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Kaier K, Heidenreich A, Jäckel M, Oettinger V, Maier A, Hilgendorf I, Breitbart P, Hartikainen T, Keller T, Westermann D, von Zur Mühlen C. Reweighting and validation of the hospital frailty risk score using electronic health records in Germany: a retrospective observational study. BMC Geriatr 2024; 24:517. [PMID: 38872086 DOI: 10.1186/s12877-024-05107-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 05/24/2024] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND In the hospital setting, frailty is a significant risk factor, but difficult to measure in clinical practice. We propose a reweighting of an existing diagnoses-based frailty score using routine data from a tertiary care teaching hospital in southern Germany. METHODS The dataset includes patient characteristics such as sex, age, primary and secondary diagnoses and in-hospital mortality. Based on this information, we recalculate the existing Hospital Frailty Risk Score. The cohort includes patients aged ≥ 75 and was divided into a development cohort (admission year 2011 to 2013, N = 30,525) and a validation cohort (2014, N = 11,202). A limited external validation is also conducted in a second validation cohort containing inpatient cases aged ≥ 75 in 2022 throughout Germany (N = 491,251). In the development cohort, LASSO regression analysis was used to select the most relevant variables and to generate a reweighted Frailty Score for the German setting. Discrimination is assessed using the area under the receiver operating characteristic curve (AUC). Visualization of calibration curves and decision curve analysis were carried out. Applicability of the reweighted Frailty Score in a non-elderly population was assessed using logistic regression models. RESULTS Reweighting of the Frailty Score included only 53 out of the 109 frailty-related diagnoses and resulted in substantially better discrimination than the initial weighting of the score (AUC = 0.89 vs. AUC = 0.80, p < 0.001 in the validation cohort). Calibration curves show a good agreement between score-based predictions and actual observed mortality. Additional external validation using inpatient cases aged ≥ 75 in 2022 throughout Germany (N = 491,251) confirms the results regarding discrimination and calibration and underlines the geographic and temporal validity of the reweighted Frailty Score. Decision curve analysis indicates that the clinical usefulness of the reweighted score as a general decision support tool is superior to the initial version of the score. Assessment of the applicability of the reweighted Frailty Score in a non-elderly population (N = 198,819) shows that discrimination is superior to the initial version of the score (AUC = 0.92 vs. AUC = 0.87, p < 0.001). In addition, we observe a fairly age-stable influence of the reweighted Frailty Score on in-hospital mortality, which does not differ substantially for women and men. CONCLUSIONS Our data indicate that the reweighted Frailty Score is superior to the original Frailty Score for identification of older, frail patients at risk for in-hospital mortality. Hence, we recommend using the reweighted Frailty Score in the German in-hospital setting.
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Affiliation(s)
- Klaus Kaier
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Hugstetter Str. 49, Freiburg, 79106, Germany.
- Centre for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Adrian Heidenreich
- Centre for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Medical Centre, Department of Cardiology and Angiology, Faculty of Medicine, University of Freiburg, University Heart Centre Freiburg - Bad Krozingen, University of Freiburg, Freiburg, Germany
| | - Markus Jäckel
- Centre for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Medical Centre, Department of Cardiology and Angiology, Faculty of Medicine, University of Freiburg, University Heart Centre Freiburg - Bad Krozingen, University of Freiburg, Freiburg, Germany
| | - Vera Oettinger
- Centre for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Medical Centre, Department of Cardiology and Angiology, Faculty of Medicine, University of Freiburg, University Heart Centre Freiburg - Bad Krozingen, University of Freiburg, Freiburg, Germany
| | - Alexander Maier
- Centre for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Medical Centre, Department of Cardiology and Angiology, Faculty of Medicine, University of Freiburg, University Heart Centre Freiburg - Bad Krozingen, University of Freiburg, Freiburg, Germany
| | - Ingo Hilgendorf
- Medical Centre, Department of Cardiology and Angiology, Faculty of Medicine, University of Freiburg, University Heart Centre Freiburg - Bad Krozingen, University of Freiburg, Freiburg, Germany
| | - Philipp Breitbart
- Medical Centre, Department of Cardiology and Angiology, Faculty of Medicine, University of Freiburg, University Heart Centre Freiburg - Bad Krozingen, University of Freiburg, Freiburg, Germany
| | - Tau Hartikainen
- Medical Centre, Department of Cardiology and Angiology, Faculty of Medicine, University of Freiburg, University Heart Centre Freiburg - Bad Krozingen, University of Freiburg, Freiburg, Germany
| | - Till Keller
- Medical Centre, Department of Cardiology and Angiology, Faculty of Medicine, University of Freiburg, University Heart Centre Freiburg - Bad Krozingen, University of Freiburg, Freiburg, Germany
| | - Dirk Westermann
- Medical Centre, Department of Cardiology and Angiology, Faculty of Medicine, University of Freiburg, University Heart Centre Freiburg - Bad Krozingen, University of Freiburg, Freiburg, Germany
| | - Constantin von Zur Mühlen
- Centre for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Medical Centre, Department of Cardiology and Angiology, Faculty of Medicine, University of Freiburg, University Heart Centre Freiburg - Bad Krozingen, University of Freiburg, Freiburg, Germany
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Christensen NL, Gouliaev A, McPhail S, Lyratzopoulos G, Rasmussen TR, Jensen H. Routes to Diagnosis in Danish Lung Cancer Patients: Emergency Presentation, Age and Smoking History-A Population-Based Cohort Study. Clin Lung Cancer 2024:S1525-7304(24)00108-6. [PMID: 38890094 DOI: 10.1016/j.cllc.2024.05.009] [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: 01/18/2024] [Revised: 05/16/2024] [Accepted: 05/24/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND The fast-track cancer pathway aims to expedite diagnosis of lung cancer and treatment and is the preferred route to diagnosis. Diagnosis following an unplanned admission (unplanned route) has been associated with poor outcomes. OBJECTIVE This study explores factors associated with lung cancer diagnosis following unplanned admissions, focusing on the elderly population. METHODS A retrospective cohort study using population-based data from Danish registries. Factors such as age, comorbidity, performance status, smoking history, socioeconomic parameters and treatment modality were analyzed in relation to route to diagnosis and prognosis. RESULTS Among 17,835 patients, 16% were elderly (≥ 80 years). The unplanned route constituted 28% of diagnostic routes, with higher proportion among the elderly (33%). Poor performance status and advanced disease stage were associated with the unplanned route. Married patients were less likely to undergo an unplanned route to diagnosis. Smoking did not significantly influence diagnostic route. The adjusted odds ratio for curative treatment and dying 12 months after diagnosis, following unplanned route to diagnosis were 0.68 (95% CI, 0.61-0.76) and 1.48 (95% CI, 1.36-1.61), respectively. CONCLUSION Frailty (poor performance status and high burden of comorbidity) in addition to unfavorable socioeconomic factors, which all were more prevalent among elderly patients, were associated with undergoing an unplanned route to diagnosis. However, age itself was not. Diagnosis following unplanned admission correlated with reduced likelihood of curative treatment and poorer prognosis. Expanding screening initiatives to include frail elderly individuals living alone, along with alertness by primary care clinicians, is warranted to improve outcomes for these patients.
