Validade preditiva de instrumento para identificação do idoso em risco de hospitalização

Development and validation of predictive model for long-term hospitalization, readmission, and in-hospital death of patients over 60 years old

Objective

To develop and validate a high-risk predictive model that identifies, at least, one common adverse event in older population: early readmission (up to 30 days after discharge), long hospital stays (10 days or more) or in-hospital deaths.

Methods

This was a retrospective cohort study including patients aged 60 years or older (n=340) admitted at a 630-beds tertiary hospital, located in the city of São Paulo, Brazil. A predictive model of high-risk indication was developed by analyzing logistical regression models. This model prognostic capacity was assessed by measuring accuracy, sensitivity, specificity, and positive and negative predictive values. Areas under the receiver operating characteristic curve with 95% confidence intervals were also obtained to assess the discriminatory power of the model. Internal validation of the prognostic model was performed in a separate sample (n=168).

Results

Statistically significant predictors were identified, such as current Barthel Index, number of medications in use, presence of diabetes mellitus, difficulty chewing or swallowing, extensive surgery, and dementia. The study observed discrimination model acceptance in the construction sample 0.77 (95% confidence interval: 0.71-0.83) and good calibration. The characteristics of the validation samples were similar, and the receiver operating characteristic curve area was 0.687 (95% confidence interval: 0.598-0.776). We could assess an older patient’s adverse health events during hospitalization after admission.

Conclusion

A predictive model with acceptable discrimination was obtained, with satisfactory results for early readmission (30 days), long hospital stays (10 days), or in-hospital death.

Analysis of Medical Management in Geriatric Patients in the Hospital Emergency Department by Example of Selected Cities with County Status in Poland: A Retrospective Cohort Study

The aim of this study was to analyse medical management in geriatric patients in the Hospital Emergency Departments in the Biała Podlaska County and Chełm County (Poland) between 2016 and 2018 in a group of patients ≥65 years of age. We analysed medical records of 829 patients transported to Hospital Emergency Departments by Medical Emergency Teams. The research was conducted in the period from June 2019 to March 2020. We analysed emergency medical procedure forms and medical records of patients transported to the hospitals. Cardiovascular diseases were diagnosed in 40% of patients. Mortality cases accounted for 3.1% of the 1200 interventions analysed. Ambulance dispatch resulted in the patient being transported to the Hospital Emergency Departments in more than ²/₃ of cases. The concordance between the diagnoses made by the Medical Emergency Teams and those made at the Hospital Emergency Departments was confirmed for 78% patients admitted to the department (n = 647), whereas the concordance of classification at the group level was estimated at 71.7% (n = 594). Further in-patient treatment was initiated in some of the patients admitted to the department (n = 385). The mean time of hospital stay was 10.1 days. In conclusion, differences between the initial diagnosis made by the heads of the Medical Emergency Teams and the diagnosis made by the doctor on duty in the Hospital Emergency Departments depended on the chapter of diseases in the ICD-10 classification, but they were acceptable. The majority of the patients were transported to Hospital Emergency Departments. The most common groups of diseases that require Hospital Emergency Departments admission include cardiovascular diseases, injuries due to external causes, and respiratory diseases. A moderate percentage of patients were qualified for further specialist treatment in hospital departments.

Screening for vulnerable older people: Is the Probability of Repeated Admission scale an accurate tool?

AIM

To evaluate the Probability of Repeated Admission (Pra) scale performance in predicting healthcare utilization and death in a community sample of Rio de Janeiro city, Brazil.

METHODS

This was a prospective longitudinal study. The sample was composed of community-dwelling older people who participated in the research network Frailty in Brazilian Older People Study, Rio de Janeiro section. It analyzed data from the baseline and the follow up. At the baseline, 764 older adults were stratified by the Pra, and, 3 years later, data on health services utilization and survival status were collected. The Pra accuracy, obtained by the area under the curve, the sensitivity and the specificity to predict hospitalization in 3 years; visits to the emergency department; and death were determined. Cox regression estimated the survival curves, according to the risk strata.

RESULTS

The accuracy, the sensitivity and the specificity of Pra were 62% (95% CI 57-68%), 8.8% and 95.4% for hospitalization in 3 years; 59% (95% CI 53-64%), 8.3% and 94.8% for emergency room visits; 66% (95% CI 59-74%) and 68% (95% CI 63-73%), 15.0% and 96.0% for death. Survival curves showed that high-risk individuals were more likely to die compared with the low-risk individuals, adjusted to covariables (P < 0.001).

