, Rome, Italy
| | - M Florczak
- Department of Immunology, Transplantology and Internal Medicine. Medical University of Warsaw, Warsaw, Poland
| | - S Kuhn
- Institute of Digital Medicine, University Hospital of Giessen and Marburg, Phillips-University Marburg, Marburg, Germany
| | - K Kärberg
- Department of Internal Medicine, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - T Leung
- Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands
- Department of Internal Medicine (Adjunct), Southern Illinois University School of Medicine, Springfield, IL, United States
| | - I Said Criado
- Palliative Care Unit, Internal Medicine Department, Pontevedra-El Salnés Healthcare Area, Institute of Healthcare Research, Vigo, Spain
| | - S Sikorski
- Institute of Law Studies, Faculty of Law and Administration, Cardinal Stefan Wyszyński University in Warsaw, Warsaw, Poland
| | - M Ruggeri
- Saint Camillus International University of Health Sciences, Rome, Italy
| | - A Signorini
- Saint Camillus International University of Health Sciences, Rome, Italy
| | - F Rosiello
- Saint Camillus International University of Health Sciences, Rome, Italy
- Department of Public Health and Infectious Disease, Sapienza-University of Rome, Rome, Italy
| | - C Drago
- University Niccolò Cusano. Department of Economics, Psichology and Communication Sciences, Rome, Italy
| | - A Vinci
- Local Health Authority ASL Roma 1, Health Management Unit, Rome, Italy
| | - V Barreto
- Pedro Hispano Hospital, Porto, Portugal
| | - N Montano
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - D Dicker
- Internal Medicine Department and Obesity Clinic, Hasharon Hospital, Rabin Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - R Gomez Huelgas
- Internal Medicine Department, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), University of Málaga, Málaga, Spain
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Greene L, Crotty M, Whitehead C, Rahja M, Murad J, Dang K, Partington A, Laver K. Assessing the reach and safety of an innovative urgent care service tailored to older adults. Australas J Ageing 2024; 43:387-393. [PMID: 38268230 DOI: 10.1111/ajag.13267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 11/02/2023] [Accepted: 11/19/2023] [Indexed: 01/26/2024]
Abstract
Traditional emergency departments (EDs) are overcrowded and sometimes not suitable for older adults with complex needs. Specialised geriatric urgent care pathways for selected patients can alleviate ED demand and improve patient experience. To address urgent care needs for older adults in Southern Adelaide, the Complex And RestorativE (CARE) service was established. CARE offers alternative, geriatrician-led treatment pathways consisting of a ward-based treatment centre and an in-home visiting team called Eyes on Scene (EoS). Both pathways offer medical, nursing and allied health treatment. Routinely collected clinical data were analysed to explore the reach of the service and the incidence and nature of adverse events. Between September 2021 and March 2023, the CARE service attended to 5324 older adults requiring urgent care. A significant proportion of patients were discharged to or remained in their regular place of residence, with few requiring inpatient admissions or referrals to other facilities. A total of 7% of patients required transfer to ED and adverse events were rare. The CARE service demonstrates a feasible and safe alternative model of urgent care for older Australians.
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Affiliation(s)
- Leanne Greene
- Rehabilitation, Aged and Extended Care, Flinders University, Adelaide, South Australia, Australia
| | - Maria Crotty
- Rehabilitation, Aged and Extended Care, Flinders University, Adelaide, South Australia, Australia
| | - Craig Whitehead
- Rehabilitation, Aged and Extended Care, Flinders University, Adelaide, South Australia, Australia
| | - Miia Rahja
- Rehabilitation, Aged and Extended Care, Flinders University, Adelaide, South Australia, Australia
| | - Javaria Murad
- The Complex and RestorativE (CARE) Service, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Kwok Dang
- The Complex and RestorativE (CARE) Service, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Andrew Partington
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia
| | - Kate Laver
- Rehabilitation, Aged and Extended Care, Flinders University, Adelaide, South Australia, Australia
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Ronksley PE, Scory TD, McRae AD, MacRae JM, Manns BJ, Lang E, Donald M, Hemmelgarn BR, Elliott MJ. Emergency Department Use Among Adults Receiving Dialysis. JAMA Netw Open 2024; 7:e2413754. [PMID: 38809552 PMCID: PMC11137633 DOI: 10.1001/jamanetworkopen.2024.13754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/27/2024] [Indexed: 05/30/2024] Open
Abstract
Importance People with kidney failure receiving maintenance dialysis visit the emergency department (ED) 3 times per year on average, which is 3- to 8-fold more often than the general population. Little is known about the factors that contribute to potentially preventable ED use in this population. Objective To identify the clinical and sociodemographic factors associated with potentially preventable ED use among patients receiving maintenance dialysis. Design, Setting, and Participants This cohort study used linked administrative health data within the Alberta Kidney Disease Network to identify adults aged 18 years or older receiving maintenance dialysis (ie, hemodialysis or peritoneal dialysis) between April 1, 2010, and March 31, 2019. Patients who had been receiving dialysis for more than 90 days were followed up from cohort entry (defined as dialysis start date plus 90 days) until death, outmigration from the province, receipt of a kidney transplant, or end of study follow-up. The Andersen behavioral model of health services was used as a conceptual framework to identify variables related to health care need, predisposing factors, and enabling factors. Data were analyzed in March 2024. Main Outcomes and Measures Rates of all-cause ED encounters and potentially preventable ED use associated with 4 kidney disease-specific ambulatory care-sensitive conditions (hyperkalemia, heart failure, volume overload, and malignant hypertension) were calculated. Multivariable negative binomial regression models were used to examine the association between clinical and sociodemographic factors and rates of potentially preventable ED use. Results The cohort included 4925 adults (mean [SD] age, 60.8 [15.5] years; 3071 males [62.4%]) with kidney failure receiving maintenance hemodialysis (3183 patients) or peritoneal dialysis (1742 patients) who were followed up for a mean (SD) of 2.5 (2.0) years. In all, 3877 patients had 34 029 all-cause ED encounters (3100 [95% CI, 2996-3206] encounters per 1000 person-years). Of these, 755 patients (19.5%) had 1351 potentially preventable ED encounters (114 [95% CI, 105-124] encounters per 1000 person-years). Compared with patients with a nonpreventable ED encounter, patients with a potentially preventable ED encounter were more likely to be in the lowest income quintile (38.8% vs 30.9%; P < .001); to experience heart failure (46.8% vs 39.9%; P = .001), depression (36.6% vs 32.5%; P = .03), and chronic pain (60.1% vs 54.9%; P = .01); and to have a longer duration of dialysis (3.6 vs 2.6 years; P < .001). In multivariable regression analyses, potentially preventable ED use was higher for younger adults (incidence rate ratio [IRR], 1.69 [95% CI, 1.33-2.15] for those aged 18 to 44 years) and patients with chronic pain (IRR, 1.35 [95% CI, 1.14-1.61]), greater material deprivation (IRR, 1.57 [95% CI, 1.16-2.12]), a history of hyperkalemia (IRR, 1.31 [95% CI, 1.09-1.58]), and historically high ED use (ie, ≥3 ED encounters in the prior year; IRR, 1.46 [95% CI, 1.23-1.73). Conclusions and Relevance In this study of adults receiving maintenance dialysis in Alberta, Canada, among those with ED use, 1 in 5 had a potentially preventable ED encounter; reasons for such encounters were associated with both psychosocial and medical factors. The findings underscore the need for strategies that address social determinants of health to avert potentially preventable ED use in this population.
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Affiliation(s)
- Paul E. Ronksley
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Tayler D. Scory
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrew D. McRae
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer M. MacRae
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Braden J. Manns
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Eddy Lang
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Maoliosa Donald
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brenda R. Hemmelgarn
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Meghan J. Elliott
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
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Memedovich A, Asante B, Khan M, Eze N, Holroyd BR, Lang E, Kashuba S, Clement F. Strategies for improving ED-related outcomes of older adults who seek care in emergency departments: a systematic review. Int J Emerg Med 2024; 17:16. [PMID: 38302890 PMCID: PMC10835906 DOI: 10.1186/s12245-024-00584-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 01/12/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND Despite constituting 14% of the general population, older adults make up almost a quarter of all emergency department (ED) visits. These visits often do not adequately address patient needs, with nearly 80% of older patients discharged from the ED carrying at least one unattended health concern. Many interventions have been implemented and tested in the ED to care for older adults, which have not been recently synthesized. METHODS A systematic review was conducted to identify interventions initiated in the ED to address the needs of older adults. Embase, MEDLINE, CINAHL, Cochrane CENTRAL, the Cochrane Database of Systematic Reviews, and grey literature were searched from January 2013 to January 18, 2023. Comparative studies assessing interventions for older adults in the ED were included. The quality of controlled trials was assessed with the Cochrane risk-of-bias tool for randomized trials, and the quality of observational studies was assessed with the risk of bias in non-randomized studies of interventions tool. Due to heterogeneity, meta-analysis was not possible. RESULTS Sixteen studies were included, assessing 12 different types of interventions. Overall study quality was low to moderate: 10 studies had a high risk of bias, 5 had a moderate risk of bias, and only 1 had a low risk of bias. Follow-up telephone calls, referrals, geriatric assessment, pharmacist-led interventions, physical therapy services, care plans, education, case management, home visits, care transition interventions, a geriatric ED, and care coordination were assessed, many of which were combined to create multi-faceted interventions. Care coordination with additional support and early assessment and intervention were the only two interventions that consistently reported improved outcomes. Most studies did not report significant improvements in ED revisits, hospitalization, time spent in the ED, costs, or outpatient utilization. Two studies reported on patient perspectives. CONCLUSION Few interventions demonstrate promise in reducing ED revisits for older adults, and this review identified significant gaps in understanding other outcomes, patient perspectives, and the effectiveness in addressing underlying health needs. This could suggest, therefore, that most revisits in this population are unavoidable manifestations of frailty and disease trajectory. Efforts to improve older patients' needs should focus on interventions initiated outside the ED.
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Affiliation(s)
- Ally Memedovich
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Benedicta Asante
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Maha Khan
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Nkiruka Eze
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Brian R Holroyd
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada
- Emergency Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
| | - Eddy Lang
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
- Emergency Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
- O'Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada
| | - Sherri Kashuba
- Emergency Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
| | - Fiona Clement
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
- O'Brien Institute of Public Health, University of Calgary, Calgary, AB, Canada.
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Stuckenschneider T, Schmidt L, Speckmann EM, Koschate J, Zieschang T. Recruiting patients for falls prevention in the emergency department - worth the challenge. BMC Geriatr 2023; 23:880. [PMID: 38129767 PMCID: PMC10740331 DOI: 10.1186/s12877-023-04607-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 12/16/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Severe falls escalate the risk of future falls and functional decline as indicated by recent global guidelines. To establish effective falls prevention, individuals at highest risk must be thoroughly studied and, therefore, successfully recruited. OBJECTIVE Recruiting from an emergency department (ED) may mitigate common selection biases, such as overrepresentation of individuals with a higher social status and healthier lifestyle. However, this approach presents unique challenges due to ED-specific conditions. Hence, we present the successes and challenges of an ED-based recruitment for an observational study. METHODS The SeFallED study targets older adults aged ≥60 years, who present to either of two hospitals in Oldenburg after a fall without subsequent admission. A study nurse addressed individuals in the EDs. Subsequently, potential participants were contacted by phone to arrange a home visit for obtaining written consent. Data of participants were compared with total admissions during the recruitment period to determine recruitment rate and compare patients' characteristics. RESULTS Over 1.500 individuals met the inclusion criteria. Of these, 288 participants were successfully recruited. Most patients presented to the ED outside of the study team's working hours, and some opted not to participate (main reason: too unwell (40%)). Compared to working hours, a participant was recruited every 14 h. Comparing characteristics, a trend towards better health and younger age was observed. CONCLUSION ED-based recruitment offers the opportunity to include more diverse individuals in falls prevention. To achieve adequate sample sizes, flexibility in working days and hours of the research team are obligatory. TRIAL REGISTRATION DRKS00025949.
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Affiliation(s)
- Tim Stuckenschneider
- Department for Health Services Research, Geriatric Medicine, School of Medicine and Health Services, Carl von Ossietzky University, Ammerländer Heerstraße 114-118, Lower Saxony, 26129, Oldenburg, Germany.
| | - Laura Schmidt
- Department for Health Services Research, Geriatric Medicine, School of Medicine and Health Services, Carl von Ossietzky University, Ammerländer Heerstraße 114-118, Lower Saxony, 26129, Oldenburg, Germany
| | - Elisa-Marie Speckmann
- Department for Health Services Research, Geriatric Medicine, School of Medicine and Health Services, Carl von Ossietzky University, Ammerländer Heerstraße 114-118, Lower Saxony, 26129, Oldenburg, Germany
| | - Jessica Koschate
- Department for Health Services Research, Geriatric Medicine, School of Medicine and Health Services, Carl von Ossietzky University, Ammerländer Heerstraße 114-118, Lower Saxony, 26129, Oldenburg, Germany
| | - Tania Zieschang
- Department for Health Services Research, Geriatric Medicine, School of Medicine and Health Services, Carl von Ossietzky University, Ammerländer Heerstraße 114-118, Lower Saxony, 26129, Oldenburg, Germany
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Jones A, Watt JA, Maclagan LC, Swayze S, Jaakkimainen L, Schull MJ, Bronskill SE. Factors associated with recurrent emergency department visits among people living with dementia: A retrospective cohort study. J Am Geriatr Soc 2023; 71:3731-3743. [PMID: 37314108 DOI: 10.1111/jgs.18457] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/12/2023] [Accepted: 05/14/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Research on factors associated with recurrent emergency department (ED) visits and their implications for improving dementia care is lacking. The objective of this study was to examine associations between the individual characteristics of older adults living with dementia and recurrent ED visits. METHODS We used health administrative databases to conduct a population-based retrospective cohort study among older adults with dementia in Ontario, Canada. We included community-dwelling adults 66 years and older who visited the ED between April 1, 2010, and March 31, 2019 and were discharged home. We recorded all ED visits within one year after the baseline visit. We used recurrent event Cox regression to examine associations between repeat ED visits and individual clinical, demographic, and health service use characteristics. We fit conditional inference trees to identify the most important factors and define subgroups of varying risk. RESULTS Our cohort included 175,863 older adults with dementia. ED use in the year prior to baseline had the strongest association with recurrent visits (3+ vs.0 adjusted hazard ratio (aHR): 1.92 (1.89, 1.94), 2vs.0 aHR: 1.45 (1.43, 1.47), 1vs.0 aHR: 1.23 (1.21, 1.24)). The conditional inference tree utilized history of ED visits and comorbidity count to define 12 subgroups with ED revisit rates ranging from 0.79 to 7.27 per year. Older adults in higher risk groups were more likely to live in rural and low-income areas and had higher use of anticonvulsants, antipsychotics, and benzodiazepines. CONCLUSIONS History of ED visits may be a useful measure to identify older adults with dementia who would benefit from additional interventions and supports. A substantial proportion of older adults with dementia have a pattern of recurrent visits and may benefit from dementia-friendly and geriatric-focused EDs. Collaborative medication review in the ED and closer follow-up and engagement with community supports could improve patient care and experience.