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Affiliation(s)
- Niels Lyhne Christensen
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Research Unit for General Practice, Aarhus, Denmark
| | - Anja Gouliaev
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Sean McPhail
- National Disease Registration Service, NHS England, Leeds, UK
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care (IEHC), University College London, London, UK
| | - Torben Riis Rasmussen
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Henry Jensen
- The Danish Clinical Quality Program, National Clinical Registries (RKKP), Aarhus, Denmark
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André L, Björkelund A, Ekelund U, Vedin T, Björk J, Forberg JL. The prevalence of clinically relevant delayed intracranial hemorrhage in head trauma patients treated with oral anticoagulants is very low: a retrospective cohort register study. Scand J Trauma Resusc Emerg Med 2024; 32:42. [PMID: 38730480 PMCID: PMC11084042 DOI: 10.1186/s13049-024-01214-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/27/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Current guidelines from Scandinavian Neuro Committee mandate a 24-hour observation for head trauma patients on anticoagulants, even with normal initial head CT scans, as a means not to miss delayed intracranial hemorrhages. This study aimed to assess the prevalence, and time to diagnosis, of clinically relevant delayed intracranial hemorrhage in head trauma patients treated with oral anticoagulants. METHOD Utilizing comprehensive two-year data from Region Skåne's emergency departments, which serve a population of 1.3 million inhabitants, this study focused on adult head trauma patients prescribed oral anticoagulants. We identified those with intracranial hemorrhage within 30 days, defining delayed intracranial hemorrhage as a bleeding not apparent on their initial CT head scan. These cases were further defined as clinically relevant if associated with mortality, any intensive care unit admission, or neurosurgery. RESULTS Out of the included 2,362 head injury cases (median age 84, 56% on a direct acting oral anticoagulant), five developed delayed intracranial hemorrhages. None of these five cases underwent neurosurgery nor were admitted to an intensive care unit. Only two cases (0.08%, 95% confidence interval [0.01-0.3%]) were classified as clinically relevant, involving subdural hematomas in patients aged 82 and 87 years, who both subsequently died. The diagnosis of these delayed intracranial hemorrhages was made at 4 and 7 days following initial presentation to the emergency department. CONCLUSION In patients with head trauma, on oral anticoagulation, the incidence of clinically relevant delayed intracranial hemorrhage was found to be less than one in a thousand, with detection occurring four days or later after initial presentation. This challenges the effectiveness of the 24-hour observation period recommended by the Scandinavian Neurotrauma Committee guidelines, suggesting a need to reassess these guidelines to optimise care and resource allocation. TRIAL REGISTRATION This is a retrospective cohort study, does not include any intervention, and has therefore not been registered.
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Affiliation(s)
- Lars André
- Department of Clinical Sciences, Lund University, Lund, Sweden.
- Department of Emergency Medicine, Helsingborg Hospital, Helsingborg, Sweden.