CONCLUSIONS

The Pra presented low accuracy, low sensitivity and high specificity for all outcomes observed, indicating a poor performance to screen vulnerable older adults in Brazil. Therefore, this tool should not be used alone, as a case-finding instrument. Geriatr Gerontol Int 2020; 20: 360-365.

Risk of hospitalization of elderly rural workers in the state of Rio Grande do Sul

Abstract Objective : To analyze the risk of hospitalization of elderly rural workers in the state of Rio Grande do Sul, Brazil. Method : A cross-sectional, population-based study was carried out of retired rural workers (N=604), over 60 years of age, of both genders, selected by clusters. In order to evaluate the risk of hospitalization, the Probability of Repeated Hospitalization (or PIR) instrument validated and evaluated for Brazil was used. Risk of hospitalization was calculated through logistic regression analysis, and was classified into the following strata: low (<0.300); medium (0.300-0.399); medium-high (0.400-0.499) and high (≥0.500). Results : The rural elderly persons surveyed had a low risk of hospitalization (n=553; 91.6%). There was a predominance of men among the medium to high risk categories (n=42; 82.3%), distributed mainly in the Santa Maria, Sul and Camaquã regions. Conclusion: The results of the present study suggest a low risk of hospitalization among this population, however, there is a need for improved, more profound and robust research into the identification of factors associated with the health specificities of this population.

Identifying Older Patients at High Risk for Emergency Department Visits and Hospitalization

Hospitalizations are costly, potentially hazardous for older patients, and sometimes preventable. With Medicare's implementation of hospital penalties for 30-day readmissions on certain index conditions, health care organizations have prioritized addressing those issues that lead to avoidable hospitalizations. Little is known about the utility and feasibility of using standardized tools to identify adults at risk for hospitalizations in primary care. In this study, the goal was to determine, from a sample of 60 adults aged 65 and older, whether the Probability of Repeat Admission (PRA), the Vulnerable Elders Survey (VES-13), or a provider estimate of likelihood of hospitalization could identify patients at high risk for emergency department (ED) visits or hospitalization at 6 and 12 months, while being feasible to administer in a primary care setting. PRA, VES-13, and provider estimate were administered in an outpatient practice. Number of ED visits and hospitalizations at 6 and 12 months were assessed through follow-up phone calls and chart review. PRA and provider estimate were not significant predictors of hospitalizations at 6 months (PRA odds ratio [OR] 1.95; P = 0.39; physician estimate OR 4.33, P = 0.08), but were at 12 months (PRA OR 6.00; P < 0.001; physician estimate OR 2.3; P < 0.05). Additionally, a hospitalization during the prior year was not a significant predictor of hospitalization at 6 months (OR 2.97; P = 0.15) but was at 12 months (OR 3.89, P < 0.05). No tool was a significant predictor of ED visits at either time. PRA and the physician estimate were easy to administer and feasible to implement in a primary care setting.

A associação entre capacidade física e probabilidade de internação hospitalar em idosos que vivem na comunidade

RESUMO O crescimento da população idosa exige reorganização política, econômica e social, em especial na área da saúde, devido ao impacto sobre esta. A avaliação da Probabilidade de Internação Hospitalar (PIH) é usada como indicador da condição de saúde do idoso. Entretanto, variáveis de capacidade física (CF) ainda não foram associadas com a PIH. Analisou-se a associação entre CF e a PIH de idosos. O estudo realizado foi epidemiológico, transversal e analítico. A seleção da amostra ocorreu de forma aleatória em uma das Equipes de Saúde da Família no bairro Passo d’Areia, no município de Porto Alegre, sendo avaliados 317 idosos com idade ≥ 65 anos. A CF foi avaliada por testes de força de membros superiores e inferiores, flexibilidade e equilíbrio. A PIH foi avaliada pelo instrumento de triagem rápida de Boult. Para análise estatística, a PIH foi ajustada em dois grupos: baixa-média e média alta-alta (MAA) e realizada a análise multivariada de regressão de Poisson. O nível de significância adotado foi de p ≤ 0,05. Nos resultados encontrados, as variáveis físicas que permaneceram associadas à PIH-MAA foram a força de membros inferiores (RP = 1,78; IC 95% = 1,04 - 3,04) e flexibilidade (RP = 2,13; IC 95% = 1,28 - 3,56). Houve associação negativa entre os baixos níveis de força de membro inferior e de flexibilidade com PIH-MAA. A prevalência da PIH-MAA entre indivíduos com força alterada para membros inferiores foi 78% maior em relação àqueles com força normal e 113% entre aqueles com alteração de flexibilidade.