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Affiliation(s)
- Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Jennifer A Watt
- ICES, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Liisa Jaakkimainen
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Michael J Schull
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Susan E Bronskill
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
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8
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Chiu WY, Yeh TC, Yang CC. Factors Associated With Emergency Department Visits Among Patients Receiving Publicly-Funded Homecare Services: A Retrospective Chart Review From Southern Taiwan Regional Hospital. Int J Health Policy Manag 2023; 12:7377. [PMID: 38618794 PMCID: PMC10699816 DOI: 10.34172/ijhpm.2023.7377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 09/25/2023] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND The public health strategy of increasing access to comprehensive home or community-based healthcare services and emergency home visits is intent on reducing the overcrowding of emergency departments. However, scientific evidence regarding the association between home-based healthcare services and emergency department uses is surprisingly insufficient and controversial so far. The present retrospective study identified the risk factors for emergency department visits among patients receiving publicly-funded homecare services. METHODS The personal demographic and medical information, caregiver characteristics, and behaviours related to homecare services and emergency department visits from the medical records and structured questionnaires of 108 patients who were recipients of integrated homecare services in a regional hospital in southern Taiwan between January 1, 2020, and December 31, 2020, were collected. After screening the potential predictor variables using the preliminary univariate analyses, the multivariate logistic regression with best subset selection approach was conducted to identify best combination of determinants to predict unplanned emergency department utilizations. RESULTS Best subset selection regression analysis showed Charlson Comorbidity Index (odds ratio (OR)=1.33, 95% CI=1.05 to 1.70), male caregiver (OR=0.18, 95% CI=0.05 to 0.66), duration of introducing homecare services (OR=0.97, 95% CI=0.95 to 1.00), working experience of dedicated nurses (OR=0.89, 95% CI=0.79 to 0.99) and number of emergency department utilizations within previous past year before enrollment (OR=1.54, 95% CI=1.14 to 2.10) as significant determinants for unplanned emergency department visits. CONCLUSIONS The present evidence may help government agencies propose supportive policies to improve access to integrated homecare resources and promote appropriate care recommendations to reduce unplanned or nonurgent emergency department visits among patients receiving homecare services.
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Affiliation(s)
- Wen-Yi Chiu
- Department of Family Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
- The Master Program of Long-Term Care in Aging, College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ta-Chuan Yeh
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chia-Chi Yang
- The Master Program of Long-Term Care in Aging, College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan
- Center for Long-Term Care Research, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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Lønhaug-Næss M, Jakobsen MD, Blix BH, Bergmo TS, Hoben M, Moholt JM. Older high-cost patients in Norwegian somatic hospitals: a register-based study of patient characteristics. BMJ Open 2023; 13:e074411. [PMID: 37793934 PMCID: PMC10551970 DOI: 10.1136/bmjopen-2023-074411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 09/13/2023] [Indexed: 10/06/2023] Open
Abstract
OBJECTIVE Two-thirds of the economic resources in Norwegian hospitals are used on 10% of the patients. Most of these high-cost patients are older adults, which experience more unplanned hospital admissions, longer hospital stays and higher readmission rates than other patients. This study aims to examine the individual and clinical characteristics of older patients with unplanned admissions to Norwegian somatic hospitals and how these characteristics differ between high-cost and low-cost older patients. DESIGN Observational cross-sectional study. SETTING Norwegian somatic hospitals. PARTICIPANTS National registry data of older Norwegian patients (≥65 years) with ≥1 unplanned contact with somatic hospitals in 2019 (n=2 11 738). PRIMARY OUTCOME MEASURE High-cost older patients were defined as those within the 10% of the highest diagnosis-related group weights in 2019 (n=21 179). We compared high-cost to low-cost older patients using bivariate analyses and logistic regression analysis. RESULTS Men were more likely to be high-cost older patients than women (OR=1.25, 95% CI 1.21 to 1.29) and the oldest (90+ years) compared with the youngest older adults (65-69 years) were less likely to cause high costs (OR=0.47, 95% CI 0.43 to 0.51). Those with the highest level of education were less likely to cause high costs than those with primary school degrees (OR=0.74, 95% CI 0.69 to 0.80). Main diagnosis group (OR=3.50, 95% CI 3.37 to 3.63) and dying (OR=4.13, 95% CI 3.96 to 4.30) were the clinical characteristics most strongly associated with the likelihood of being a high-cost older patient. CONCLUSION Several of the observed patient characteristics in this study may warrant further investigation as they might contribute to high healthcare costs. For example, MDGs, reflecting comprehensive healthcare needs and lower education, which is associated with poorer health status, increase the likelihood of being high-cost older patients. Our results indicate that Norwegian hospitals function according to the intentions of those having the highest needs receiving most services.
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Affiliation(s)
- Morten Lønhaug-Næss
- Department of Health and Care Sciences, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromso, Norway
| | - Monika Dybdahl Jakobsen
- Department of Health and Care Sciences, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromso, Norway
- Center for Care Research North, UiT The Arctic University of Norway, Tromso, Norway
| | - Bodil Hansen Blix
- Department of Health and Care Sciences, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromso, Norway
- Western Norway University of Applied Sciences, Bergen, Norway
| | - Trine Strand Bergmo
- Department of Pharmacy, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromso, Norway
- Digital Health Services, Norwegian Center for E-health Research, Tromso, Norway
| | - Matthias Hoben
- Faculty of Health, School of Health Policy & Management, York University, Toronto, Ontario, Canada
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Jill-Marit Moholt
- Department of Health and Care Sciences, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromso, Norway
- Center for Care Research North, UiT The Arctic University of Norway, Tromso, Norway
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Kurteva S, Abrahamowicz M, Beauchamp ME, Tamblyn R. Comparison of Different Modeling Approaches for Prescription Opioid Use and Its Association With Adverse Events. Am J Epidemiol 2023; 192:1592-1603. [PMID: 37191340 PMCID: PMC10472496 DOI: 10.1093/aje/kwad115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 01/30/2023] [Accepted: 05/05/2023] [Indexed: 05/17/2023] Open
Abstract
Previous research linking opioid prescribing to adverse drug events has failed to properly account for the time-varying nature of opioid exposure. This study aimed to explore how the risk of opioid-related emergency department visits, readmissions, or deaths (composite outcome) varies with opioid dose and duration, comparing different novel modeling techniques. A prospective cohort of 1,511 hospitalized patients discharged from 2 McGill-affiliated hospitals in Montreal, 2014-2016, was followed from the first postdischarge opioid dispensation until 1 year after discharge. Marginal structural Cox proportional hazards models and their flexible extensions were used to explore the association between time-varying opioid use and the composite outcome. Weighted cumulative exposure models assessed cumulative effects of past use and explored how its impact depends on the recency of exposure. The patient mean age was 69.6 (standard deviation = 14.9) years; 57.7% were male. In marginal structural model analyses, current opioid use was associated with a 71% increase in the hazard of opioid-related adverse events (adjusted hazard ratio = 1.71, 95% confidence interval: 1.21, 2.43). The weighted cumulative exposure results suggested that the risk cumulates over the previous 50 days of opioid consumption. Flexible modeling techniques helped assess how the risk of opioid-related adverse events may be associated with time-varying opioid exposures while accounting for nonlinear relationships and the recency of past use.
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Affiliation(s)
- Siyana Kurteva
- Correspondence to Siyana Kurteva, Clinical and Health Informatics Research Group, Department of Medicine, McGill University, 2001 McGill College Avenue, Suite 1200, Montreal Quebec, H3A 1A3, Canada (e-mail: )
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Kurteva S, Tamblyn R, Meguerditchian AN. Predictors of frequent emergency department visits among hospitalized cancer patients: a comparative cohort study using integrated clinical and administrative data to improve care delivery. BMC Health Serv Res 2023; 23:887. [PMID: 37608371 PMCID: PMC10464437 DOI: 10.1186/s12913-023-09854-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 07/27/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Frequent emergency department (FED) visits by cancer patients represent a significant burden to the health system. This study identified determinants of FED in recently hospitalized cancer patients, with a particular focus on opioid use. METHODS A prospective cohort discharged from surgical/medical units of the McGill University Health Centre was assembled. The outcome was FED use (≥ 4 ED visits) within one year of discharge. Data retrieved from the universal health insurance system was analyzed using Cox Proportional Hazards (PH) model, adopting the Lunn-McNeil approach for competing risk of death. RESULTS Of 1253 patients, 14.5% became FED users. FED use was associated with chemotherapy one-year pre-admission (adjusted hazard ratio (aHR) 2.60, 95% CI: 1.80-3.70), ≥1 ED visit in the previous year (aHR: 1.80, 95% CI 1.20-2.80), ≥15 pre-admission ambulatory visits (aHR 1.54, 95% CI 1.06-2.34), previous opioid and benzodiazepine use (aHR: 1.40, 95% CI: 1.10-1.90 and aHR: 1.70, 95% CI: 1.10-2.40), Charlson Comorbidity Index ≥ 3 (aHR: 2.0, 95% CI: 1.2-3.4), diabetes (aHR: 1.60, 95% CI: 1.10-2.20), heart disease (aHR: 1.50, 95% CI: 1.10-2.20) and lung cancer (aHR: 1.70, 95% CI: 1.10-2.40). Surgery (cardiac (aHR: 0.33, 95% CI: 0.16-0.66), gastrointestinal (aHR: 0.34, 95% CI: 0.14-0.82) and thoracic (aHR: 0.45, 95% CI: 0.30-0.67) led to a decreased risk of FED use. CONCLUSIONS Cancer patients with higher co-morbidity, frequent use of the healthcare system, and opioid use were at increased risk of FED use. High-risk patients should be flagged for preventive intervention.
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Affiliation(s)
- Siyana Kurteva
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada.
- Clinical and Health Informatics Research Group, McGill University, Montreal, Canada.
- Department of Science, Aetion, Inc, New York, USA.
- Clinical & Health Informatics Research Group, Department of Medicine, McGill University, 2001 McGill College Avenue, Suite 1200, H3A 1G1, Montreal, Canada.
| | - Robyn Tamblyn
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada
- Clinical and Health Informatics Research Group, McGill University, Montreal, Canada
- Department of Medicine, McGill University Health Center, Montreal, Canada
- McGill University Health Centre, Montreal, Canada
| | - Ari N Meguerditchian
- Clinical and Health Informatics Research Group, McGill University, Montreal, Canada
- Department of Surgery, McGill University Health Center, Montreal, Canada
- Center for Outcomes Research and Evaluation, McGill University Health Centre, Montreal, Canada
- St. Mary's Research Centre, Montreal, Canada
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Bime C, Wang Y, Carr G, Swearingen D, Kou S, Thompson P, Kusupati V, Parthasarathy S. Disparities in outcomes of COVID-19 hospitalizations in native American individuals. Front Public Health 2023; 11:1220582. [PMID: 37649785 PMCID: PMC10465166 DOI: 10.3389/fpubh.2023.1220582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/17/2023] [Indexed: 09/01/2023] Open
Abstract
Objectives This study aimed to investigate COVID-19-related disparities in clinical presentation and patient outcomes in hospitalized Native American individuals. Methods The study was performed within 30 hospitals of the Banner Health system in the Southwest United States and included 8,083 adult patients who tested positive for SARS-CoV-2 infection and were hospitalized between 1 March 2020 and 4 September 2020. Bivariate and multivariate analyses were used to assess racial and ethnic differences in clinical presentation and patient outcomes. Results COVID-19-related hospitalizations in Native American individuals were over-represented compared with non-Hispanic white individuals. Native American individuals had fewer symptoms at admission; greater prevalence of chronic lung disease in the older adult; two times greater risk for ICU admission despite being younger; and 20 times more rapid clinical deterioration warranting ICU admission. Compared with non-Hispanic white individuals, Native American individuals had a greater prevalence of sepsis, were more likely to require invasive mechanical ventilation, had a longer length of stay, and had higher in-hospital mortality. Conclusion Native American individuals manifested greater case-fatality rates following hospitalization than other races/ethnicities. Atypical symptom presentation of COVID-19 included a greater prevalence of chronic lung disease and a more rapid clinical deterioration, which may be responsible for the observed higher hospital mortality, thereby underscoring the role of pulmonologists in addressing such disparities.
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Affiliation(s)
- Christian Bime
- Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Department of Medicine, University of Arizona, Tucson, AZ, United States
| | - Ying Wang
- Department of Informatics Technology, Banner Health, Phoenix, AZ, United States
| | - Gordon Carr
- Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Department of Medicine, University of Arizona, Tucson, AZ, United States
- Department of Medicine, University of Arizona College of Medicine, Tucson, AZ, United States
| | - Dennis Swearingen
- Department of Biomedical Informatics, University of Arizona College of Medicine, Phoenix, AZ, United States
- Department of Medical Informatics, Banner Health, Phoenix, AZ, United States
| | - Sherri Kou
- Department of Informatics Technology, Banner Health, Phoenix, AZ, United States
| | - Pam Thompson
- Department of Academic and Facilities Research, Banner Health, Phoenix, AZ, United States
| | - Vinita Kusupati
- Division of General Internal Medicine, Department of Medicine, University of Arizona, Tucson, AZ, United States
| | - Sairam Parthasarathy
- Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Department of Medicine, University of Arizona, Tucson, AZ, United States
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Smeekes OS, Willems HC, Blomberg I, Buurman BM. A causal loop diagram of older persons' emergency department visits and interactions of its contributing factors: a group model building approach. Eur Geriatr Med 2023; 14:837-849. [PMID: 37391681 PMCID: PMC10447269 DOI: 10.1007/s41999-023-00816-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/05/2023] [Indexed: 07/02/2023]
Abstract
PURPOSE Understanding the etiology of older persons' emergency department (ED) visits is highly needed. Many contributing factors have been identified, however, the role their interactions play remains unclear. Causal loop diagrams (CLDs), as conceptual models, can visualize these interactions and therefore may elucidate their role. This study aimed to better understand why people older than 65 years of age visit the ED in Amsterdam by capturing the interactions of contributing factors as perceived by an expert group in a CLD through group model building (GMB). METHODS Six qualitative online focus group like sessions, known as GMB, were conducted with a purposefully recruited interdisciplinary expert group of nine that resulted in a CLD that depicted their shared view. RESULTS The CLD included four direct contributing factors, 29 underlying factors, 66 relations between factors and 18 feedback loops. The direct factors included, 'acute event', 'frailty', 'functioning of the healthcare professional' and 'availability of alternatives for the ED'. All direct factors showed direct as well as indirect contribution to older persons' ED visits in the CLD through interaction. CONCLUSION Functioning of the healthcare professional and availability of alternatives for the ED were considered pivotal factors, together with frailty and acute event. These factors, as well as many underlying factors, showed extensive interaction in the CLD, thereby contributing directly and indirectly to older persons' ED visits. This study helps to better understand the etiology of older persons' ED visits and in specific the way contributing factors interact. Furthermore, its CLD can help to find solutions for the increasing numbers of older adults in the ED.
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Affiliation(s)
- Oscar S Smeekes
- Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Hanna C Willems
- Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Ilse Blomberg
- Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Bianca M Buurman
- Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Medicine for Older People, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, De Boelelaan 117, Amsterdam, The Netherlands
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Furia G, Vinci A, Colamesta V, Papini P, Grossi A, Cammalleri V, Chierchini P, Maurici M, Damiani G, De Vito C. Appropriateness of frequent use of emergency departments: A retrospective analysis in Rome, Italy. Front Public Health 2023; 11:1150511. [PMID: 37081951 PMCID: PMC10110884 DOI: 10.3389/fpubh.2023.1150511] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 02/28/2023] [Indexed: 04/07/2023] Open
Abstract
BackgroundFrequent users (FUs) are patients who repeatedly and inappropriately visit the emergency department (ED) for low-grade symptoms that could be treated outside the hospital setting. This study aimed to investigate the phenomenon of the FU in Rome by profiling such users and analyzing ED attendance by FUs.MethodsThe analysis was carried out for attendance in 2021 at 15 EDs in the Local Health Authority Roma 1 geographical area. A digital app collected data, including information on the following variables: number of attendance, demographic characteristics, emergency medical service (EMS) usage, triage code, and appropriateness of attendance. COVID-19 diagnosis was also studied to analyze any possible influence on ED attendance. Differences between FUs and non-FUs were investigated statistically by t-test and chi-square test. Univariate analysis and multivariable logistic regression were performed to analyze the associated factors.ResultsA total of 122,762 ED attendance and 89,036 users were registered. The FU category represented 2.9% of all users, comprising 11.9% of total ED attendance. There was a three times higher frequency of non-urgent codes in attendance of FU patients (FU: 9.7%; non-FU: 3.2%). FUs were slightly more likely to have used the EMS (13.6% vs. 11.4%) and had a lower frequency of appropriate ED attendance (23.8% vs. 27.0%). Multivariate logistic analysis confirmed a significant effect of triage code, gender, age, EMS usage, and COVID-19 diagnosis for the appropriateness of attendance. The results were statistically significant (p < 0.001).ConclusionThe FU profile describes mostly non-urgent and inappropriate attendance at the ED, including during the COVID-19 pandemic. This study represents an important tool for strengthening preventive policies outside the hospital setting. The Italian National Recovery and Resilience Plan represents an excellent opportunity for the development of new strategies to mitigate the phenomenon of FUs.