| | - Anders Björkelund
- Centre for Environmental and Climate Science, Lund University, Lund, Sweden
| | - Ulf Ekelund
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Internal medicine and Emergency care, Skåne University Hospital, Lund, Sweden
| | - Tomas Vedin
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Surgery, Skåne University Hospital, Malmö, Sweden
| | - Jonas Björk
- Department of Laboratory Medicine, Lund University, Lund, Sweden
- Skåne University Hospital, Forum South, Clinical Studies Sweden, Lund, Sweden
| | - Jakob Lundager Forberg
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Emergency Medicine, Helsingborg Hospital, Helsingborg, Sweden
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Dolu İ, Hayter M, Serrant L, Lee A. 'Hearing silences': Exploring culturally safe transitional care: A qualitative study among Turkish-speaking migrant frail older adults. J Adv Nurs 2024; 80:1997-2017. [PMID: 37950376 DOI: 10.1111/jan.15955] [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: 09/22/2023] [Revised: 10/25/2023] [Accepted: 10/28/2023] [Indexed: 11/12/2023]
Abstract
AIMS This study aimed to investigate the experiences and transitional care needs of Turkish frail older adults living in the UK and determine how this information can be utilized to improve the provision of culturally sensitive care during the transitional period. DESIGN Qualitative descriptive research with semi-structured individual interviews. METHODS "The 'Silences' Framework guided the research design, from conceptualizing the research question to structuring the report of final outputs. For this study, semi-structured, in-depth interviews were conducted with sixteen older adults living with frailty and five family caregivers between January and May of 2023 in the United Kingdom. RESULTS Major themes that were identified included: (i) information and communication, (ii) care and support, (iii) the role of culture and (iv) trust and satisfaction. Further analysis, through discussion and immersion in the data, revealed that care transition periods were presented alongside three phases of transitional care: pre-transition (during hospitalization), early-transition (the period between discharge and the 7th day after discharge) and late transition (the period between the 8th day and 12th month after discharge). CONCLUSIONS Our study revealed that the communication and informational needs of frail older individuals change during the transition period. While Turkish older adults and family caregivers expressed satisfaction with healthcare services in the UK, many struggled due to a lack of knowledge on how to access them. IMPACT The support of family caregivers is a crucial component in facilitating transitional care for frail older patients, as they help in accessing healthcare services and using technological devices or platforms. It should be noted that family caregivers often hold the same level of authority as their elderly Turkish counterparts. PATIENT OR PUBLIC CONTRIBUTION No patient or public contribution.
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Affiliation(s)
- İlknur Dolu
- Department of Nursing, Faculty of Health Science, Bartın University, Bartın, Turkey
| | - Mark Hayter
- Department of Nursing, Faculty of Health and Education, Manchester Metropolitan University, Manchester, UK
| | - Laura Serrant
- Health Education England (North East & Yorkshire), Sheffield, UK
| | - Amanda Lee
- Department of Nursing, Faculty of Health and Education, Manchester Metropolitan University, Manchester, UK
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van Oppen JD, Suzanne M. Frailty screening in the Emergency Department: why does it matter? Age Ageing 2024; 53:afae056. [PMID: 38655587 DOI: 10.1093/ageing/afae056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Indexed: 04/26/2024] Open
Affiliation(s)
- James David van Oppen
- Centre for Urgent and Emergency Care Research, The University of Sheffield, Sheffield, UK
| | - Mason Suzanne
- Centre for Urgent and Emergency Care Research, The University of Sheffield, Sheffield, UK
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Attwood D, Vafidis J, Boorer J, Long S, Ellis W, Earley M, Denovan J, Hart G', Williams M, Burdett N, Lemon M, Hope S. IT-assisted comprehensive geriatric assessment for residents in care homes: quasi-experimental longitudinal study. BMC Geriatr 2024; 24:269. [PMID: 38504155 PMCID: PMC10949740 DOI: 10.1186/s12877-024-04824-6] [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: 12/13/2022] [Accepted: 02/19/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND Frailty interventions such as Comprehensive Geriatric Assessment (CGA) can provide significant benefits for older adults living with frailty. However, incorporating such proactive interventions into primary care remains a challenge. We developed an IT-assisted CGA (i-CGA) process, which includes advance care planning (ACP). We assessed if, in older care home residents, particularly those with severe frailty, i-CGA could improve access to advance care planning discussions and reduce unplanned hospitalisations. METHOD As a quality improvement project we progressively incorporated our i-CGA process into routine primary care for older care home residents, and used a quasi-experimental approach to assess its interim impact. Residents were assessed for frailty by General Practitioners. Proactive i-CGAs were completed, including consideration of traditional CGA domains, deprescribing and ACP discussions. Interim analysis was conducted at 1 year: documented completion, preferences and adherence to ACPs, unplanned hospital admissions, and mortality rates were compared for i-CGA and control (usual care) groups, 1-year post-i-CGA or post-frailty diagnosis respectively. Documented ACP preferences and place of death were compared using the Chi-Square Test. Unplanned hospital admissions and bed days were analysed using the Mann-Whitney U test. Survival was estimated using Kaplan-Meier survival curves. RESULTS At one year, the i-CGA group comprised 196 residents (severe frailty 111, 57%); the control group 100 (severe frailty 56, 56%). ACP was documented in 100% of the i-CGA group, vs. 72% of control group, p < 0.0001. 85% (94/111) of severely frail i-CGA residents preferred not to be hospitalised if they became acutely unwell. For those with severe frailty, mean unplanned admissions in the control (usual care) group increased from 0.87 (95% confidence interval ± 0.25) per person year alive to 2.05 ± 1.37, while in the i-CGA group they fell from 0.86 ± 0.24 to 0.68 ± 0.37, p = 0.22. Preferred place of death was largely adhered to in both groups, where documented. Of those with severe frailty, 55% (62/111) of the i-CGA group died, vs. 77% (43/56) of the control group, p = 0.0013. CONCLUSIONS Proactive, community-based i-CGA can improve documentation of care home residents' ACP preferences, and may reduce unplanned hospital admissions. In severely frail residents, a mortality reduction was seen in those who received an i-CGA.