Hospitalization in older adults: association with multimorbidity, primary health care and private health plan

OBJECTIVE

Evaluate the association of multimorbidity, primary health care model and possession of a private health plan with hospitalization.

METHODS

A population-based cross-sectional study with 1,593 elderly individuals (60 years old or older) living in the urban area of the city of Bagé, State of Rio Grande do Sul, Brazil. The outcome was hospitalization in the year preceding the interview. The multimorbidity was evaluated through two cut-off points (≥ 2 and ≥ 3). The primary health care model was defined by residence in areas covered by traditional care or by Family Health Strategy. The older adults mentioned the possession of a private health plan. We performed a gross and adjusted analysis by Poisson regression using a hierarchical model. The adjustment included demographic, socioeconomic, functional capacity disability and health services variables.

RESULTS

The occurrence of overall and non-surgical hospitalization was 17.7% (95%CI 15.8–19.6) and 10.6% (95%CI 9.1–12.1), respectively. Older adults with multimorbidity were admitted to hospitals more often when to older adults without multimorbidity, regardless of the exhibition’ form of operation. Having a private health plan increased the hospitalization by 1.71 (95%CI 1.09–2.69) times among residents in the areas of the Family Health Strategy when compared to elderly residents in traditional areas without a private health plan.

CONCLUSIONS

The multimorbidity increased the occurrence of hospitalizations, especially non-surgical ones. Hospitalization was more frequent in older adults with private health plan and those living in Family Health Strategy areas, regardless of the presence of multiple diseases.

[Screening the risk for functional loss: a basic strategy for organizing the elderly health care network]

From a critical analysis of experiments in the use of screening tools for functional loss in the elderly, it was observed that the main motivation to develop and implement a screening instrument is to improve health care for the frail elderly or those at risk of functional loss and repeated hospital admissions. The instruments are preferably short questionnaires with no more than 16 self-reported questions. The main intervention performed after screening was monitoring the elderly by a specialized nursing service that, when necessary, referring them to the medical service. The results of this approach included the reduction of functional loss, hospital admissions, deaths, lower health expenses and greater consumer satisfaction.

Declínio de atividades instrumentais de vida diária associado à perda de força de preensão palmar em idosos internados em enfermaria geriátrica

OBJETIVO: Verificar a associação entre a capacidade de executar as atividades instrumentais de vida diária (AIVDs) e a força de preensão palmar em idosos sem comprometimento cognitivo internados em enfermaria geriátrica. MÉTODOS: Estudo transversal. Foram incluídos pacientes idosos, com idade igual ou superior a 60 anos, de ambos os gêneros, admitidos em enfermaria de Geriatria. Foram excluídos indivíduos com doenças neurológicas, osteomusculares agudas e respiratórias exacerbadas; com indicação médica de repouso ou com uso de algum aparato clínico, bem como aqueles com déficits cognitivos e/ou delirium. Os dados foram coletados do prontuário e foi realizada a avaliação da capacidade de realizar atividades instrumentais de vida diária, por meio da Escala de Lawton, e a avaliação da força de preensão palmar, por meio da dinamometria do membro superior dominante. Os dados foram descritos em média e desvio- padrão. O teste de correlação de Pearson foi aplicado para verificar associação entre a capacidade de realizar AIVDs e a força de preensão palmar. RESULTADOS: Participaram do estudo 12 idosos (75% mulheres) com idade média de 80,67±6,35 anos. As médias da força de preensão palmar e pontuação total da Escala de Lawton foram 11,96±6,71 quilogramas-força (kgf) e 22,58±1,67 pontos, respectivamente. Verificou-se associação moderada e positiva entre a força de preensão palmar e a pontuação na Escala de Lawton (r=0,640; p=0,025). CONCLUSÃO: A capacidade de realizar AIVDs e a força de preensão palmar apresentaram associação na amostra estudada.