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Affiliation(s)
- Giuseppe Furia
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
- Local Health Authority Roma 1, Borgo Santo Spirito, Rome, Italy
- *Correspondence: Giuseppe Furia
| | - Antonio Vinci
- Local Health Authority Roma 1, Borgo Santo Spirito, Rome, Italy
- Nursing Sciences and Public Health, University of Rome “Tor Vergata”, Rome, Italy
| | | | - Paolo Papini
- Local Health Authority Roma 1, Borgo Santo Spirito, Rome, Italy
| | - Adriano Grossi
- Local Health Authority Roma 1, Borgo Santo Spirito, Rome, Italy
| | - Vittoria Cammalleri
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | | | - Massimo Maurici
- Department of Biomedicine and Prevention, University of Rome “Tor Vergata”, Rome, Italy
| | - Gianfranco Damiani
- Section of Hygiene, University Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Corrado De Vito
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
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Ng CJ, Chien LT, Huang CH, Chaou CH, Gao SY, Chiu SYH, Hsu KH, Chien CY. Integrating the clinical frailty scale with emergency department triage systems for elder patients: A prospective study. Am J Emerg Med 2023; 66:16-21. [PMID: 36657321 DOI: 10.1016/j.ajem.2023.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 12/14/2022] [Accepted: 01/03/2023] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND This prospective study investigated whether integrating the Clinical Frailty Scale (CFS) with a triage system would improve triage for older adult emergency department (ED) patients. METHODS We enrolled ED patients aged 65 years or older at 5 study sites in Taiwan between December 2020 and April 2021. All eligible patients were assigned a triage level by using the Taiwan Triage and Acuity Scale (TTAS) in accordance with usual practice. A CFS score was collected from them. The primary outcome was critical events, defined as ICU admission or in-hospital mortality. The secondary outcomes were ED medical expenditures, number of orders in the ED, and length of hospital stay (LOS). We applied a reclassification concept and integrated the CFS and TTAS to create the Triage Frailty Acuity Scale (TFAS). We compared the outcomes achieved between the TTAS and TFAS. RESULTS Of 1023 screened ED patients, 890 were enrolled. The majority were assigned to TTAS level 3 (73.26%) and had CFS scores of 4 to 9 (55.96%). The primary outcomes were better predicted by the TFAS than the TTAS (area under the curve [AUC] 0.82 vs. 064). Using multivariable approach, TTAS level 1 (odds ratio [OR], 4.8; 95% confidence interval [CI], 1.7-13.4) and CFS score (OR, 5.8; 95% CI, 1.9-17.2) were significantly associated with the primary outcomes. For older adults at the highest triage level, the TFAS was not associated with an increase in the primary outcomes compared with the TTAS; however, the TFAS was associated with a significant decrease in the number of older ED patients assigned to triage levels 3 to 5. In addition, TFAS had a longer average LOS but did not have a higher average number of orders or ED medical expenditures compared to TTAS. CONCLUSIONS The TFAS identified more older ED patients who had been triaged as less emergent but proceeded to need ICU admission or in-hospital death. Incorporating the CFS into triage may reduce the under-triage of older adults in the ED.
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Affiliation(s)
- Chip-Jin Ng
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; Department of Emergency Medicine, Chang Gung Memorial Hospital, Taipei, Taiwan.
| | - Liang-Tien Chien
- Graduate Institute of Management, Chang Gung University, Taoyuan 333, Taiwan; Taoyuan Fire Department, Taoyuan 333, Taiwan.
| | - Chien-Hsiung Huang
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; Graduate Institute of Management, Chang Gung University, Taoyuan 333, Taiwan.
| | - Chung-Hsien Chaou
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan 333, Taiwan.
| | - Shi-Ying Gao
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan 333, Taiwan.
| | - Sherry Yueh-Hsia Chiu
- Department of Health Care Management, College of Management, Chang Gung University, Taoyuan 333, Taiwan.
| | - Kuang-Hung Hsu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; Laboratory for Epidemiology, Department of Health Care Management, Healthy Aging Research Center, Chang Gung University, Taoyuan 333, Taiwan; Research Center for Food and Cosmetic Safety, College of Human Ecology, Chang Gung University of Science and Technology, Taoyuan 333, Taiwan; Department of Safety, Health and Environmental Engineering, Ming Chi University of Technology, New Taipei City 243, Taiwan; Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan 333, Taiwan.
| | - Cheng-Yu Chien
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; Graduate Institute of Management, Chang Gung University, Taoyuan 333, Taiwan; Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan; Department of Emergency Medicine, Ton-Yen General Hospital, Zhubei 302, Taiwan; Minghsin University of Science and Technology, Hsinchu 304, Taiwan.
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Freak-Poli R, Hu J, Phyo AZZ, Barker SF. Social Isolation and Social Support Influence Health Service Utilisation and Survival after a Cardiovascular Disease Event: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4853. [PMID: 36981761 PMCID: PMC10049557 DOI: 10.3390/ijerph20064853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/27/2023] [Accepted: 03/06/2023] [Indexed: 06/18/2023]
Abstract
Both cardiovascular disease (CVD) and social health carry high health and economic burdens. We undertook a systematic review to investigate the association between social isolation, low social support, and loneliness with health service utilisation and survival after a CVD event among people living in Australia and New Zealand. Four electronic databases were systematically searched for the period before June 2020. Two reviewers undertook the title/abstract screen. One reviewer undertook a full-text screen and data extraction. A second author checked data extraction. Of 756 records, 25 papers met our inclusion criteria. Included studies recruited 10-12,821 participants, aged 18-98 years, and the majority were males. Greater social support was consistently associated with better outcomes on four of the five themes (discharge destination, outpatient rehabilitation attendance, rehospitalisation and survival outcomes; no papers assessed the length of inpatient stay). Positive social health was consistently associated with better discharge designation to higher independent living. As partner status and living status did not align with social isolation and social support findings in this review, we recommend they not be used as social health proxies. Our systematic review demonstrates that social health is considered in cardiac care decisions and plays a role in how healthcare is being delivered (i.e., outpatient, rehabilitation, or nursing home). This likely contributes to our finding that lower social support is associated with high-intensity healthcare services, lower outpatient rehabilitation attendance, greater rehospitalisation and poorer survival. Given our evidence, the first step to improve cardiac outcomes is acknowledging that social health is part of the decision-making process. Incorporating a formal assessment of social support into healthcare management plans will likely improve cardiac outcomes and survival. Further research is required to assess if support person/s need to engage in the risk reduction behaviours themselves for outpatient rehabilitation to be effective. Further synthesis of the impact of social isolation and loneliness on health service utilisation and survival after a CVD event is required.
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Affiliation(s)
- Rosanne Freak-Poli
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC 3168, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Jessie Hu
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Aung Zaw Zaw Phyo
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - S. Fiona Barker
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
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Naseer M, Dahlberg L, Ehrenberg A, Schön P, Calderón-Larrañaga A. The role of social connections and support in the use of emergency care in older adults. Arch Gerontol Geriatr 2023; 111:105010. [PMID: 37058774 DOI: 10.1016/j.archger.2023.105010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/18/2023] [Accepted: 03/27/2023] [Indexed: 03/30/2023]
Abstract
OBJECTIVES Limited and inconsistent findings have been reported on the link between social connections and support and emergency department (ED) visits in older populations. Moreover, the adequacy of informal care for older adults has rarely been considered. This study explored the associations of social connections, social support, and informal care with ED visits in younger-old (<78 years) and oldest-old (≥78 years) adults. METHODS This is a prospective cohort study based on community-living adults ≥60 years old participating in the Swedish National Study on Aging and Care in Kungsholmen (N=3066 at wave 1, 2001-2004; N=1885 at wave 3, 2007-2010; N=1208 at wave 5, 2013-2016). Standardised indexes were developed to measure social connections, social support, and informal care. The outcome variable was hospital-based ED visits within 4 years of the SNAC-K interview. Associations between exposure variables and ED visits were assessed through negative binomial regressions using generalised estimating equations. RESULTS Medium (IRR 0.77; 95% CI 0.59-0.99) and high (IRR 0.77; 95% CI 0.56-0.99) levels of social support were negatively associated with ED visits compared to low levels of social support, but only in oldest-old adults. No statistically significant associations were observed between social connections and ED visits. Higher ED visit rates were seen in oldest-old adults with unmet informal care needs, even if the differences did not reach statistical significance. CONCLUSIONS ED visits were associated with social support levels among adults aged ≥78 years. Public health interventions to mitigate situations of poor social support may improve health outcomes and reduce avoidable ED visits in oldest-old adults.
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de Luca K, McLachlan AJ, Maher CG, Machado GCC. Australian emergency department care for older adults diagnosed with low back pain of lumbar spine origin: a retrospective analysis of electronic medical record system data (2016-2019). BMC Emerg Med 2023; 23:17. [PMID: 36782123 PMCID: PMC9924838 DOI: 10.1186/s12873-023-00789-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 02/07/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND In Australian emergency departments, 30% of all back pain presentations are for older adults. Relatively little is known about the care that this population receives during an emergency department stay, including admission to hospital. The aim of this study is to describe emergency department management of older adults diagnosed with a lumbar spine condition and to determine predictors of healthcare use in this population. METHODS A retrospective analysis of electronic medical record data of adults aged ≥ 65 years with a lumbar spine discharge diagnosis. Demographic, clinical care (date and time of presentation and discharge, length of stay in the emergency department, mode of arrival, triage category, re-presentations to the emergency department (within 48 h), discharge mode, the administration of pain-relieving medicines, lumbar imaging, and laboratory tests) and costs data were extracted from the electronic medical record system. Descriptive analyses and multilevel mixed-effects logistic regression models were performed. RESULTS Over the period January 2016 to December 2019 there were 4,093 presentations to emergency departments by older adults with a lumbar spine discharge diagnosis (82.0% were non-specific low back pain). Most were female (58.3%), 39.9% had some form of lumbar imaging, and 34.1% were admitted to hospital. The most administered pain medicines were opioid analgesics (67.1%), followed by paracetamol (63.9%) and NSAIDs (33.0%). Predictors of healthcare use and hospital inpatient admission were receiving a laboratory test and receiving any opioid. For the financial period 2019-20, the mean (SD) total cost of care per presentation was $5,629 ($11,982). CONCLUSION In the emergency department, more than two thirds of older adults with a lumbar spine condition received opioid analgesics. They often received imaging and laboratory tests, had high costs and were admitted to hospital. Alternative pathways of care are needed to support older adults with low back pain, to receive guideline-concordant emergency department care and have good health outcomes.
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Affiliation(s)
- Katie de Luca
- Discipline of Chiropractic, School of Health, Medical and Applied Sciences, CQUniversity, Brisbane, Australia.
| | - Andrew J McLachlan
- grid.1013.30000 0004 1936 834XSydney Pharmacy School, University of Sydney, Sydney, New South Wales Australia
| | - Chris G Maher
- grid.410692.80000 0001 2105 7653Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, New South Wales Australia
| | - Gustavo C C Machado
- grid.410692.80000 0001 2105 7653Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, New South Wales Australia
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19
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Arsenault-Lapierre G, Bui TX, Le Berre M, Bergman H, Vedel I. Rural and urban differences in quality of dementia care of persons with dementia and caregivers across all domains: a systematic review. BMC Health Serv Res 2023; 23:102. [PMID: 36721162 PMCID: PMC9887943 DOI: 10.1186/s12913-023-09100-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 01/24/2023] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND There are challenges in healthcare service delivery in rural areas, and this may be especially true for persons with dementia, who have higher needs to access to the healthcare system, and may have difficulties to commute easily and safely to these services. There is a growing body of literature regarding geographical disparities, but there is no comprehensive systematic review of geographical differences in persons with dementia across all domains of care quality. Therefore, the objective of this study is to conduct a systematic review of the literature on rural and urban differences in quality of dementia care outcomes of persons with dementia across all quality-of-care domains. METHODS We performed a digital search in Ovid MEDLINE on July 16, 2019, updated on May 3, 2021, for French or English records. We selected studies that reported outcome from at least one domain of quality of dementia care (Access, Integration, Effective Care, Efficient Care, Population Health, Safety, and Patient-Centered) in both rural and urban persons with dementia or caregivers. We used rigorous, systematic methods for screening, selection, data extraction and we analyzed outcomes reported by at least two studies using vote counting and appraised the certainty of evidence. Finally, we explored sources of heterogeneity. RESULTS From the 38 included studies, we found differences in many dementia care domains. Rural persons with dementia had higher mortality rates (Population Health), lower visits to any physicians (Access), more hospitalizations but shorter stays (Integration), higher antipsychotic medications (Safety), lower use of home care services and higher use of nursing home (Patient-Centered Care) compared to urban persons with dementia. CONCLUSIONS This comprehensive portrait of rural-urban differences in dementia care highlights possible geographically based inequities and can be used by researchers and decision makers to guide development of more equitable dementia care policies.
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Affiliation(s)
- Geneviève Arsenault-Lapierre
- Lady Davis Institute for Medical Research, Jewish General Hospital, 5858 Ch. de La Côte-Des-Neiges, Suite 300, Montréal, QC, H3S 1Z1, Canada.
| | - Tammy X. Bui
- grid.414980.00000 0000 9401 2774Lady Davis Institute for Medical Research, Jewish General Hospital, 5858 Ch. de La Côte-Des-Neiges, Suite 300, Montréal, QC H3S 1Z1 Canada
| | - Mélanie Le Berre
- grid.14848.310000 0001 2292 3357Université de Montréal, Institut Universitaire de Gériatrie de Montréal, 4565 Chemin Queen Mary, Montreal, H3W 1W5 Canada
| | - Howard Bergman
- grid.14709.3b0000 0004 1936 8649Department of Family Medicine, McGill University, 5858 Ch. de La Côte-Des-Neiges, Suite 300, Montreal, QC H3S 1Z1 Canada
| | - Isabelle Vedel
- grid.414980.00000 0000 9401 2774Lady Davis Institute for Medical Research, Jewish General Hospital, 5858 Ch. de La Côte-Des-Neiges, Suite 300, Montréal, QC H3S 1Z1 Canada ,grid.14709.3b0000 0004 1936 8649Department of Family Medicine, McGill University, 5858 Ch. de La Côte-Des-Neiges, Suite 300, Montreal, QC H3S 1Z1 Canada
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20
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Racine-Hemmings F, Vanasse A, Lacasse A, Chiu Y, Courteau J, Dépelteau A, Hudon C. Association between sustained opioid prescription and frequent emergency department use: a cohort study. J Accid Emerg Med 2023; 40:4-11. [PMID: 35288454 DOI: 10.1136/emermed-2021-211180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/21/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Chronic non-cancer pain (CNCP) is common among frequent emergency department (ED) users, although factors underlying this association are unclear. This study estimated the association between sustained opioid use and frequent ED use among patients with CNCP. METHODS Retrospective cohort study using a Canadian provincial health insurer database (Régie d'Assurance Maladie du Québec). The database included adults with both ≥1 chronic condition and ≥ 1 ED visit in 2012 or 2013. Inclusion in the study further required a CNCP diagnosis, public drug insurance coverage and 1-year survival after the first ED visit in 2012 or 2013 (index visit). Multivariable logistic regression was used to derive ORs of frequent ED use (≥5 visits in the year following the index visit) subsequent to sustained opioid use (≥60 days opioids prescription within 90 days preceding the index visit), adjusting for important covariables. RESULTS From 576 688 patients in the database, 58 237 were included in the study. Of these, 4109 (7.1%) had received a sustained opioid prescription and 4735 (8.1%) were frequent ED users in the follow-up year. Sustained opioid use was not associated with frequent ED use in the multivariable model (OR: 1.06, 95% CI 0.94 to 1.19). Novel associated covariables were benzodiazepine prescription (OR: 1.21, 95% CI 1.12 to 1.30) and polypharmacy (OR: 1.23, 95% CI 1.13 to 1.34). CONCLUSIONS Due to confounding by social and medical vulnerability, patients with CNCP with sustained opioid use appear to have a higher propensity for frequent ED use in unadjusted models. However, sustained opioid use was not associated with frequent ED use in these patients after adjustment.