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Affiliation(s)
| | - Jim Vafidis
- University of the West of England, Bristol, UK
| | | | | | | | | | | | | | | | | | | | - Suzy Hope
- University of Exeter, Exeter, UK
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
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Rosario BH, Quah JL, Chang TY, Barrera VC, Lim A, Sim LE, Conroy S, Dhaliwal TK. Validation of the Hospital Frailty Risk Score in older adults hospitalized with community-acquired pneumonia. Geriatr Gerontol Int 2024; 24 Suppl 1:135-141. [PMID: 37846810 DOI: 10.1111/ggi.14697] [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: 07/07/2023] [Revised: 09/03/2023] [Accepted: 09/24/2023] [Indexed: 10/18/2023]
Abstract
AIM Frailty results from age-associated declines in physiological reserve and function and is prevalent in older people. Our aim is to examine the association of the Hospital Frailty Risk Score (HFRS) with adverse events in older patients hospitalized with community-acquired pneumonia (CAP) and hypothesise that frailty is a comparable predictor of outcomes in CAP versus traditional severity indices such as CURB-65. METHODS Retrospective review of electronic medical records in patients ≥65 years with CAP admitted to a tertiary hospital from 1 January to 30 April 2021. Patients were identified using ICD codes for CAP and categorized as high risk (>15), intermediate risk (5-15) and low risk (<5) of frailty using the HFRS. RESULTS Of 429 patients with CAP, 53.8% male, mean age of 82.9 years, older patients (85 vs. 79.7 years, P < 0.001) were at higher risk of frailty. Using the HFRS, 47.6% were deemed at high risk, 35.9% at intermediate risk, and 16.6% at low risk of frailty. Multivariate logistic regression shows that HFRS was more strongly associated (≥7 days, OR 1.042, CI 1.017-1.069) than CURB-65 (OR 0.995, CI 0.810-1.222) with long hospital length of stay (LOS), while CURB-65 (Confusion, Urea >7mmol/L, Respiratory rate >30, Blood pressure, age => 65 years old) was more strongly associated with mortality at 30, 90 and 365 days, compared with the HFRS. Comparing the values for the area under the receiver operator characteristic curve, the HFRS was found to be a better predictor of long LOS, while CURB-65 remains a better predictor of mortality. CONCLUSIONS Patients with high risk of frailty have higher healthcare utilization and HFRS is a better predictor of long LOS than CURB-65 but CURB-65 was a better predictor of mortality. Geriatr Gerontol Int 2024; 24: 135-141.
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Affiliation(s)
- Barbara H Rosario
- Department of Geriatric Medicine, Changi General Hospital, Singapore, Singapore
| | - Jessica Lishan Quah
- Department of Respiratory Medicine, Changi General Hospital, Singapore, Singapore
| | - Ting Yu Chang
- National University of Singapore, Singapore, Singapore
| | | | - Aileen Lim
- Health Systems Intelligence, Changi General Hospital, Singapore, Singapore
| | - Lydia Euphemia Sim
- Health Systems Intelligence, Changi General Hospital, Singapore, Singapore
| | - Simon Conroy
- University College London, London, United Kingdom
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Chau CSM, Ee SCE, Huang X, Siow WS, Tan MBH, Sim SKR, Chang TY, Kwok KM, Ng K, Yeo LF, Lim A, Sim LE, Conroy S, Rosario BH. Frailty-aware surgical care: Validation of Hospital Frailty Risk Score (HFRS) in older surgical patients. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2024; 53:90-100. [PMID: 38920233 DOI: 10.47102/annals-acadmedsg.2023221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
Introduction Frailty has an important impact on the health outcomes of older patients, and frailty screening is recommended as part of perioperative evaluation. The Hospital Frailty Risk Score (HFRS) is a validated tool that highlights frailty risk using 109 International Classification of Diseases, 10th revision (ICD-10) codes. In this study, we aim to compare HFRS to the Charlson Comorbidity Index (CCI) and validate HFRS as a predictor of adverse outcomes in Asian patients admitted to surgical services. Method A retrospective study of electronic health records (EHR) was undertaken in patients aged 65 years and above who were discharged from surgical services between 1 April 2022 to 31 July 2022. Patients were stratified into low (HFRS <5), interme-diate (HFRS 5-15) and high (HFRS >15) risk of frailty. Results Those at high risk of frailty were older and more likely to be men. They were also likely to have more comorbidities and a higher CCI than those at low risk of frailty. High HFRS scores were associated with an increased risk of adverse outcomes, such as mortality, hospital length of stay (LOS) and 30-day readmission. When used in combination with CCI, there was better prediction of mortality at 90 and 270 days, and 30-day readmission. Conclusion To our knowledge, this is the first validation of HFRS in Singapore in surgical patients and confirms that high-risk HFRS predicts long LOS (≥7days), increased unplanned hospital readmissions (both 30-day and 270-day) and increased mortality (inpatient, 10-day, 30-day, 90-day, 270-day) compared with those at low risk of frailty.
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Affiliation(s)
| | | | - Xiaoting Huang
- Department of Geriatric Medicine, Changi General Hospital, Singapore
| | - Wei Shyan Siow
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, Singapore
| | - Michelle Bee Hua Tan
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, Singapore
| | | | | | - Kah Meng Kwok
- Department of Rehabilitation Medicine, Changi General Hospital, Singapore
| | - Kangqi Ng
- Department of Internal Medicine, Changi General Hospital, Singapore
| | - Li Fang Yeo
- Department of Internal Medicine, Changi General Hospital, Singapore
| | - Aileen Lim
- Health Systems Intelligence, Changi General Hospital, Singapore
| | | | - Simon Conroy
- University College London, London, United Kingdom
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Werner C, Sturm M, Heldmann P, Fleiner T, Bauer JM, Hauer K. Predictors of 2-Year Post-Discharge Mortality in Hospitalized Older Patients. J Clin Med 2024; 13:1352. [PMID: 38592184 PMCID: PMC10931743 DOI: 10.3390/jcm13051352] [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: 01/19/2024] [Revised: 02/24/2024] [Accepted: 02/27/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Understanding prognostic factors for adverse health outcomes is clinically relevant for improving treatment decision-making processes, potentially leading to enhanced patient prognosis. This secondary analysis of a prospective observational study aimed to identify independent factors associated with 2-year post-discharge mortality in acutely hospitalized older patients. METHODS All-cause mortality and date of death of 115 patients (83.3 ± 6.3 years, females: n = 75, 65.2%) admitted to acute geriatric wards were determined two years after hospital discharge through telephone interviews. Potential prognostic factors measured at hospital admission included demographic and clinical characteristics, nutritional, cognitive, and psychological status, Fried frailty phenotype, functioning in activities of daily living, locomotor capacity, and 24 h in-hospital mobility and objectively measured physical activity (PA) behaviors. RESULTS The 2-year mortality rate was 36.7% (n = 41). Univariate and multivariate Cox proportional hazards regression models revealed that mean daily PA level (hazards ratio (HR) = 0.59, 95% confidence interval (CI) 0.90-1.00; p = 0.042), frailty (HR = 3.39, 95% CI 1.20-9.51; p = 0.020), and underweight, in contrast to overweight (HR = 3.10, 95% CI 1.07-9.01; p = 0.038), at hospital admission were independently predictive of post-discharge mortality. CONCLUSION PA, frailty, and underweight at hospital admission should be considered when evaluating long-term survival prognosis, establishing risk profiles, and developing personalized care pathways in acute hospital care of older adults.