Rede FIBRA-RJ: fragilidade e risco de hospitalização em idosos da cidade do Rio de Janeiro, Brasil

O objetivo do estudo foi determinar o perfil de risco e fatores associados à fragilidade em idosos da comunidade. A população-fonte constituiu-se de indivíduos com 65 anos ou mais, residentes nos bairros da zona norte da cidade do Rio de Janeiro, Brasil, e clientes de uma operadora de saúde. O estudo foi transversal, na linha de base de uma coorte, com amostra estratificada por sexo e idade, composta por 764 indivíduos. Para a estratificação de risco, utilizou-se o instrumento de rastreio probabilidade de internações repetidas (PIR). A análise de regressão logística foi realizada para estudar a associação entre a PIR e um conjunto de variáveis sociodemográficas, de estado de saúde, funcionais e cognitivas, após a análise bivariada. Encontraram-se 6,7% de idosos com alto risco de internação. Associaram-se ao risco de internação câncer, quedas, doença pulmonar obstrutiva crônica e medicamentos usados, bem como as seguintes condições: receber visita de profissional da saúde, ter estado acamado no domicílio, morar só e praticar as atividades de vida diária. O instrumento parece ser útil na estratificação de risco dos idosos.

Avaliação de efetividade da atenção domiciliar de uma cooperativa médica de Belo Horizonte, Minas Gerais, Brasil

Foi realizado estudo de coorte retrospectiva com o objetivo de avaliar o impacto do plano de cuidados do Programa de Atenção Domiciliar da Unimed-BH, modalidade Gerenciamento de Casos (PrGC/AD), sobre o tempo livre de hospitalização entre os pacientes com 60 anos ou mais assistidos pelo programa. Utilizou-se o modelo de Cox para avaliar o efeito do intervalo entre as visitas domiciliares dos profissionais do programa sobre o tempo livre de hospitalização de 2.943 idosos, ajustado por idade, medicamentos em uso, via de alimentação, úlcera de pressão, déficit cognitivo, dependência física, oxigenioterapia, consultas ambulatoriais e hospitalizações no trimestre anterior. Foram fatores de risco para menor tempo livre de hospitalização: o grau de dependência física, alimentação enteral, oxigenioterapia suplementar, úlceras de pressão e hospitalizações no trimestre anterior. Observouse efeito protetor dose-resposta da frequência de visitas médicas e de enfermagem. Os resultados sugerem que visitas domiciliares regulares de médico e enfermeiro aumentam significativamente o tempo livre de hospitalização nos pacientes assistidos pelo PrGC/AD.

Risco de fragilização e uso de medicamentos em idosos residentes em uma localidade do sul de Santa Catarina

OBJETIVO: Conhecer o risco de fragilização (repetidas internações hospitalares) e o perfil de utilização de medicamentos em idosos vinculados ao Serviço de Assistência Integral à Saúde da Universidade do Sul de Santa Catarina, localizado na cidade de Tubarão. MÉTODOS: Em 2009, quando foram coletadas as informações, 772 idosos estavam cadastrados pelos agentes comunitários vinculados ao serviço, e 135 fizeram parte da amostra desta pesquisa. Para a seleção dos participantes, as residências dos idosos foram distribuídas geograficamente. A coleta de dados ocorreu através de entrevistas realizadas no ambiente domiciliar. Os resultados foram apresentados por estatística descritiva, sendo posteriormente adotado o teste do qui-quadrado (p<0,05) para determinar os fatores associados. RESULTADOS: Dos entrevistados, 65,9% possuíam até três problemas de saúde e 21,5% eram polimedicados, sendo os medicamentos mais comuns aqueles pertencentes ao sistema cardiovascular e ao sistema nervoso. Utilizaram antibióticos no último mês 14,3% dos entrevistados e 17,0% dos idosos estavam utilizando medicamentos considerados potencialmente impróprios. Dos idosos, 29,2% afirmaram adotar a prática da automedicação e 64,4% referiram utilizar plantas medicinais. Quando avaliado o risco de fragilização desta população, 88,1% foram classificados como baixo risco. Associaram-se ao maior risco de fragilização a polimedicação (p<0,001), possuir mais que três problemas de saúde (p<0,001) e o fato de ter utilizado antibiótico no último mês (p=0,015). CONCLUSÕES: Os idosos em ambiente domiciliar apresentam baixo risco de fragilização e o maior risco está associado a presença de múltiplos problemas de saúde, polimedicação e uso de antibiótico no último mês.