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Affiliation(s)
- François Racine-Hemmings
- Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke (CRCHUS), Sherbrooke, Quebec, Canada .,Département de médecine de famille et de médecine d'urgence, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Alain Vanasse
- Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke (CRCHUS), Sherbrooke, Quebec, Canada.,Département de médecine de famille et de médecine d'urgence, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Anaïs Lacasse
- Département des Sciences de la santé, Université du Québec en Abitibi-Témiscamingue, Rouyn-Noranda, Quebec, Canada
| | - Yohann Chiu
- Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke (CRCHUS), Sherbrooke, Quebec, Canada.,Département de médecine de famille et de médecine d'urgence, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Josiane Courteau
- Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke (CRCHUS), Sherbrooke, Quebec, Canada
| | - Andréa Dépelteau
- École de Réadaptation, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Catherine Hudon
- Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke (CRCHUS), Sherbrooke, Quebec, Canada.,Département de médecine de famille et de médecine d'urgence, Université de Sherbrooke, Sherbrooke, Quebec, Canada
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21
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Franz K, Deutschbein J, Riedlinger D, Pigorsch M, Schenk L, Lindner T, Möckel M, Norman K, Müller-Werdan U. Malnutrition is associated with six-month mortality in older patients admitted to the emergency department with hip fracture. Front Med (Lausanne) 2023; 10:1173528. [PMID: 37153099 PMCID: PMC10158933 DOI: 10.3389/fmed.2023.1173528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 03/30/2023] [Indexed: 05/09/2023] Open
Abstract
Background Hip fractures in older people are a common health problem often associated with malnutrition that might affect outcomes. Screening for malnutrition is not a routine examination in emergency departments (ED). This analysis of the EMAAge study, a prospective, multicenter cohort study, aimed to evaluate the nutritional status of older patients (≥ 50 years) with hip fracture, factors associated with malnutrition risk, and the association between malnutrition and the six-months mortality. Methods Risk of malnutrition was evaluated using the Short Nutritional Assessment Questionnaire. Clinical data as well as data on depression and physical activity were determined. Mortality was captured for the first six months after the event. To assess factors associated with malnutrition risk we used a binary logistic regression. A Cox proportional hazards model was used to assess the association of malnutrition risk with six-month survival adjusted for other relevant risk factors. Results The sample consisted of N = 318 hip fracture patients aged 50 to 98 (68% women). The prevalence of malnutrition risk was 25.3% (n = 76) at the time of injury. There were no differences in triage categories or routine parameters measured in the ED that could point to malnutrition. 89% of the patients (n = 267) survived for six months. The mean survival time was longer in those without malnutrition risk (171.9 (167.1-176.9) days vs. 153.1 (140.0-166.2) days). The Kaplan Meier curves and the unadjusted Cox regression (Hazard Ratio (HR) 3.08 (1.61-5.91)) showed differences between patients with and patients without malnutrition risk. In the adjusted Cox regression model, risk of death was associated with malnutrition risk (HR 2.61, 1.34-5.06), older age (70-76 years: HR 2.5 (0.52-11.99); 77-82 years: HR 4.25 (1.15-15.62); 83-99 years: HR 3.82 (1.05-13.88)) and a high burden of comorbidities (Charlson Comorbidity Index ≥3: HR 5.4 (1.53-19.12)). Conclusion Risk of malnutrition was associated with higher mortality after hip fracture. ED parameters did not differentiate between patients with nutritional deficiencies and those without. Therefore, it is particularly important to pay attention to malnutrition in EDs to detect patients at risk of adverse outcomes and to initiate early interventions.
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Affiliation(s)
- Kristina Franz
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Geriatrics and Medical Gerontology, Geriatrics Research Group, Berlin, Germany
- *Correspondence: Kristina Franz,
| | - Johannes Deutschbein
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Medical Sociology and Rehabilitation Science, Berlin, Germany
| | - Dorothee Riedlinger
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Division of Emergency Medicine Campus Mitte and Virchow, Berlin, Germany
| | - Mareen Pigorsch
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
| | - Liane Schenk
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Medical Sociology and Rehabilitation Science, Berlin, Germany
| | - Tobias Lindner
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Division of Emergency Medicine Campus Mitte and Virchow, Berlin, Germany
| | - Martin Möckel
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Division of Emergency Medicine Campus Mitte and Virchow, Berlin, Germany
| | - Kristina Norman
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Geriatrics and Medical Gerontology, Geriatrics Research Group, Berlin, Germany
| | - Ursula Müller-Werdan
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Geriatrics and Medical Gerontology, Geriatrics Research Group, Berlin, Germany
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22
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Melchiorre MG, D’Amen B, Quattrini S, Lamura G, Socci M. Health Emergencies, Falls, and Use of Communication Technologies by Older People with Functional and Social Frailty: Ageing in Place in Deprived Areas of Italy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:14775. [PMID: 36429499 PMCID: PMC9691100 DOI: 10.3390/ijerph192214775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/07/2022] [Accepted: 11/08/2022] [Indexed: 06/16/2023]
Abstract
Frail older people ageing alone in place need help to perform daily living activities, especially when functional limitations are increasing and formal/informal supports are lacking. This context represents a risk of experiencing health emergencies, in particular falls. It is thus important to understand how seniors manage these potential difficulties and who helps them. The present study aimed to explore these dimensions in Italy, where 120 qualitative interviews were carried out in 2019 within the "Inclusive ageing in place" (IN-AGE) research project, involving frail older people living alone at home. A content analysis was conducted. Results showed that seniors need to manage health emergencies regarding heart and breathing problems but mainly episodes of falls are reported, with consequent fractures and fear of falling again. In several cases, the use of a mobile phone was crucial in order to seek for help, and the first to intervene were children, in addition to some neighbors. Some seniors also referred their ability to call independently the General Practitioner (GP) or the emergency room, in order to not disturb family members. These findings highlight new useful insights for policy makers, regarding health emergencies prevention and management measures to put in place, especially concerning falls, and the support provided by communication technologies.
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23
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Hone T, Macinko J, Trajman A, Palladino R, Coeli CM, Saraceni V, Rasella D, Durovni B, Millett C. Expansion of primary healthcare and emergency hospital admissions among the urban poor in Rio de Janeiro Brazil: A cohort analysis. LANCET REGIONAL HEALTH. AMERICAS 2022; 15:100363. [PMID: 36778075 PMCID: PMC9904151 DOI: 10.1016/j.lana.2022.100363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Robust evidence on the relationship between primary care and emergency admissions is lacking in low- and middle-income countries. This study evaluates how the phased roll out of the family health strategy (FHS) to the urban poor in Rio de Janeiro Brazil affected emergency hospital admissions and readmissions from ambulatory-care sensitives conditions (ACSCs). Methods A cohort of 1.2 million adults in Rio de Janeiro city were followed for five years (Jan 2012 to Dec 2016). The association between FHS use and the likelihood of emergency hospital admissions and 30-day readmissions were evaluated using multi-level Poisson regression models with inverse probability treatment weighting and regression adjustment (IPTW-RA) for socioeconomic and household characteristics. Inequalities in associations were examined across groups of causes and by key socioeconomic groups. Results Records from 2,551,934 primary care consultations and 15,627 admissions were analysed. In IPTW-RA analyses, each additional FHS consultation was associated with a 3% lower rate of ACSC admission (RR: 0.97; 95%CI: 0.95, 0.98), a 63% lower rate of 30-day readmissions from any non-birth cause (RR: 0.37; 95%CI: 0.30, 0.46), and an 57% lower rate of 30-day readmissions from ACSCs (RR: 0.43; 95%CI: 0.33, 0.55). Individuals who were older, had the lowest educational attainment, were unemployed, and had higher incomes had larger reductions in ACSC admissions associated with FHS use. Interpretation Investment in primary care is important for reducing emergency hospital admissions and their associated costs in LMICs. Funding DFID/MRC/Wellcome Trust/ESRC.
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Affiliation(s)
- Thomas Hone
- Public Health Policy Evaluation Unit, Imperial College London, London, United Kingdom,Corresponding author at: Public Health Policy Evaluation Unit, Imperial College London, Third Floor, Reynold's Building, Charing Cross Hospital, St Dunstan's Road, London W6 8RP, United Kingdom.
| | - James Macinko
- Departments of Health Policy and Management and Community Health Sciences, Jonathan and Karin Fielding School of Public Health, University of California Los Angeles, United States
| | | | - Raffaele Palladino
- Public Health Policy Evaluation Unit, Imperial College London, London, United Kingdom,Department of Public Health, University “Federico II” of Naples, Italy
| | - Claudia Medina Coeli
- Instituto de Estudos em Saúde Coletiva, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Valeria Saraceni
- Secretaria Municipal de Saúde do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Davide Rasella
- ISGlobal, Hospital Clinic - Universitat de Barcelona, Barcelona, Spain,Center of Data and Knowledge Integration for Health (CIDACS), Instituto Gonçalo Muniz, Fundação Oswaldo Cruz, Salvador, Brazil
| | - Betina Durovni
- Secretaria Municipal de Saúde do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Christopher Millett
- Public Health Policy Evaluation Unit, Imperial College London, London, United Kingdom,Center of Data and Knowledge Integration for Health (CIDACS), Instituto Gonçalo Muniz, Fundação Oswaldo Cruz, Salvador, Brazil,Comprehensive Health Research Center and Public Health Research Centre, NOVA National School of Public Health, NOVA University of Lisbon, Lisbon, Portugal
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24
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Beauchet O, Afilalo M, Allali G, Lubov J, Galery K, Launay CP. "Emergency Room Evaluation and Recommendations" and Incident Hospital Admissions in Older People with Major Neurocognitive Disorders Visiting Emergency Department: Results of an Experimental Study. Dement Geriatr Cogn Disord 2022; 51:291-296. [PMID: 35551122 DOI: 10.1159/000524533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 04/02/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Older people with major neurocognitive disorders (MNCDs) visiting the emergency department (ED) are at high risk of hospital admissions. The "Emergency Room Evaluation and Recommendations" (ER2) tool decreases the length of stay (LOS) in the hospital when older people visiting ED are hospitalized after an index ED visit, regardless of their cognitive status. Its effect on hospital admissions has not yet been examined in older people with MNCD visiting ED. This study aimed to examine whether ER2 recommendations were associated with incident hospital admissions and LOS in ED in older people with MNCD visiting ED. METHODS A total of 356 older people with MNCD visiting ED of the Jewish General Hospital (Montreal, Quebec, Canada) were recruited in this non-randomized, pre-post-intervention, single arm, prospective and longitudinal open label trial. ED staff and patients were blinded of the ER2 score, and patients received usual ED care during the observation period, whereas ED staff were informed about the ER2 score, and patients had ER2 tailor-made recommendations in addition to usual care during the intervention period. Hospital admissions and the LOS in ED were the outcomes. RESULTS There were less incident hospital admissions (odds ratio ≤ 0.61 with p ≤ 0.022) and longer LOS in ED (coefficient beta ≥4.28 with p ≤ 0.008) during the intervention period compared to the observation period. DISCUSSION/CONCLUSION ER2 recommendations have mixed effects in people with MNCD visiting ED. They were associated with reduced incident hospital admissions and increased LOS in ED, suggesting that they may have benefits in addition to usual ED care.
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Affiliation(s)
- Olivier Beauchet
- Departments of Medicine, University of Montreal, Montreal, Québec, Canada.,Research Centre of the Geriatric University Institute of Montreal, Montreal, Québec, Canada.,Department of Medicine, Division of Geriatric Medicine, Sir Mortimer B. Davis Jewish General Hospital and Lady Davis Institute for Medical Research, McGill University, Montreal, Québec, Canada.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Marc Afilalo
- Emergency Department, Jewish General Hospital, McGill University, Montreal, Québec, Canada
| | - Gilles Allali
- Leenaards Memory Center, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Joshua Lubov
- Department of Medicine, Division of Geriatric Medicine, Sir Mortimer B. Davis Jewish General Hospital and Lady Davis Institute for Medical Research, McGill University, Montreal, Québec, Canada
| | - Kevin Galery
- Research Centre of the Geriatric University Institute of Montreal, Montreal, Québec, Canada
| | - Cyrille P Launay
- Department of Medicine, Division of Geriatric Medicine, Sir Mortimer B. Davis Jewish General Hospital and Lady Davis Institute for Medical Research, McGill University, Montreal, Québec, Canada
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25
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Characteristics and Resource Utilization Associated with Frequent Users of Emergency Departments. Emerg Med Int 2022; 2022:8064011. [PMID: 35912391 PMCID: PMC9334063 DOI: 10.1155/2022/8064011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/24/2022] [Accepted: 07/01/2022] [Indexed: 11/17/2022] Open
Abstract
Background Frequent emergency department (ED) users place a huge influence and burden on healthcare systems and medical costs. In Taiwan, citizens have very easy access to medical services and the national health insurance (NHI) puts very few restrictions on the frequency and facilities which the patients go to. However, there is still a certain percentage of frequent ED users in Taiwan, and yet, there are few research studies investigating the features of such users and their impact on the healthcare system. We conducted this study to investigate the prevalence and characteristics of the repeated ED users in a tertiary care medical center with more than 80000 emergency visits in a year and hypothesized that frequent ED users have unique medical and social characteristics and results in increased medical expense. Methods We searched the integrated medical database of an urban tertiary medical center in 2017. We compared frequent ED users (≧4 visits/year) with nonfrequent users (<4 visits/year) with regards to the medical history, distance from home to the hospital, main visiting purposes, whether patients had used outpatient care or other medical resources at the same time, and the charge to the patients for each visit. Results In 2017, 2191 patients (3.37%) were listed as frequent users and accounted for 12166 visits (14.20%). Most of the frequent users were over 65 years old (53.1%) and more than half of them had suffered from cancer (55.1%). The most significant features of frequent ED users were male, educational attainment below university, low-income households, drug or food allergies, terminal stage of illness, possession of IC Cards for Severe Illness, hospitalization in the past year, multiple outpatient visits in same year, and with certain medical history including anemia, cerebrovascular accident, congestive heart failure, peptic ulcer disease, ileus, cirrhosis, chronic obstructive pulmonary disease, and psychiatric disease. There were significant differences between frequent and nonfrequent users in disposition and median charge per visit (US$137 vs. $117, p < 0.001). Conclusions Frequent users of ED are a heterogeneous group who usually suffer from multiple chronic diseases. There were higher rates of hospital admission and medical costs among frequent ED users compared to nonfrequent users. In addition to emergency services, frequent users also utilized outpatient resources heavily.