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Affiliation(s)
- Christian Werner
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Rohrbacher Str. 149, 69216 Heidelberg, Germany
| | - Melanie Sturm
- Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 672, 69120 Heidelberg, Germany
| | - Patrick Heldmann
- Network Aging Research (NAR), Heidelberg University, Bergheimer Str. 20, 69115 Heidelberg, Germany
- Division of Physiotherapy, Department of Applied Health Sciences, Hochschule für Gesundheit (University of Applied Sciences), Gesundheitscampus 6-8, 44801 Bochum, Germany
| | - Tim Fleiner
- Institute for Geriatric Research, Ulm University Medical Centre, Zollernring 26, 89073 Ulm, Germany
- Department of Geriatric Psychiatry and Psychotherapy, LVR-Hospital Cologne, Wilhelm-Griesinger Straße 23, 51109 Cologne, Germany
| | - Jürgen M. Bauer
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Rohrbacher Str. 149, 69216 Heidelberg, Germany
- Network Aging Research (NAR), Heidelberg University, Bergheimer Str. 20, 69115 Heidelberg, Germany
| | - Klaus Hauer
- Geriatric Centre, Heidelberg University Hospital, Agaplesion Bethanien Hospital Heidelberg, Rohrbacher Str. 149, 69216 Heidelberg, Germany
- Department of Clinical Gerontology, Robert-Bosch-Hospital, Auerbachstraße 110, 70376 Stuttgart, Germany
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Smedemark SA, Laursen CB, Jarbøl DE, Rosenvinge FS, Andersen-Ranberg K. Extended use of point-of-care technology versus usual care for in-home assessment by acute community nurses in older adults with signs of potential acute respiratory disease: an open-label randomised controlled trial protocol. BMC Geriatr 2024; 24:161. [PMID: 38365595 PMCID: PMC10870485 DOI: 10.1186/s12877-024-04774-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 02/03/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Due to ageing-related physiological changes, diagnosing older adults is challenging. Delayed disease recognition may lead to adverse health outcomes and increased hospitalisation, necessitating the development of new initiatives for timely diagnosis and treatment of older adults. Point-of-care technology, such as focused lung ultrasound scan and bedside analysis of blood samples (leucocytes with differential count, electrolytes, and creatinine) conducted in the patients' home, may support clinical decision-making, and potentially reduce acute hospital admissions. We present the protocol for a randomized controlled trial, which aims at assessing the effect of focused lung ultrasound scan and bedside blood analysis during in-home assessments among older adults with signs of potential acute respiratory disease on hospital admissions. METHOD We will use a parallel open-label, individually randomised controlled trial design in an acute community healthcare setting. The trial will initiate on October 2022 and is expected to end one year later. The study population will include older adults (65 + year), with at least one of the following inclusion criteria: Cough, dyspnoea, fever, fall, or rapid functional decline. Expected study sample will comprise 632 participants. Participants in the control group will receive usual care, while the intervention group will undergo extended point-of-care technology (focused lung ultrasound scan and bedside venous blood analysis), in addition to usual care. The primary outcome is acute hospital admission within 30 days follow-up. Secondary outcomes include readmissions, mortality, length of hospital stay, hospital-free days, complications during hospital admission, treatment initiations or changes, functional level, re-referrals to the acute community healthcare service, and contacts to the primary care physician. A tertiary outcome is the diagnostic accuracy of Acute Community Nurses for conducting focused lung ultrasound compared with a specialist. Outcomes will be analysed as intention-to-treat. DISCUSSION To our knowledge, this is the first randomised controlled trial examining the effect of extended use of point-of-care technology conducted in an in-home setting. We expect that the results may contribute to the development of new interventions aiming to improve timely diagnostics, treatment decisions, and reduce acute hospital admissions. TRIAL REGISTRATION www. CLINICALTRIALS org NCT05546073 (Date of registration: September 19th, 2022).
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Affiliation(s)
- Siri Aas Smedemark
- Department of Geriatric Medicine, Geriatric Research Unit, Odense University Hospital, Odense, Denmark.