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Jehloh L, Songwathana P, Sae-Sia W. Transitional care interventions to reduce emergency department visits in older adults: A systematic review. BELITUNG NURSING JOURNAL 2022; 8:187-196. [PMID: 37547112 PMCID: PMC10401376 DOI: 10.33546/bnj.2100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/24/2022] [Accepted: 05/30/2022] [Indexed: 08/08/2023] Open
Abstract
Background Preventable illnesses cause many emergency department visits in older adults, which can be minimized by implementing appropriate transitional care interventions. However, the most effective transitional care strategies for older adults are unknown. Objective To discover and consolidate transitional care interventions that can help older people avoid going to the emergency department. Methods From January 2011 to August 2021, PubMed, The Cochrane Library, CINAHL, Web of Science, ProQuest, and The JAMA Network were used to search. Two authors independently screened and selected papers, assessed the risk of bias, and extracted data into a standardized form in accordance with Cochrane guidelines. For the risk of bias in studies, the RevMan 5.4.1 program was utilized. Results Six randomized controlled trials, four non-randomized controlled trials, and three retrospective investigations were among the 13 studies examined. All studies evaluated emergency department visits but in different periods (ranging from 1-12 months after discharge) and with varying groups of baselines (pre-post intervention and between groups). The multi-component strategies, either pre or postdischarge phase using high-intensity care delivered within six months of discharge, were implemented in transitional care that had been shown to reduce emergency department visits in older adults. Conclusion To prevent emergency department visits by older patients, nurses should arrange for a high-intensity transitional care intervention that involves both pre-and postdischarge interventions. The effectiveness of the intervention in reducing emergency department visits in older adults is difficult to determine due to inter-study heterogeneity and poor methodological quality. There is a need for more evidence-based research with consistent and trustworthy effect assessments. PROSPERO registration number CRD42021261326.
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Affiliation(s)
- Latifah Jehloh
- Faculty of Nursing, Prince of Songkla University, Thailand
| | | | - Wipa Sae-Sia
- Faculty of Nursing, Prince of Songkla University, Thailand
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27
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Hosseini_Shokouh S, Mohammadi K, Yaghoubi M. Optimization of Service Process in Emergency Department Using Discrete Event Simulation and Machine Learning Algorithm. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2022; 10:e44. [PMID: 35765608 PMCID: PMC9206831 DOI: 10.22037/aaem.v10i1.1545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Introduction Emergency departments are operating with limited resources and high levels of unexpected requests. This study aimed to minimize patients' waiting time and the percentage of units' engagement to improve the emergency department (ED) efficiency. Methods A comprehensive combination method involving Discrete Event Simulation (DES), Artificial Neural Network (ANN) algorithm, and finally solving the model by use of Genetic Algorithm (GA) was used in this study. After simulating the case and making sure about the validity of the model, experiments were designed to study the effects of change in individuals and equipment on the average time that patients wait, as well as units' engagement in ED. Objective functions determined using Artificial Neural Network algorithm and MATLAB software were used to train it. Finally, after estimating objective functions and adding related constraints to the problem, a fractional Genetic Algorithm was used to solve the model. Results According to the model optimization result, it was determined that the hospitalization unit, as well as the hospitalization units' doctors, were in an optimized condition, but the triage unit, as well as the fast track units' doctors, should be optimized. After experiments in which the average waiting time in the triage section reached near zero, the average waiting time in the screening section was reduced to 158.97 minutes and also the coefficient of units' engagement in both sections were 69% and 84%, respectively. Conclusions Using the service optimization method creates a significant improvement in patient's waiting time and stream at emergency departments, which is made possible through appropriate allocation of the human and material resources.
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Affiliation(s)
- Sayyed_Morteza Hosseini_Shokouh
- Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran. ,Faculty of Health, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Kasra Mohammadi
- Industrial Management Department, Allame Tabataba’i University, Tehran, Iran
| | - Maryam Yaghoubi
- Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran. ,Corresponding author: Maryam Yaghoubi; Nosrati Alley, South Sheykhbahaee Ave., Mollasadra Ave., Vanak Square, Tehran, Iran. PO Box. 14359164471
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Conneely M, Leahy S, Dore L, Trépel D, Robinson K, Jordan F, Galvin R. The effectiveness of interventions to reduce adverse outcomes among older adults following Emergency Department discharge: umbrella review. BMC Geriatr 2022; 22:462. [PMID: 35643453 PMCID: PMC9145107 DOI: 10.1186/s12877-022-03007-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/30/2022] [Indexed: 12/04/2022] Open
Abstract
Background Population ageing is increasing rapidly worldwide. Older adults are frequent users of health care services including the Emergency Department (ED) and experience a number of adverse outcomes following an ED visit. Adverse outcomes include functional decline, unplanned hospital admission and an ED revisit. Given these adverse outcomes a number of interventions have been examined to improve the outcomes of older adults following presentation to the ED. The aim of this umbrella review was to evaluate the effectiveness of ED interventions in reducing adverse outcomes in older adults discharged from the ED. Methods Systematic reviews of randomised controlled trials investigating ED interventions for older adults presenting to the ED exploring clinical, patient experience and healthcare utilisation outcomes were included. A comprehensive search strategy was employed in eleven databases and the PROSPERO register up until June 2020. Grey literature was also searched. Quality was assessed using the A MeaSurement Tool to Assess Systematic Reviews 2 tool. Overlap between systematic reviews was assessed using a matrix of evidence table. An algorithm to assign the Grading of Recommendations Assessment, Development and Evaluation to assess the strength of evidence was applied for all outcomes. Results Nine systematic reviews including 29 randomised controlled trials were included. Interventions comprised of solely ED-based or transitional interventions. The specific interventions delivered were highly variable. There was high overlap and low methodological quality of the trials informing the systematic reviews. There is low quality evidence to support ED interventions in reducing functional decline, improving patient experience and improving quality of life. The quality of evidence of the effectiveness of ED interventions to reduce mortality and ED revisits varied from very low to moderate. Results were presented narratively and summary of evidence tables created. Conclusion Older adults are the most important emerging group in healthcare for several economic, social and political reasons. The existing evidence for the effectiveness of ED interventions for older adults is limited. This umbrella review highlights the challenge of synthesising evidence due to significant heterogeneity in methods, intervention content and reporting of outcomes. Higher quality intervention studies in line with current geriatric medicine research guidelines are recommended, rather than the publication of further systematic reviews. Trial registration UMBRELLA REVIEW REGISTRATION: PROSPERO (CRD42020145315). Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03007-5.
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Nishioka D, Kino S, Ueno K, Kondo N. Risk profiles of frequent outpatients among public assistance recipients in Japan: a retrospective cohort study using a classification and regression trees algorithm. BMJ Open 2022; 12:e054035. [PMID: 35618333 PMCID: PMC9137343 DOI: 10.1136/bmjopen-2021-054035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Although several individual risk factors of frequent outpatient attendance (FOA) have previously been reported, identifying a specific risk profile is needed to provide effective intervention for impoverished citizens with complex biopsychosocial needs. We aimed to identify potential risk profiles of FOA among public assistance recipients in Japan by using classification and regression trees (CART) and discussed the possibilities of applying the CART to policypractice as compared with the results of conventional regression analyses. DESIGN We conducted a retrospective cohort study. SETTING We used secondary data from the public assistance databases of six municipalities in Japan. PARTICIPANTS The study population included all adults on public assistance in April 2016, observed until March 2017. We obtained the data of 15 739 people on public assistance. During the observational period, 435 recipients (2.7%) experienced FOA. OUTCOME MEASURE We dichotomised a cumulative incidence of FOA during the study period into a binary variable of exhibiting FOA or not. We adopted the definition of FOA by the Ministry of Health, Labour, and Welfare: visiting the same medical institution more than 15 days a month. RESULTS The results of the CART showed that an employed subpopulation with mental disabilities exhibited the highest risk of FOA (incidence proportion: 16.7%). Meanwhile, multiple Poisson regression showed that the adjusted incidence ratio of being unemployed (vs employed) was 1.71 (95% CI 1.13 to 2.59). CONCLUSIONS Using the CART model, we could identify specific risk profiles that could have been overlooked when considering only the risk factors obtained from regression analysis. Public health activities can be provided effectively by focusing on risk factors and the risk profiles.
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Affiliation(s)
- Daisuke Nishioka
- Department of Medical Statistics, Research & Development Center, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
- Department of Social Epidemiology, Kyoto University, Kyoto, Japan
| | - Shiho Kino
- Department of Social Epidemiology, Kyoto University, Kyoto, Japan
- Department of Oral Health Promotion, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Keiko Ueno
- Department of Social Epidemiology, Kyoto University, Kyoto, Japan
| | - Naoki Kondo
- Department of Social Epidemiology, Kyoto University, Kyoto, Japan
- Institute for Future Initiatives, The University of Tokyo, Bunkyo-ku, Japan
- Japan Agency for Gerontological Evaluation Study (JAGES Agency), Bunkyo-ku, Japan
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Bloomfield K, Wu Z, Tatton A, Calvert C, Peel N, Hubbard R, Jamieson H, Hikaka J, Boyd M, Bramley D, Connolly MJ. An interRAI derived frailty index predicts acute hospitalizations in older adults residing in retirement villages: A prospective cohort study. PLoS One 2022; 17:e0264715. [PMID: 35235598 PMCID: PMC8890727 DOI: 10.1371/journal.pone.0264715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 02/11/2022] [Indexed: 11/18/2022] Open
Abstract
Objectives The development of frailty tools from electronically recorded healthcare data allows frailty assessments to be routinely generated, potentially beneficial for individuals and healthcare providers. We wished to assess the predictive validity of a frailty index (FI) derived from interRAI Community Health Assessment (CHA) for outcomes in older adults residing in retirement villages (RVs), elsewhere called continuing care retirement communities. Design Prospective cohort study. Setting and participants 34 RVs across two district health boards in Auckland, Aotearoa New Zealand (NZ). 577 participants, mean age 81 years; 419 (73%) female; 410 (71%) NZ European, 147 (25%) other European, 8 Asian (1%), 7 Māori (1%), 1 Pasifika (<1%), 4 other (<1%). Methods interRAI-CHA FI tool was used to stratify participants into fit (0–0.12), mild (>0.12–0.24), moderate (>0.24–0.36) and severe (>0.36) frail groups at baseline (the latter two grouped due to low numbers of severely frail). Primary outcome was acute hospitalization; secondary outcomes included long-term care (LTC) entry and mortality. The relationship between frailty and outcomes were explored with multivariable Cox regression, estimating hazard ratios (HRs) and 95% confidence intervals (95%CIs). Results Over mean follow-up of 2.5 years, 33% (69/209) of fit, 58% (152/260) mildly frail and 79% (85/108) moderate-severely frail participants at baseline had at least one acute hospitalization. Compared to the fit group, significantly increased risk of acute hospitalization were identified in mildly frail (adjusted HR = 1.88, 95%CI = 1.41–2.51, p<0.001) and moderate-severely frail (adjusted HR = 3.52, 95%CI = 2.53–4.90, p<0.001) groups. Similar increased risk in moderate-severely frail participants was seen in LTC entry (adjusted HR = 5.60 95%CI = 2.47–12.72, p<0.001) and mortality (adjusted HR = 5.06, 95%CI = 1.71–15.02, p = 0.003). Conclusions and implications The FI derived from interRAI-CHA has robust predictive validity for acute hospitalization, LTC entry and mortality. This adds to the growing literature of use of interRAI tools in this way and may assist healthcare providers with rapid identification of frailty.
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Affiliation(s)
- Katherine Bloomfield
- Department of Medicine, Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
- Waitematā District Health Board, Auckland, New Zealand
- * E-mail:
| | - Zhenqiang Wu
- Department of Medicine, Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Annie Tatton
- Waitematā District Health Board, Auckland, New Zealand
| | | | - Nancye Peel
- Centre for Health Services Research, University of Queensland, Brisbane, Queensland, Australia
| | - Ruth Hubbard
- Centre for Health Services Research, University of Queensland, Brisbane, Queensland, Australia
| | - Hamish Jamieson
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Joanna Hikaka
- Department of Medicine, Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Michal Boyd
- Department of Medicine, Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Dale Bramley
- Waitematā District Health Board, Auckland, New Zealand
| | - Martin J. Connolly
- Department of Medicine, Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
- Waitematā District Health Board, Auckland, New Zealand
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Conneely M, Leahy A, O'Connor M, Barry L, Corey G, Griffin A, O'Shaughnessy Í, O'Carroll I, Leahy S, Trépel D, Ryan D, Robinson K, Galvin R. A physiotherapy-led transition to home intervention for older adults following emergency department discharge: protocol for a pilot feasibility randomised controlled trial. Pilot Feasibility Stud 2022; 8:3. [PMID: 34980285 PMCID: PMC8720939 DOI: 10.1186/s40814-021-00954-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/28/2021] [Indexed: 12/12/2022] Open
Abstract
Background Older adults frequently attend the emergency department (ED) and experience high rates of adverse outcomes following ED presentation including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. This paper reports a protocol designed to evaluate the feasibility of conducting a three arm randomised controlled trial (RCT) within the ED setting and in the patient’s home. The interventions are comprehensive geriatric assessment (CGA), ED PLUS and usual care. Methods The ED PLUS pilot trial is designed as a feasibility RCT conducted in the ED and Acute Medical Assessment Unit of a university teaching hospital in the mid-west region of Ireland. We aim to recruit 30 patients, aged 65 years and over presenting to the ED with undifferentiated medical complaints and discharged within 72 h of index visit. Patients will be randomised by a computer in a ratio of 1:1:1 to deliver usual care, CGA or ED PLUS during a 6-month study period. A randomised algorithm is used to perform randomization. CGA will include a medical assessment, medication review, nursing assessment, falls assessment, assessment of mobility and stairs, transfers, personal care, activities of daily living (ADLs), social supports and baseline cognition. ED PLUS, a physiotherapist led, multidisciplinary intervention, aims to bridge the transition of care between the index visit to the ED and the community by initiating a CGA intervention in the ED and implementing a 6-week follow-up self-management programme in the patient’s own home following discharge from the ED. The outcomes will be parameters of the feasibility of the intervention and trial methods and will be assessed quantitatively and qualitatively. Discussion Rising ED visits and an ageing population with chronic health issues render ED interventions to reduce adverse outcomes in older adults a research priority. This feasibility RCT will generate data and experience to inform the conduct and delivery of a definite RCT. Trial registration The trial was registered in Clinical Trials Protocols and Results System as of 21st July 2021, with registration number NCT049836020. Supplementary Information The online version contains supplementary material available at 10.1186/s40814-021-00954-5.
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Affiliation(s)
- Mairéad Conneely
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland.
| | - Aoife Leahy
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland.,Department of Ageing and Therapeutics, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Margaret O'Connor
- Department of Ageing and Therapeutics, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Louise Barry
- School of Nursing and Midwifery, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Gillian Corey
- School of Nursing and Midwifery, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Anne Griffin
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Íde O'Shaughnessy
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland.,Department of Ageing and Therapeutics, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Ida O'Carroll
- Department of Ageing and Therapeutics, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Siobhán Leahy
- Department of Sport, Exercise & Nutrition, School of Science & Computing, Galway-Mayo Institute of Technology, Dublin Road, Galway, Ireland
| | - Dominic Trépel
- Trinity Institute of Neurosciences, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Damian Ryan
- Limerick EM Education Research Training (ALERT), Emergency Department, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Katie Robinson
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Rose Galvin
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
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Dufour I, Dubuc N, Chouinard MC, Hudon C. Characteristics of frequent users of emergency departments living with major neurocognitive disorders: a cohort study. GERIATRICS, GERONTOLOGY AND AGING 2022. [DOI: 10.53886/gga.e0220040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Objective: This study aimed to describe and compare the characteristics of community-dwelling older adults living with or without major neurocognitive disorders who made frequent use of emergency departments. Methods: This is a retrospective cohort study based on a secondary analysis of provincial health administrative data in Quebec, Canada. We included community-dwelling older adults from Quebec who were considered frequent emergency department users (a minimum of 4 visits in the year following an index emergency department visit chosen randomly between January 1, 2012, and December 31, 2013) and who had been diagnosed with at least one chronic condition. We compared characteristics of frequent users living with or without major neurocognitive disorders using chi-square and Kruskal-Wallis tests. Results: The study cohort consisted of 21 393 frequent emergency department users, of which 3051 (14.26%) were identified as having a major neurocognitive disorder. The results highlight a higher burden of chronic conditions, polypharmacy, antipsychotic use, and past use of healthcare services among these individuals. The results also reveal a higher proportion of conditions associated with geriatric syndromes such as trauma and injury, malnutrition, orthostatic hypertension, and gait disorders. Conclusion: Frequent emergency department users living with major neurocognitive disorders represent a complex population. Our results highlight the importance of systematically addressing their needs in appropriate settings and through customized interventions.
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Bloomfield K, Wu Z, Broad JB, Tatton A, Calvert C, Hikaka J, Boyd M, Peri K, Bramley D, Higgins AM, Connolly MJ. Factors associated with healthcare utilization and trajectories in retirement village residents. J Am Geriatr Soc 2021; 70:754-765. [PMID: 34910296 DOI: 10.1111/jgs.17602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 11/01/2021] [Accepted: 11/17/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND To study healthcare utilization and trajectories, and associated factors, in older adults in retirement villages (RVs), also known as continuing care retirement communities. METHODS Prospective cohort study of 578 cognitively intact residents from 34 RVs in Auckland, New Zealand (NZ). MEASUREMENT InterRAI-Community Health Assessment (includes core items that may trigger functional supplement (FS) completion in those with higher needs, and generates clinical assessment protocols (CAPs) in those with potential unmet needs). OUTCOMES time to acute hospitalization, long-term care (LTC), and death during average 2.5 years follow-up. RESULTS Three hundred seven (53%) residents had acute hospitalizations, 65 (11%) moved to LTC, and 51 (9%) died over a mean of 2.5 years. Factors associated with increased risk of acute hospitalization included CAP-falls (high risk) triggered, number of comorbidities, not having left RV in 2 weeks prior, moderate/severe hearing impairment, CAP-cardiorespiratory conditions triggered, acute hospitalization in year prior and age, with significant hazard ratios (HR) ranging between 1.03 and 2.90. Factors associated with reduced risk of hospitalization included other (non-NZ) European ethnicity (HR 0.73, 95% CI 0.55-0.98, p = 0.04), presence of on-site clinic (HR 0.62, 95% CI 0.45-0.85, p = 0.003), no influenza vaccination (HR 0.56, 95% CI 0.38-0.83, p = 0.004). Factors associated with LTC transition included FS triggered (HR 3.84, 95% CI 1.92-7.66, p < 0.001), CAP-instrumental activities of daily living (IADL) (HR 2.62, 95% CI 1.22-5.62, p = 0.01), CAP-social relationship triggered (HR 2.00, 95% CI 1.13-3.55, p = 0.02), and age (HR 1.13, 95% CI 1.07-1.18 p < 0.001). Factors associated with mortality included number of comorbidities (HR 3.75, 95% CI 1.54-9.10, p = 0.004 for 3-5 comorbidities), CAP-IADL triggered (HR 3.05, 95% CI 1.30-7.16, p = 0.01), and age (HR 1.11, 95% CI 1.05-1.18, p < 0.001). CONCLUSION A large proportion of cognitively intact RV residents are admitted to hospital in mean 2.5 years of follow-up. Multiple factors were associated with acute hospitalization risk. On-site clinics were associated with reduced risk and should be considered in RV development.
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Affiliation(s)
- Katherine Bloomfield
- Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand.,Older Adults' Health, Waitematā District Health Board, Auckland, New Zealand
| | - Zhenqiang Wu
- Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Joanna B Broad
- Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Annie Tatton
- Older Adults' Health, Waitematā District Health Board, Auckland, New Zealand
| | - Cheryl Calvert
- Community and Long Term Conditions, Auckland District Health Board, Auckland, New Zealand
| | - Joanna Hikaka
- Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand.,Older Adults' Health, Waitematā District Health Board, Auckland, New Zealand
| | - Michal Boyd
- Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Kathy Peri
- Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Dale Bramley
- Older Adults' Health, Waitematā District Health Board, Auckland, New Zealand
| | - Ann-Marie Higgins
- Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Martin J Connolly
- Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand.,Older Adults' Health, Waitematā District Health Board, Auckland, New Zealand
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Hu Z, Siddiqui FJ, Fan Q, Lian SWQ, Liu N, Ong MEH. Trends of chronic illness in emergency department admissions among elderly adults in a tertiary hospital over ten years. BMC Health Serv Res 2021; 21:1305. [PMID: 34863159 PMCID: PMC8645127 DOI: 10.1186/s12913-021-07309-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 11/17/2021] [Indexed: 12/02/2022] Open
Abstract
Background This study aimed to determine to what extent an aging population and shift to chronic illness has contributed to emergency admissions at a tertiary care hospital over ten years. Methods This was a retrospective observational study performed using a database of all emergency admissions from the Emergency Department (ED) at a single tertiary hospital in Singapore during a ten-year period (January 1st, 2008 to December 31st, 2017). Emergency admissions were defined as ED visits with inpatient admission as the disposition. This study analyzed the trends of demographics, pre-existing comorbidities, chronic conditions or ambulatory care sensitive conditions (ACSC) of all patients who underwent emergency admissions in Singapore General Hospital. Results A total of 446,484 emergency records were included. For elderly patients, the proportions of them had pre-existing multimorbidity at the time of undergoing emergency admissions were found to be lower at the end the 10-year study period relative to the beginning of the study period. The proportions of emergency admissions whose ED primary diagnoses were categorized as chronic conditions and certain chronic ACSC including chronic obstructive pulmonary disease, congestive heart failure, diabetes complications, and epilepsy also decreased for elderly patients over the 10-year study period. Conclusions In Singapore, despite a rapidly aging population, there have been surprisingly lower proportions of chronic conditions, pre-existing comorbidities, and chronic ACSC among the elderly emergency admissions. This is possibly consistent with an overall improved management of the chronic conditions among the elderly population. Future studies should include similar studies at the national level and comparison with other healthcare settings in different countries. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07309-z.
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Affiliation(s)
- Zhongxun Hu
- Duke-NUS Medical School, Singapore, Singapore.
| | - Fahad Javaid Siddiqui
- Prehospital and Emergency Research Centre, Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Qiao Fan
- Center for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore
| | - Sherman W Q Lian
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Nan Liu
- Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Marcus E H Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore.,Health Services and Systems Research, Prehospital and Emergency Research Center, Duke-NUS Medical School, Singapore, Singapore
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Klunder JH, Bordonis V, Heymans MW, van der Roest HG, Declercq A, Smit JH, Garms-Homolova V, Jónsson PV, Finne-Soveri H, Onder G, Joling KJ, Maarsingh OR, van Hout HPJ. Predicting unplanned hospital visits in older home care recipients: a cross-country external validation study. BMC Geriatr 2021; 21:551. [PMID: 34649526 PMCID: PMC8515741 DOI: 10.1186/s12877-021-02521-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 09/24/2021] [Indexed: 11/10/2022] Open
Abstract
Background Accurate identification of older persons at risk of unplanned hospital visits can facilitate preventive interventions. Several risk scores have been developed to identify older adults at risk of unplanned hospital visits. It is unclear whether risk scores developed in one country, perform as well in another. This study validates seven risk scores to predict unplanned hospital admissions and emergency department (ED) visits in older home care recipients from six countries. Methods We used the IBenC sample (n = 2446), a cohort of older home care recipients from six countries (Belgium, Finland, Germany, Iceland, Italy and The Netherlands) to validate four specific risk scores (DIVERT, CARS, EARLI and previous acute admissions) and three frailty indicators (CHESS, Fried Frailty Criteria and Frailty Index). Outcome measures were unplanned hospital admissions, ED visits or any unplanned hospital visits after 6 months. Missing data were handled by multiple imputation. Performance was determined by assessing calibration and discrimination (area under receiver operating characteristic curve (AUC)). Results Risk score performance varied across countries. In Iceland, for any unplanned hospital visits DIVERT and CARS reached a fair predictive value (AUC 0.74 [0.68–0.80] and AUC 0.74 [0.67–0.80]), respectively). In Finland, DIVERT had fair performance predicting ED visits (AUC 0.72 [0.67–0.77]) and any unplanned hospital visits (AUC 0.73 [0.67–0.77]). In other countries, AUCs did not exceed 0.70. Conclusions Geographical validation of risk scores predicting unplanned hospital visits in home care recipients showed substantial variations of poor to fair performance across countries. Unplanned hospital visits seem considerably dependent on healthcare context. Therefore, risk scores should be validated regionally before applied to practice. Future studies should focus on identification of more discriminative predictors in order to develop more accurate risk scores. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02521-2.
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Affiliation(s)
- Jet H Klunder
- Department of General Practice, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands.
| | - Veronique Bordonis
- Department of General Practice, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | - Martijn W Heymans
- Department of Epidemiology and Data Science, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | - Henriëtte G van der Roest
- Department on Aging, Netherlands Institute of Mental Health and Addiction (Trimbos Institute), Utrecht, The Netherlands
| | - Anja Declercq
- Center for Care Research & Consultancy (LUCAS) & Center for Sociological Research (CESO), KU Leuven, Leuven, Belgium
| | - Jan H Smit
- Department of Psychiatry, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | - Vjenka Garms-Homolova
- Department of Economics and Law, HTW Berlin University of Applied Sciences, Berlin, Germany
| | - Pálmi V Jónsson
- Department of Geriatrics, Landspitali University Hospital and Faculty of Medicine, University of Iceland, Reykjavík, Iceland
| | - Harriet Finne-Soveri
- Department of Wellbeing, National Institute for Health and Wellbeing, Helsinki, Finland
| | - Graziano Onder
- Department of Cardiovascular, Endocrine-Metabolic Diseases and Aging, Istituto Superiore di Sanità, Rome, Italy
| | - Karlijn J Joling
- Department of Medicine for Older People, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | - Otto R Maarsingh
- Department of General Practice, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | - Hein P J van Hout
- Department of General Practice, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands.,Department of Medicine for Older People, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
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Gentili S, Emberti Gialloreti L, Riccardi F, Scarcella P, Liotta G. Predictors of Emergency Room Access and Not Urgent Emergency Room Access by the Frail Older Adults. Front Public Health 2021; 9:721634. [PMID: 34540791 PMCID: PMC8446358 DOI: 10.3389/fpubh.2021.721634] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/06/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Emergency rooms (ERs) overcrowded by older adults have been the focus of public health policies during the recent COVID-19 outbreak too. This phenomenon needed a change in the nursing care of older frail people. Health policies have tried to mitigate the frequent use of ER by implementing community care to meet the care demands of older adults. The present study aimed to investigate the predictors of emergency room access (ERA) and not-urgent emergency room access (NUERA) of community-dwelling frail older adults in order to provide an indication for out-of-hospital care services. Method: Secondary analysis of an observational longitudinal cohort study was carried out. The cohort consisted of 1,246 community-dwelling frail older adults (over 65 years) in the Latium region in Italy. The ER admission rate was assessed over 3 years from the administration of the functional geriatric evaluation (FGE) questionnaire. The ordinal regression model was used to identify the predictors of ERA and NUERA. Moreover, the ERA and NUERA rate per 100 observations/year was analyzed. Results: The mean age was 73.6 (SD ± 7.1) years, and 53.4% were women. NUERAs were the 39.2% of the ERAs; robust and pre-frail individuals (79.3% of the sample) generated more than two-third of ERAs (68.17%), even if frails and very frails showed the higher ER rates per observation/year. The ordinal logistic regression model highlighted a predictive role on ERAs of comorbidity (OR = 1.13, p < 0.001) and frailty level (OR = 1.29; p < 0.001). Concerning NUERAs, social network (OR 0.54, P = 0.015) and a medium score of pulmo-cardio-vascular function (OR 1.50, P = 0.006) were the predictors. Conclusion: Comorbidity, lack of social support, and functional limitations increase both ERA and NUERA rates generated by the older adult population. Overall, bio-psycho-social frailty represents an indicator of the frequency of ERAs. However, to reduce the number of ERAs, intervention should focus mainly on the robust and pre-frail needs for prevention and care.
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Affiliation(s)
- Susanna Gentili
- Department of Biomedicine and Prevention, University of Rome "Tor Vergata,"Rome, Italy
| | | | - Fabio Riccardi
- Department of Biomedicine and Prevention, University of Rome "Tor Vergata,"Rome, Italy
| | - Paola Scarcella
- Department of Biomedicine and Prevention, University of Rome "Tor Vergata,"Rome, Italy
| | - Giuseppe Liotta
- Department of Biomedicine and Prevention, University of Rome "Tor Vergata,"Rome, Italy
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Cetin-Sahin D, McCusker J, Ciampi A, Cossette S, Vadeboncoeur A, Vu TTM, Veillette N, Ducharme F, Belzile E, Lachance PA, Mah R, Berthelot S. Front-line emergency department nurses' and physicians' assessments of processes of elder-friendly care for quality improvement. Int Emerg Nurs 2021; 58:101049. [PMID: 34509169 DOI: 10.1016/j.ienj.2021.101049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 06/10/2021] [Accepted: 06/23/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Geriatric emergency department (ED) care has gained increasing importance and interest due to increasing visits in seniors. AIM Among ED front-line nurses and physicians, to assess and compare ratings of elder-friendly care process indicators, variability in ratings, and concurrent validity of ratings. METHODS Four Quebec EDs' full-time registered nurses and physicians rated their geriatric care using 9 subscales. Nurse and physician subscale scores were compared. Inter-rater variability within disciplines and variability between nurses and physicians were measured. Associations between the subscale scores and perceived overall quality of care were tested. RESULTS 38 nurses and 36 physicians completed the survey (83% of 89 eligible). Scores differed by discipline for 3 of 9 subscales computed; nurses had higher mean scores on Protocols, Family-Centered Discharge, and Staff Education. Very high variation for Staff Education was found within disciplines. Variations for Family-Centered Discharge differed significantly between nurses and physicians. Almost all subscale scores were significantly positively associated with perceived overall quality of care. CONCLUSIONS ED nurses and physicians rate geriatric care components similarly except for protocols, discharge processes, and continuing education. The subscales have concurrent validity. Results suggest a need for improvement in continuing educational strategies with a particular attention to discharge processes.
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Affiliation(s)
- Deniz Cetin-Sahin
- St. Mary's Research Centre, St. Mary's Hospital Center, 3830 Avenue Lacombe, Suite 4720, Montreal, QC H3T 1M5, Canada; Department of Family Medicine, McGill University, 5858 chemin de la Côte-des-Neiges, Montreal, QC H3S 1Z1, Canada; Center for Research in Aging, Donald Berman Maimonides Geriatric Centre, 5795 Avenue Caldwell, Côte Saint-Luc, QC H4W 1W3, Canada.
| | - Jane McCusker
- St. Mary's Research Centre, St. Mary's Hospital Center, 3830 Avenue Lacombe, Suite 4720, Montreal, QC H3T 1M5, Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 1020 Avenue des Pins Ouest, Montreal, QC H3A 1A2, Canada.
| | - Antonio Ciampi
- St. Mary's Research Centre, St. Mary's Hospital Center, 3830 Avenue Lacombe, Suite 4720, Montreal, QC H3T 1M5, Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 1020 Avenue des Pins Ouest, Montreal, QC H3A 1A2, Canada.
| | - Sylvie Cossette
- University of Montreal, 2900 Edouard Montpetit Blvd, Montreal, QC H3T 1J4, Canada; Montreal Heart Institute Research Center, 5000 rue Bélanger, Montreal, QC H1T 1C8, Canada.
| | - Alain Vadeboncoeur
- University of Montreal, 2900 Edouard Montpetit Blvd, Montreal, QC H3T 1J4, Canada; Emergency Department, Montreal Heart Institute, rue 5000 Bélanger, Montreal, QC H1T 1C8, Canada.
| | - T T Minh Vu
- University of Montreal, 2900 Edouard Montpetit Blvd, Montreal, QC H3T 1J4, Canada; Research Centre, Institut universitaire de gériatrie de Montréal, 4545 chemin Queen Mary, Montreal, QC H3W 1W6, Canada; Centre hospitalier de l'Université de Montréal, 1051 Rue Sanguinet, Montreal, QC H2X 3E4, Canada.
| | - Nathalie Veillette
- University of Montreal, 2900 Edouard Montpetit Blvd, Montreal, QC H3T 1J4, Canada; Research Centre, Institut universitaire de gériatrie de Montréal, 4545 chemin Queen Mary, Montreal, QC H3W 1W6, Canada.
| | - Francine Ducharme
- University of Montreal, 2900 Edouard Montpetit Blvd, Montreal, QC H3T 1J4, Canada; Research Centre, Institut universitaire de gériatrie de Montréal, 4545 chemin Queen Mary, Montreal, QC H3W 1W6, Canada; Faculty of Nursing, Université de Montréal, Pavillon Marguerite-d'Youville, 2375, chemin de la Côte-Ste-Catherine, Montreal, QC H3T 1A8, Canada.
| | - Eric Belzile
- St. Mary's Research Centre, St. Mary's Hospital Center, 3830 Avenue Lacombe, Suite 4720, Montreal, QC H3T 1M5, Canada.
| | - Paul-André Lachance
- University of Montreal, 2900 Edouard Montpetit Blvd, Montreal, QC H3T 1J4, Canada; Hôpital Cité-de-la-Santé, 1755 Boulevard René-Laennec, Laval, QC H7M 3L9, Canada.
| | - Rick Mah
- St. Mary's Hospital Center, 3830 Avenue Lacombe, Emergency Department, Montreal, QC H3T 1M5, Canada; Department of Emergency Medicine, Faculty of Medicine, McGill University, 1001, boul. Décarie, D05.2017.2, Montreal, QC H4A 3J1, Canada.
| | - Simon Berthelot
- Centre de recherche du Centre hospitalier universitaire de Québec-Université Laval, 2705, boulevard Laurier, Quebec City, QC G1V 4G2, Canada.