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Christian B Laursen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Respiratory Medicine, Odense Respiratory Research Unit, Odense University Hospital, Odense, Denmark
| | - Dorte Ejg Jarbøl
- Department of Public Health, Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | | | - Karen Andersen-Ranberg
- Department of Geriatric Medicine, Geriatric Research Unit, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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11
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Allen MJ, Carter HE, Cyarto E, Meyer C, Dwyer T, Oprescu F, Aitken C, Farrington A, Shield C, Rowland J, Lee XJ, Graves N, Parkinson L, Harvey G. From pilot to a multi-site trial: refining the Early Detection of Deterioration in Elderly Residents (EDDIE +) intervention. BMC Geriatr 2023; 23:811. [PMID: 38057722 PMCID: PMC10698876 DOI: 10.1186/s12877-023-04491-z] [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: 05/05/2023] [Accepted: 11/20/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Early Detection of Deterioration in Elderly Residents (EDDIE +) is a multi-modal intervention focused on empowering nursing and personal care workers to identify and proactively manage deterioration of residents living in residential aged care (RAC) homes. Building on successful pilot trials conducted between 2014 and 2017, the intervention was refined for implementation in a stepped-wedge cluster randomised trial in 12 RAC homes from March 2021 to May 2022. We report the process used to transition from a small-scale pilot intervention to a multi-site intervention, detailing the intervention to enable future replication. METHODS The EDDIE + intervention used the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to guide the intervention development and refinement process. We conducted an environmental scan; multi-level context assessments; convened an intervention working group (IWG) to develop the program logic, conducted a sustainability assessment and deconstructed the intervention components into fixed and adaptable elements; and subsequently refined the intervention for trial. RESULTS The original EDDIE pilot intervention included four components: nurse and personal care worker education; decision support tools; diagnostic equipment; and facilitation and clinical support. Deconstructing the intervention into core components and what could be flexibly tailored to context was essential for refining the intervention and informing future implementation across multiple sites. Intervention elements considered unsustainable were updated and refined to enable their scalability. Refinements included: an enhanced educational component with a greater focus on personal care workers and interactive learning; decision support tools that were based on updated evidence; equipment that aligned with recipient needs and available organisational support; and updated facilitation model with local and external facilitation. CONCLUSION By using the i-PARIHS framework in the scale-up process, the EDDIE + intervention was tailored to fit the needs of intended recipients and contexts, enabling flexibility for local adaptation. The process of transitioning from a pilot to larger scale implementation in practice is vastly underreported yet vital for better development and implementation of multi-component interventions across multiple sites. We provide an example using an implementation framework and show it can be advantageous to researchers and health practitioners from pilot stage to refinement, through to larger scale implementation. TRIAL REGISTRATION The trial was prospectively registered with the Australia New Zealand Clinical Trial Registry (ACTRN12620000507987, registered 23/04/2020).
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Affiliation(s)
- Michelle J Allen
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia.
| | - Hannah E Carter
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Elizabeth Cyarto
- School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Claudia Meyer
- Bolton Clarke Research Institute, Forest Hill, Victoria, Australia
- Rehabilitation, Ageing and Independent Living Research Centre, Monash University, Melbourne, Australia
- Centre for Health Communication and Participation, La Trobe University, Bundoora, Australia
| | - Trudy Dwyer
- Central Queensland University, Norman Gardens, Australia
| | - Florin Oprescu
- School of Health, University of the Sunshine Coast, Sippy Downs, QLD, Australia
| | - Christopher Aitken
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Alison Farrington
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Carla Shield
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Jeffrey Rowland
- Faculty of Medicine, University of Queensland, Herston, Australia
- Faculty of Health, School of Nursing, Queensland University of Technology, Kelvin Grove, Australia
- Metro North Hospital and Health Service, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Xing J Lee
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | | | - Lynne Parkinson
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Gillian Harvey
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
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12
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Street A, Maynou L, Conroy S. Did the Acute Frailty Network improve outcomes for older people living with frailty? A staggered difference-in-difference panel event study. BMJ Qual Saf 2023; 32:721-731. [PMID: 37414555 DOI: 10.1136/bmjqs-2022-015832] [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: 12/13/2022] [Accepted: 05/24/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVES To evaluate whether the Acute Frailty Network (AFN) was more effective than usual practice in supporting older people living with frailty to return home from hospital sooner and healthier. DESIGN Staggered difference-in-difference panel event study allowing for differential effects across intervention cohorts. SETTING All English National Health Service (NHS) acute hospital sites. PARTICIPANTS All 1 410 427 NHS patients aged 75+ with high frailty risk who had an emergency hospital admission to acute, general or geriatric medicine departments between 1 January 2012 and 31 March 2019. INTERVENTION Membership of the AFN, a quality improvement collaborative designed to support acute hospitals in England deliver evidence-based care for older people with frailty. 66 hospital sites joined the AFN in six sequential cohorts, the first starting in January 2015, the sixth in May 2018. Usual care was delivered in the remaining 248 control sites. MAIN OUTCOME MEASURES Length of hospital stay, in-hospital mortality, institutionalisation, hospital readmission. RESULTS No significant effects of AFN membership were found for any of the four outcomes nor were there significant effects for any individual cohort. CONCLUSIONS To realise its aims, the AFN might need to develop better resourced intervention and implementation strategies.
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Affiliation(s)
- Andrew Street
- Department of Health Policy, The London School of Economics and Political Science, London, UK
| | - Laia Maynou
- Department of Health Policy, The London School of Economics and Political Science, London, UK
- Deparment of Econometrics, Statistics and Applied Economics, Universitat de Barcelona, Barcelona, Spain
- Center for Research in Health and Economics (CRES), Universitat Pompeu Fabra, Barcelona, Spain
| | - Simon Conroy
- MRC Unit for Lifelong Health and Ageing, University College London, London, UK
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13
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van Oppen JD, Conroy SP, Coats TJ, Mackintosh NJ, Valderas JM. Measuring health-related quality of life of older people with frailty receiving acute care: feasibility and psychometric performance of the EuroQol EQ-5D. BMC Emerg Med 2023; 23:137. [PMID: 37981703 PMCID: PMC10659073 DOI: 10.1186/s12873-023-00909-4] [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: 07/05/2023] [Accepted: 11/11/2023] [Indexed: 11/21/2023] Open
Abstract
BACKGROUND Although outcome goals for acute healthcare among older people living with frailty often include Health-Related Quality of Life (HRQoL) and other patient-reported outcome measures (PROMs), current quality metrics usually focus on waiting times and survival. Lay and patient review have identified the EuroQol EQ-5D as a candidate measure for this setting. This research appraised the EQ-5D for feasibility, psychometric performance, and respondents' outcomes in the acute frailty setting. METHODS People aged 65 + with Clinical Frailty Scale (CFS) 5-8 were recruited from eight UK hospitals' emergency care and acute admissions settings. They completed the five-level EQ-5D and the EQ-VAS. Feasibility was assessed with completion times and completeness. For reliability, response distributions and internal consistency were analysed. Finally, EQ-Index values were compared with demographic characteristics and service outcomes for construct validity. RESULTS The 232 participants were aged 65-102. 38% responded in emergency departments and 62% in admissions wards. Median completion time was 12 (IQR, 11) minutes. 98% responses were complete. EQ-5D had acceptable response distribution (SD 1.1-1.3) and internal consistency (Cronbach's alpha 0.69). EQ-VAS demonstrated a midpoint response pattern. Median EQ-Index was 0.574 (IQR, 0.410) and was related positively with increasing age (p = 0.010) and negatively with CFS (p < 0.001). Participants with higher CFS had more frequent problems with mobility, self-care, and usual activities. CONCLUSIONS Administration of the EQ-5D was feasible in these emergency and acute frailty care settings. EQ-5D had acceptable properties, while EQ-VAS appeared problematic. Participants with more severe frailty had also poorer HRQoL.
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Affiliation(s)
- James D van Oppen
- College of Life Sciences, George Davies Centre, University of Leicester, Leicester, UK.
- Emergency and Specialist Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK.
| | - Simon P Conroy
- MRC Unit for Lifelong Health and Ageing, University College London, London, UK
| | - Timothy J Coats
- College of Life Sciences, George Davies Centre, University of Leicester, Leicester, UK
- Emergency and Specialist Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Nicola J Mackintosh
- College of Life Sciences, George Davies Centre, University of Leicester, Leicester, UK
| | - Jose M Valderas
- Department of Family Medicine, National University Health System, Singapore, Singapore
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14
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Brack C, Kynn M, Murchie P, Makin S. Validated frailty measures using electronic primary care records: a review of diagnostic test accuracy. Age Ageing 2023; 52:afad173. [PMID: 37993406 PMCID: PMC10873280 DOI: 10.1093/ageing/afad173] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Indexed: 11/24/2023] Open
Abstract
INTRODUCTION Identification of people who have or are at risk of frailty enables targeted interventions, and the use of tools that screen for frailty using electronic records (which we term as validated electronic frailty measures (VEFMs)) within primary care is incentivised by NHS England. We carried out a systematic review to establish the sensitivity and specificity of available primary care VEFMs when compared to a reference standard in-person assessment. METHODS Medline, Pubmed, CENTRAL, CINHAL and Embase searches identified studies comparing a primary care VEFM with in-person assessment. Studies were quality assessed using Quality Assessment of Diagnostic Accuracy Studies revised tool. Sensitivity and specificity values were extracted or were calculated and pooled using StatsDirect. RESULTS There were 2,245 titles screened, with 10 studies included. These described three different index tests: electronic frailty index (eFI), claims-based frailty index (cFI) and polypharmacy. Frailty Phenotype was the reference standard in each study. One study of 60 patients examined the eFI, reporting a sensitivity of 0.84 (95% CI = 0.55, 0.98) and a specificity of 0.78 (0.64, 0.89). Two studies of 7,679 patients examined cFI, with a pooled sensitivity of 0.48 (95% CI = 0.23, 0.74) and a specificity of 0.80 (0.53, 0.98). Seven studies of 34,328 patients examined a polypharmacy as a screening tool (defined as more than or equal to five medications) with a pooled sensitivity of 0.61 (95% CI = 0.50, 0.72) and a specificity of 0.66 (0.58, 0.73). CONCLUSIONS eFI is the best-performing VEFM; however, based on our analysis of an average UK GP practice, it would return a high number of false-positive results. In conclusion, existing electronic frailty tools may not be appropriate for primary care-based population screening.