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Conneely M, Robinson K, Leahy S, Trépel D, Jordan F, Galvin R. Effectiveness of interventions to reduce adverse outcomes among older adults following emergency department discharge: Protocol for an overview of systematic reviews. HRB Open Res 2021; 3:27. [PMID: 33969262 PMCID: PMC8078215 DOI: 10.12688/hrbopenres.13027.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2021] [Indexed: 11/13/2023] Open
Abstract
Background: Older adults are frequent users of Emergency departments (ED) and this trend will continue due to population ageing and the associated increase in healthcare needs. Older adults are vulnerable to adverse outcomes following ED discharge. A number of heterogeneous interventions have been developed and implemented to improve clinical outcomes among this cohort. A growing number of systematic reviews have synthesised evidence regarding ED interventions using varying methodologies. This overview aims to synthesise the totality of evidence in order to evaluate the effectiveness of interventions to reduce adverse outcomes in older adults discharged from the ED. Methods: To identify relevant reviews, the following databases will be searched: Cochrane Database of Systematic reviews, Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Databases of Abstracts of Reviews of Effects, PubMed, MEDLINE, Epistemonikos, Ageline, Embase, PEDro, Scopus, CINAHL and the PROSPERO register. The search for grey literature will include Open Grey and Grey Literature Reports. Systematic reviews of randomised controlled trials will be analysed to assess the effect of ED interventions on clinical and process outcomes in older adults. Methodological quality of the reviews will be assessed using the Assessment of Multiple Systematic Reviews 2 tool. The review will be reported in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Summary of findings will include a hierarchical rank of interventions based on estimates of effects and the quality of evidence. Discussion: This overview is required given the number of systematic reviews published regarding the effectiveness of various ED interventions for older adults at risk of adverse outcomes following discharge from the ED. There is a need to examine the totality of evidence using rigorous analytic techniques to inform best care and potentially develop a hierarchy of treatment options. PROSPERO registration: CRD42020145315 (28/04/2020).
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Affiliation(s)
- Mairéad Conneely
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland, V94 TPPX, Ireland
| | - Katie Robinson
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland, V94 TPPX, Ireland
| | - Siobhán Leahy
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland, V94 TPPX, Ireland
| | - Dominic Trépel
- Trinity Institute of Neurosciences, School of Medicine, Trinity College Dublin, Dublin, Ireland, DO2 PN40, Ireland
| | - Fionnuala Jordan
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland, H91 TK33, Ireland
| | - Rose Galvin
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland, V94 TPPX, Ireland
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Conneely M, Robinson K, Leahy S, Trépel D, Jordan F, Galvin R. Effectiveness of interventions to reduce adverse outcomes among older adults following emergency department discharge: Protocol for an overview of systematic reviews. HRB Open Res 2021; 3:27. [PMID: 33969262 PMCID: PMC8078215 DOI: 10.12688/hrbopenres.13027.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2021] [Indexed: 12/23/2022] Open
Abstract
Background: Older adults are frequent users of Emergency departments (ED) and this trend will continue due to population ageing and the associated increase in healthcare needs. Older adults are vulnerable to adverse outcomes following ED discharge. A number of heterogeneous interventions have been developed and implemented to improve clinical outcomes among this cohort. A growing number of systematic reviews have synthesised evidence regarding ED interventions using varying methodologies. This overview aims to synthesise the totality of evidence in order to evaluate the effectiveness of interventions to reduce adverse outcomes in older adults discharged from the ED. Methods: To identify relevant reviews, the following databases will be searched: Cochrane Database of Systematic reviews, Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Databases of Abstracts of Reviews of Effects, PubMed, MEDLINE, Epistemonikos, Ageline, Embase, PEDro, Scopus, CINAHL and the PROSPERO register. The search for grey literature will include Open Grey and Grey Literature Reports. Systematic reviews of randomised controlled trials will be analysed to assess the effect of ED interventions on clinical and process outcomes in older adults. Methodological quality of the reviews will be assessed using the Assessment of Multiple Systematic Reviews 2 tool. The review will be reported in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Summary of findings will include a hierarchical rank of interventions based on estimates of effects and the quality of evidence. Discussion: This overview is required given the number of systematic reviews published regarding the effectiveness of various ED interventions for older adults at risk of adverse outcomes following discharge from the ED. There is a need to examine the totality of evidence using rigorous analytic techniques to inform best care and potentially develop a hierarchy of treatment options. PROSPERO registration: CRD42020145315 (28/04/2020).
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Affiliation(s)
- Mairéad Conneely
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland, V94 TPPX, Ireland
| | - Katie Robinson
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland, V94 TPPX, Ireland
| | - Siobhán Leahy
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland, V94 TPPX, Ireland
| | - Dominic Trépel
- Trinity Institute of Neurosciences, School of Medicine, Trinity College Dublin, Dublin, Ireland, DO2 PN40, Ireland
| | - Fionnuala Jordan
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland, H91 TK33, Ireland
| | - Rose Galvin
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland, V94 TPPX, Ireland
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Kayser J, Morrow-Howell N, Rosen TE, Skees S, Doering M, Clark S, Hurka-Richardson K, Bin Shams R, Ringer T, Hwang U, Platts-Mills TF, Network TG. Research priorities for elder abuse screening and intervention: A Geriatric Emergency Care Applied Research (GEAR) network scoping review and consensus statement. J Elder Abuse Negl 2021; 33:123-144. [PMID: 33797344 PMCID: PMC8204570 DOI: 10.1080/08946566.2021.1904313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The Geriatric Emergency Care Applied Research (GEAR) Network (1) conducted a scoping review of the current literature on the identification of and interventions to address elder abuse among patients receiving care in emergency departments and (2) used this review to prioritize research questions for knowledge development. Two questions guided the scoping review: What is the effect of universal emergency department screening compared to targeted screening or usual practice on cases of elder abuse identified, safety outcomes, and health care utilization?; and What is the safety, health, legal, and psychosocial impact of emergency department-based interventions vs. usual care for patients experiencing elder abuse? We searched five article databases. Additional material was located through reference lists of identified publications, PsychInfo, and Google Scholar. The results were discussed in a consensus conference; and stakeholders voted to prioritize research questions. No studies were identified that directly addressed the first question regarding assessment strategies, but four instruments used for elder abuse screening in the emergency department were identified. For the second question, we located six articles on interventions for elder abuse in the emergency department; however, none directly addressed the question of comparative effectiveness. Based on these findings, GEAR participants identified five questions as priorities for future research - two related to screening, two related to intervention, and one encompassed both. In sum, research to identify best practices for elder abuse assessment and intervention in emergency departments is still needed. Although there are practical and ethical challenges, rigorous experimental studies are needed.
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Affiliation(s)
- Jay Kayser
- School of Social Work, University of Michigan - Ann Arbor, Ann Arbor, Michigan, USA.,Department of Developmental Psychology, University of Michigan - Ann Arbor, Ann Arbor, Michigan, USA
| | - Nancy Morrow-Howell
- Brown School of Social Work, Washington University, St. Louis, Missouri, USA
| | - Tony E Rosen
- Department of Emergency Medicine, Weill Cornell Medicine, New York - Presbyterian Hospital, New York, USA
| | - Stephanie Skees
- Brown School of Social Work, Washington University, St. Louis, Missouri, USA
| | - Michelle Doering
- Becker Medical Library, Washington University, St Louis, Missouri, USA
| | - Sunday Clark
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Karen Hurka-Richardson
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Rayad Bin Shams
- Quantworks, Inc, Healthcare and Life Sciences, Carrboro, North Carolina, USA
| | - Thom Ringer
- Department of Emergency Medicine, Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada.,Department of Emergency Medicine, Schwartz/Reisman Emergency Centre, Mount Sinai Hospital, Toronto, Ontario, Canada.,Department of Emergency Medicine, University Health Network, Toronto, Ontario, Canada
| | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Mota-Romero E, Tallón-Martín B, García-Ruiz MP, Puente-Fernandez D, García-Caro MP, Montoya-Juarez R. Frailty, Complexity, and Priorities in the Use of Advanced Palliative Care Resources in Nursing Homes. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:70. [PMID: 33466767 PMCID: PMC7830978 DOI: 10.3390/medicina57010070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/07/2021] [Accepted: 01/10/2021] [Indexed: 12/28/2022]
Abstract
Background and objectives: This study aimed to determine the frailty, prognosis, complexity, and palliative care complexity of nursing home residents with palliative care needs and define the characteristics of the cases eligible for receiving advanced palliative care according to the resources available at each nursing home. Materials and Methods: In this multi-centre, descriptive, and cross-sectional study, trained nurses from eight nursing homes in southern Spain selected 149 residents with palliative care needs. The following instruments were used: the Frail-VIG index, the case complexity index (CCI), the Diagnostic Instrument of Complexity in Palliative Care (IDC-Pal), the palliative prognosis index, the Barthel index (dependency), Pfeiffer's test (cognitive impairment), and the Charlson comorbidity index. A consensus was reached on the complexity criteria of the Diagnostic Instrument of Complexity in Palliative Care that could be addressed in the nursing home (no priority) and those that required a one-off (priority 2) or full (priority 1) intervention of advanced palliative care resources. Non-parametric tests were used to compare non-priority patients and patients with some kind of priority. Results: A high percentage of residents presented frailty (80.6%), clinical complexity (80.5%), and palliative care complexity (65.8%). A lower percentage of residents had a poor prognosis (10.1%) and an extremely poor prognosis (2%). Twelve priority 1 and 14 priority 2 elements were identified as not matching the palliative care complexity elements that had been previously identified. Of the studied cases, 20.1% had priority 1 status and 38.3% had priority 2 status. Residents with some kind of priority had greater levels of dependency (p < 0.001), cognitive impairment (p < 0.001), and poorer prognoses (p < 0.001). Priority 1 patients exhibited higher rates of refractory delirium (p = 0.003), skin ulcers (p = 0.041), and dyspnoea (p = 0.020). Conclusions: The results indicate that there are high levels of frailty, clinical complexity, and palliative care complexity in nursing homes. The resources available at each nursing home must be considered to determine when advanced palliative care resources are required.
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Affiliation(s)
- Emilio Mota-Romero
- Primary Care Center Dr. Salvador Caballero García Andalusian, Health Service, Government of Andalusia, 18012 Granada, Andalusia, Spain;
| | | | | | - Daniel Puente-Fernandez
- Doctoral Program in Clinical Medicine and Public Health, University of Granada, 18016 Granada, Andalusia, Spain
| | - María P. García-Caro
- Department of Nursing, Mind, Brain and Behaviour Research Institute, University of Granada, 18016 Granada, Andalusia, Spain; (M.P.G.-C.); (R.M.-J.)
| | - Rafael Montoya-Juarez
- Department of Nursing, Mind, Brain and Behaviour Research Institute, University of Granada, 18016 Granada, Andalusia, Spain; (M.P.G.-C.); (R.M.-J.)
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Moe J, O'Sullivan F, McGregor MJ, Schull MJ, Dong K, Holroyd BR, Grafstein E, Hohl CM, Trimble J, McGrail KM. Characteristics of frequent emergency department users in British Columbia, Canada: a retrospective analysis. CMAJ Open 2021; 9:E134-E141. [PMID: 33653768 PMCID: PMC8034376 DOI: 10.9778/cmajo.20200168] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Frequent emergency department users disproportionately account for rising health care costs. We aimed to characterize frequent emergency department users in British Columbia, Canada. METHODS We performed a retrospective analysis using health administrative databases. We included patients aged 18 years or more with at least 1 emergency department visit from 2012/13 to 2015/16, linked to hospital, physician billing, prescription and mortality data. We used annual emergency department visits made by the top 10% of patients to define frequent users (≥ 3 visits/year). RESULTS Over the study period, 13.8%-15.3% of patients seen in emergency departments were frequent users. We identified 205 136 frequent users among 1 196 353 emergency department visitors. Frequent users made 40.3% of total visits in 2015/16. From 2012/13 to 2015/16, their visit rates per 100 000 BC population showed a relative increase of 21.8%, versus 13.1% among all emergency department patients. Only 1.8% were frequent users in all study years. Mental illness accounted for 8.2% of visits among those less than 60 years of age, and circulatory or respiratory diagnoses for 13.3% of visits among those aged 60 or more. In 2015/16, frequent users were older and had lower household incomes than nonfrequent users; the sex distribution was similar. Frequent users had more prescriptions (median 9, interquartile range [IQR] 5-14 v. 1, IQR 1-3), primary care visits (median 15, IQR 9-27 v. 7, IQR 4-12) and hospital admissions (median 2, IQR 1-3 v. 1, IQR 1-1), and higher 1-year mortality (10.2% v. 3.5%) than nonfrequent users. INTERPRETATION Emergency department use by frequent users increased in BC between 2012/13 and 2015/16; these patients were heterogenous, had high mortality and rarely remained frequent users over multiple years. Our results suggest that interventions must account for heterogeneity and address triggers of frequent use episodes.
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Affiliation(s)
- Jessica Moe
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Fiona O'Sullivan
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Margaret J McGregor
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Michael J Schull
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Kathryn Dong
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Brian R Holroyd
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Eric Grafstein
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Corinne M Hohl
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Johanna Trimble
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Kimberlyn M McGrail
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
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Bazargan M, Cobb S, Assari S. Discrimination and Medical Mistrust in a Racially and Ethnically Diverse Sample of California Adults. Ann Fam Med 2021; 19:4-15. [PMID: 33431385 PMCID: PMC7800756 DOI: 10.1370/afm.2632] [Citation(s) in RCA: 118] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 10/30/2020] [Accepted: 11/02/2020] [Indexed: 01/15/2023] Open
Abstract
PURPOSE Although we know that racial and ethnic minorities are more likely to have mistrust in the health care system, very limited knowledge exists on correlates of such medical mistrust among this population. In this study, we explored correlates of medical mistrust in a representative sample of adults. METHODS We analyzed cross-sectional study data from the Survey of California Adults on Serious Illness and End-of-Life 2019. We ascertained race/ethnicity, health status, perceived discrimination, demographics, socioeconomic factors, and medical mistrust. For data analysis, we used multinomial logistic regression models. RESULTS Analyses were based on 704 non-Hispanic Black adults, 711 Hispanic adults, and 913 non-Hispanic White adults. Racial/ethnic background was significantly associated with the level of medical mistrust. Adjusting for all covariates, odds of reporting medical mistrust were 73% higher (adjusted odds ratio [aOR] = 1.73; 95% CI, 1.15-2.61, P <.01) and 49% higher (aOR = 1.49; 95% CI, 1.02-2.17, P <.05) for non-Hispanic Black and Hispanic adults when compared with non-Hispanic White adults, respectively. Perceived discrimination was also associated with higher odds of medical mistrust. Indicating perceived discrimination due to income and insurance was associated with 98% higher odds of medical mistrust (aOR = 1.98; 95% CI, 1.71-2.29, P <.001). Similarly, the experience of discrimination due to racial/ethnic background and language was associated with a 25% increase in the odds of medical mistrust (aOR = 1.25; 95% CI, 1.10-1.43; P <.001). CONCLUSIONS Perceived discrimination is correlated with medical mistrust. If this association is causal, that is, if perceived discrimination causes medical mistrust, then decreasing such discrimination may improve trust in medical clinicians and reduce disparities in health outcomes. Addressing discrimination in health care settings is appropriate for many reasons related to social justice. More longitudinal research is needed to understand how complex societal, economic, psychological, and historical factors contribute to medical mistrust. This type of research may in turn inform the design of multilevel community- and theory-based training models to increase the structural competency of health care clinicians so as to reduce medical mistrust.
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Affiliation(s)
- Mohsen Bazargan
- Department of Family Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, California
- Department of Public Health, Charles R. Drew University of Medicine and Science, Los Angeles, California
- Physician Assistant Program, Charles R. Drew University of Medicine and Science, Los Angeles, California
- Department of Family Medicine, University of California, Los Angeles, Los Angeles, California
| | - Sharon Cobb
- School of Nursing, Charles R. Drew University of Medicine and Science, Los Angeles, California
| | - Shervin Assari
- Department of Family Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, California
- Department of Public Health, Charles R. Drew University of Medicine and Science, Los Angeles, California
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Dufour I, Dubuc N, Chouinard MC, Chiu Y, Courteau J, Hudon C. Profiles of Frequent Geriatric Users of Emergency Departments: A Latent Class Analysis. J Am Geriatr Soc 2020; 69:753-761. [PMID: 33156527 DOI: 10.1111/jgs.16921] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 10/02/2020] [Accepted: 10/15/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES Frequent geriatric users of emergency departments (EDs) represent a complex and heterogeneous population. Identifying their specific subgroups would allow the development of interventions better customized to their needs and characteristics. Thus, this study aimed to develop profiles of frequent geriatric ED users using the individual characteristics of patients. DESIGN This was a retrospective cohort study. SETTING Databases from the Régie de l'assurance maladie du Québec (RAMQ) were utilized. PARTICIPANTSThis study included individuals aged 65 years or older living in the community in the Province of Quebec (Canada), who consulted in an ED at least four times in the year after an ED index date (an ED visit, chosen randomly, during an index period of January 1, 2012 to December 31, 2013) and who had received a diagnosis of ambulatory care-sensitive conditions (ACSCs) in the 2 years preceding the index date. MEASUREMENTS A latent class analysis was used to identify subgroups of frequent geriatric ED users according to their individual characteristics, including ACSC type, dementia, mental health disorders, cancer diagnosis, and comorbidity index. RESULTS The study cohort consisted of 21,393 frequent geriatric ED users. Four groups of frequent geriatric ED users were identified: people with low comorbidity (39.0%), comprising the individuals with the lowest number of physical and mental health conditions; people with cancer (32.7%); people with pulmonaryand cardiac diseases (18.1%); and people with dementia or mental health disorders (10.2%), composed of individuals with the highest proportion of common and severe mental health disease, as well as dementia. This group accounts for the highest use of overall healthcare services. CONCLUSION These profiles will be useful in developing customized interventions addressing the needs of each subgroup of frequent geriatric ED users. More research is needed to bridge the remaining gaps, especially regarding the healthiest frequent geriatric users of EDs.
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Affiliation(s)
- Isabelle Dufour
- École des sciences infirmières, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Canada
| | - Nicole Dubuc
- École des sciences infirmières, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Canada
| | | | - Yohann Chiu
- Département de médecine de famille et de médecine d'urgence, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Canada
| | - Josiane Courteau
- Groupe de recherche PRIMUS, Centre de recherche du Centre hospitalier universitaire de Sherbrooke (CRCHUS), Sherbrooke, Canada
| | - Catherine Hudon
- Département de médecine de famille et de médecine d'urgence, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Canada
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Oliveira J E Silva L, Jeffery MM, Campbell RL, Mullan AF, Takahashi PY, Bellolio F. Predictors of return visits to the emergency department among different age groups of older adults. Am J Emerg Med 2020; 46:241-246. [PMID: 33071094 DOI: 10.1016/j.ajem.2020.07.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/24/2020] [Accepted: 07/16/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE To identify predictors of 30-day emergency department (ED) return visits in patients age 65-79 years and age ≥ 80 years. METHODS This was a cohort study of older adults who presented to the ED over a 1-year period. A mixed-effects logistic regression model was used to identify predictors for returning to the ED within 30 days. We stratified the cohort into those aged 65-79 years and aged ≥80 years. Adjusted odds ratios (aORs) with 95% confidence intervals (CI) were reported. This study adhered to the STROBE reporting guidelines. RESULTS A total of 21,460 ED visits representing 14,528 unique patients were included. The overall return rate was 15% (1998/13,300 visits) for age 65-79 years, and 16% (1306/8160 visits) for age ≥ 80 years. A history of congestive heart failure (CHF), dementia, or prior hospitalization within 2 years were associated with increased odds of returning in both age groups (for age 65-79: CHF aOR 1.36 [CI 1.16-1.59], dementia aOR 1.27 [CI 1.07-1.49], prior hospitalization aOR 1.36 [CI 1.19-1.56]; for age ≥ 80: CHF aOR 1.32 [CI 1.13-1.55], dementia aOR 1.22 [CI 1.04-1.42], and prior hospitalization aOR 1.27 [CI 1.09-1.47]). Being admitted from the ED was associated with decreased odds of returning to the ED within 30 days (aOR 0.72 [CI 0.64-0.80] for age 65-79 years and 0.72 [CI 0.63-0.82] for age ≥ 80). CONCLUSION Age alone was not an independent predictor of return visits. Prior hospitalization, dementia and CHF were predictors of 30-day ED return. The identification of predictors of return visits may help to optimize care transition in the ED.
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Affiliation(s)
| | - Molly M Jeffery
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department of Health Science Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
| | - Aidan F Mullan
- Department of Biostatistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Paul Y Takahashi
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department of Health Science Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA.
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Nishioka D, Saito J, Ueno K, Kondo N. Frequent outpatient attendance among people on the governmental welfare programme in Japan: assessing both patient and supplier characteristics. BMJ Open 2020; 10:e038663. [PMID: 33077566 PMCID: PMC7574951 DOI: 10.1136/bmjopen-2020-038663] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Using linkage data from two municipal public assistance databases and medical assistance claim data, this study aimed to identify characteristics associated with frequent outpatient attendance by people on public assistance, who can access medical care services without copayment in Japan, with simultaneous consideration of supplier factors. DESIGN We performed a retrospective cohort study. SETTING We used secondary data from the public assistance databases of two suburban municipalities in Japan. PARTICIPANTS The study population included all adults on public assistance in January 2016, who were observed until December 2016. A total of 6016 people was included in the analysis. Among them, 2956 (49.1%) were men, and 2030 (33.7%) were living alone. OUTCOME MEASURE We adopted the definition of frequent outpatient attendance by the Japanese Ministry of Health, Labour and Welfare, visiting the same medical facility 15 times or more in a month for the same health problem. RESULTS Of 6016 included people, 139 (2.3%) were engaged in frequent outpatient attendance. Multiple Poisson regression showed that, as for the individual factors, the adjusted incidence ratio for frequent outpatient attendance was 1.58 (95% CI 1.05 to 2.39) for people living alone (vs living with others). As for the suppliers, the adjusted incidence ratio for frequent outpatient attendance was 1.74 (95% CI 1.20 to 2.52) for private institutions (vs medical corporations). There were no significant associations between frequent outpatient attendance and individual disability certificate or long-term care needs. CONCLUSIONS This study suggests that among recipients of public assistance who can access medical services without copayment, social isolation may be associated with frequent outpatient attendance. Private clinics may also be associated with this phenomenon. Interventions to prevent social isolation-by for example, providing health and social care in a more integrated manner-may thus be efficacious in reducing the healthcare demands of socially vulnerable individuals.
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Affiliation(s)
- Daisuke Nishioka
- Department of Health and Social Behavior, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
- Department of Social Epidemiology and Global Health, Graduate School of Medicine and School of Public Health, Kyoto University, Kyoto, Japan
| | - Junko Saito
- Behavioral Science Division, Behavioral Sciences and Survivorship Research Group, Center for Public Health Sciences, National Cancer Center Japan, Tokyo, Japan
| | - Keiko Ueno
- Department of Health and Social Behavior, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Naoki Kondo
- Department of Health and Social Behavior, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
- Department of Social Epidemiology and Global Health, Graduate School of Medicine and School of Public Health, Kyoto University, Kyoto, Japan
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Jones A, Bronskill SE, Seow H, Junek M, Feeny D, Costa AP. Associations between continuity of primary and specialty physician care and use of hospital-based care among community-dwelling older adults with complex care needs. PLoS One 2020; 15:e0234205. [PMID: 32559214 PMCID: PMC7304563 DOI: 10.1371/journal.pone.0234205] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 05/20/2020] [Indexed: 12/21/2022] Open
Abstract
Objective While research suggests that higher continuity of primary and specialty physician care can improve patient outcomes, their effects have rarely been examined and compared concurrently. We investigated associations between continuity of primary and specialty physician care and emergency department visits and hospital admissions among community-dwelling older adults with complex care needs. Methods We conducted a retrospective cohort study of home care patients in Ontario, Canada, from October 2014 to September 2016. We measured continuity of primary and specialty physician care over the two years prior to a home care assessment and categorized them into low, medium, and high groups using terciles of the distribution. We used Cox regression models to concurrently test the associations between continuity of primary and specialty care and risk of an emergency department visit and hospital admission within six months of assessment, controlling for potential confounders. We examined interactions between continuity of care and count of chronic conditions, count of physician specialties seen, functional impairment, and cognitive impairment. Results Of 178,686 participants, 49% had an emergency department visit during follow-up and 27% had a hospital admission. High vs. low continuity of primary care was associated with a reduced risk of an emergency department visit (HR = 0.90 (0.89–0.92)) as was continuity of specialty care (HR = 0.93 (0.91–0.95)). High vs. low continuity of primary care was associated also with a reduced risk of a hospital admission (HR = 0.94 (0.92–0.96)) as was continuity of specialty care (HR = 0.92 (0.90–0.94)). The effect of continuity of specialty care was moderately stronger among patients who saw four or more physician specialties. Conclusion Higher continuity of primary physician and specialty physician care had independent, protective effects of similar magnitude against emergency department use and hospital admissions. Improving continuity of specialty care should be a priority alongside improving continuity of primary care in complex, older adult populations with significant specialist use.
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Affiliation(s)
- Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- * E-mail:
| | - Susan E. Bronskill
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| | - Hsien Seow
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Mats Junek
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - David Feeny
- Department of Economics, McMaster University, Hamilton, Ontario, Canada
| | - Andrew P. Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Saljuqi AT, Hanna K, Asmar S, Tang A, Zeeshan M, Gries L, Ditillo M, Kulvatunyou N, Castanon L, Joseph B. Prospective Evaluation of Delirium in Geriatric Patients Undergoing Emergency General Surgery. J Am Coll Surg 2020; 230:758-765. [PMID: 32088308 DOI: 10.1016/j.jamcollsurg.2020.01.029] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/22/2020] [Accepted: 01/22/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND The prevalence of delirium and its impact on outcomes after emergency general surgery (EGS) remain unexplored. The aims of our study were to assess the impact of frailty on delirium and the impact of delirium on outcomes in geriatric EGS patients. STUDY DESIGN We performed a 1-year (2017) prospective cohort analysis of all geriatric (age ≥ 65 years) patients who underwent EGS. Frailty was calculated using the Emergency General Surgery-Specific Frailty Index (ESFI). Delirium was assessed using the Confusion Assessment Method (CAM). Patients were dichotomized as delirious or non-delirious. We performed regression analysis controlling for demographics, admission vitals, American Society of Anesthesiologists (ASA) score, comorbidity, and the diagnosis and type of surgery. RESULTS A total of 163 patients underwent emergency general surgery and were included. Mean age was 71 ± 7 years, and 59% were male. Overall, the incidence of postoperative delirium was 26%. Patients who developed postoperative delirium were more likely to be frail (40% vs 14%, p < 0.01), on more than 3 medications (29% vs 18%, p < 0.01), and were more likely to have 3 or more comorbidities (32% vs 21%, p < 0.01). On regression analysis, frail status (odds ratio [OR] 3.7 [2.4-4.2], p < 0.01) and receiving more than 3 medications (OR 1.3 [range 1.1-1.4], p < 0.01) were independent predictors of developing postoperative delirium. An episode of delirium was associated with longer hospital length of stay (LOS) (6 days vs 3 days, p < 0.01), higher odds of ICU admission (OR 2 [1.3-4.5], p < 0.01), longer ICU LOS (2 days vs 1 day, p < 0.01), and higher odds of unplanned intubation (OR 1.8 [1.2-3.4], p < 0.01). CONCLUSIONS The incidence of delirium after EGS was 26%. Frailty and polypharmacy were associated with increased risk of delirium. Delirium appears to be associated with higher rates of in-hospital adverse events.
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Affiliation(s)
- Abdul Tawab Saljuqi
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
| | - Kamil Hanna
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
| | - Samer Asmar
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
| | - Andrew Tang
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
| | - Muhammad Zeeshan
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
| | - Lynn Gries
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
| | - Michael Ditillo
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
| | - Narong Kulvatunyou
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
| | - Lourdes Castanon
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
| | - Bellal Joseph
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ.
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Dufour I, Chiu Y, Courteau J, Chouinard MC, Dubuc N, Hudon C. Frequent emergency department use by older adults with ambulatory care sensitive conditions: A population-based cohort study. Geriatr Gerontol Int 2020; 20:317-323. [PMID: 32017348 PMCID: PMC7187263 DOI: 10.1111/ggi.13875] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 01/13/2020] [Indexed: 01/18/2023]
Abstract
Aim To identify factors associated with frequent emergency department (ED) use among older adults with ambulatory care sensitive conditions. Methods This was a retrospective cohort study using databases from the Régie de l'assurance maladie du Québec. We included community‐dwelling individuals aged ≥65 years in the Province of Quebec (Canada), who consulted in ED at least once between 2012 and 2013 (index period), and were diagnosed with at least one ambulatory care sensitive condition in the 2 years preceding and including the index date (n = 264 473). We used a multivariate logistic regression model to evaluate the association between independent variables and being a frequent geriatric ED user, defined as four or more visits during the year after the index date. Results Out of the total study population, 17 332 (6.6%) individuals were considered frequent ED users in the year after the index date, accounting for 38% of ED uses for this period. The main variables associated with frequent geriatric ED use were older age, presence of chronic obstructive pulmonary disorder or diabetes, higher comorbidity index, common mental health disorders, polypharmacy, higher number of past ED and specialist visits, rural residence, and higher material and social deprivation. Dementia was inversely associated with frequent ED use. Conclusions Frequent geriatric ED users constitute a complex population whose characteristics need to be managed thoroughly in order to enhance the quality and efficiency of their care. Further studies should address their description in administrative databases so as to combine self‐perceived and professionally evaluated variables. Geriatr Gerontol Int 2020; 20: 317–323.
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Affiliation(s)
- Isabelle Dufour
- School of Nursing, Department of Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Yohann Chiu
- Department of Family and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Josiane Courteau
- Department of Family and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | | | - Nicole Dubuc
- School of Nursing, Department of Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Catherine Hudon
- Department of Family and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada.,PRIMUS Research Group, Centre de recherche du Centre hospitalier universitaire de Sherbrooke (CRCHUS)
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