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Affiliation(s)
- Carmen Brack
- Centre for Rural Health, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, AB25 2ZD, United Kingdom
| | - Mary Kynn
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, AB25 2ZD, United Kingdom
| | - Peter Murchie
- Academic Primary Care Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, AB25 2ZD, United Kingdom
| | - Stephen Makin
- Centre for Rural Health, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, AB25 2ZD, United Kingdom
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15
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Sokhal BS, Matetić A, Abhishek A, Banerjee A, Partington R, Roddy E, Rashid M, Mallen CD, Mamas MA. Impact of Frailty on Emergency Department Encounters for Cardiovascular Disease: A Retrospective Cohort Study. Am J Cardiol 2023; 206:210-218. [PMID: 37708753 DOI: 10.1016/j.amjcard.2023.08.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 08/18/2023] [Accepted: 08/20/2023] [Indexed: 09/16/2023]
Abstract
Data are limited on whether the causes of emergency department (ED) encounters for cardiovascular diseases (CVDs) and associated clinical outcomes vary by frailty status. Using the United States Nationwide ED Sample, selected CVD encounters (acute myocardial infarction [AMI], ischemic stroke, atrial fibrillation [AF], heart failure [HF], pulmonary embolism, cardiac arrest, and hemorrhagic stroke) were stratified by hospital frailty risk score (HFRS). Logistic regression was used to determine the adjusted odds ratios (aORs) and 95% confidence intervals (CIs) of ED mortality among the different frailty groups. A total of 8,577,028 selected CVD ED encounters were included. A total of 5,120,843 (59.7%) had a low HFRS (<5), 3,041,699 (35.5%) had an intermediate HFRS (5 to 15), and 414,485 (4.8%) had a high HFRS (>15). Ischemic stroke was the most common reason for the encounter in the high HFRS group (66.9%), followed by hemorrhagic stroke (11.7%) and AMI (7.2%). For the low HFRS group, AF was the most common reason for the encounter (30.2%), followed by AMI (23.6%) and HF (16.8%). Compared with the low-risk group, high-risk patients had a decreased ED mortality and an increased overall mortality across most CVD encounters (p <0.001). The strongest association with overall mortality was observed among patients with a high HFRS admitted for AF (aOR 27.14, 95% CI 25.03 to 29.43) and HF (aOR 13.71, 95% CI 12.95 to 14.51) compared with their low-risk counterparts. In conclusion, patients presenting to the ED with acute CVD have a significant frailty burden, with different patterns of CVD according to frailty status. Frailty is associated with an increased all-cause mortality in patients for most CVD encounters.
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Affiliation(s)
- Balamrit Singh Sokhal
- School of Medicine; Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele, United Kingdom
| | - Andrija Matetić
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele, United Kingdom; Department of Cardiology, University Hospital of Split, Split, Croatia
| | - Abhishek Abhishek
- Academic Rheumatology, University of Nottingham, Nottingham, United Kingdom
| | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, United Kingdom
| | | | - Edward Roddy
- School of Medicine; Haywood Academic Rheumatology Centre, Midland Partnership Foundation Trust, Stoke-on-Trent, United Kingdom
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele, United Kingdom
| | | | - Mamas Andreas Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele, United Kingdom.
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Abstract
Frailty affects approximately one in two patients over 70 years of age in the emergency department. These are inadequately identified as high-risk patients using conventional triage tools. Frailty screening improves the identification of high-risk patients with increased hospitalisation and readmission rates, 30-day and one-year mortality. Unspecific complaints and geriatric syndromes should be recognised as red flags, and age-specific peculiarities of vital signs should be taken into account. A holistic evaluation should already be carried out in the emergency department, as focusing on individual problems is not target-oriented. All patients identified in the screening should be evaluated geriatrically in the course. For patients with frailty, the improvement of subjective well-being is in the foreground. Inpatient admission is partly avoidable, even if this is associated with health risks. This should be discussed with the patient within the framework of participatory decision-making. In advanced frailty, the needs correspond to those of palliative patients.
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Affiliation(s)
- Jan-Niklas Krohn
- Schwerpunkt Geriatrie, Klinik für Innere Medizin 2, Klinikum Nürnberg, Paracelsus Medizinische Privatuniversität Nürnberg, Nürnberg
| | - Katrin Singler
- Schwerpunkt Geriatrie, Klinik für Innere Medizin 2, Klinikum Nürnberg, Paracelsus Medizinische Privatuniversität Nürnberg, Nürnberg
- Institut für Biomedizin des Alterns, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nürnberg, Germany
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17
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Schattner A. Post-discharge syndrome in older adults. QJM 2023; 116:739-740. [PMID: 37261861 DOI: 10.1093/qjmed/hcad113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Indexed: 06/02/2023] Open
Affiliation(s)
- Ami Schattner
- Faculty of Medicine, Hebrew University and Hadassah Medical School, Jerusalem, Israel
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18
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Bergenfeldt H, Forberg JL, Lehtinen R, Anefjäll E, Vedin T. Delayed intracranial hemorrhage after head trauma seems rare and rarely needs intervention-even in antiplatelet or anticoagulation therapy. Int J Emerg Med 2023; 16:54. [PMID: 37667208 PMCID: PMC10476369 DOI: 10.1186/s12245-023-00530-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 08/20/2023] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND Traumatic brain injury causes morbidity, mortality, and at least 2,500,000 yearly emergency department visits in the USA. Computerized tomography of the head is the gold standard to detect traumatic intracranial hemorrhage. Some are not diagnosed at the first scan, and they are denoted "delayed intracranial hemorrhages. " To detect these delayed hemorrhages, current guidelines for head trauma recommend observation and/or rescanning for patients on anticoagulation therapy but not for patients on antiplatelet therapy. The aim of this study was to investigate the prevalence and need for interventions of delayed intracranial hemorrhage after head trauma. METHODS The study was a retrospective review of medical records of adult patients with isolated head trauma presenting at Helsingborg General Hospital between January 1, 2020, and December 31, 2020. Univariate statistical analyses were performed. RESULTS In total, 1627 patients were included and four (0.25%, 95% confidence interval 0.06-0.60%) patients had delayed intracranial hemorrhage. One of these patients was diagnosed within 24 h and three within 2-30 days. The patient was diagnosed within 24 h, and one of the patients diagnosed within 2-30 days was on antiplatelet therapy. None of these four patients was prescribed anticoagulation therapy, and no intensive care, no neurosurgical operations, or deaths were recorded. CONCLUSION Traumatic delayed intracranial hemorrhage is rare and consequences mild and antiplatelet and anticoagulation therapy might confer similar risk. Because serious complications appear rare, observing, and/or rescanning all patients with either of these medications can be debated. Risk stratification of these patients might have the potential to identify the patients at risk while safely reducing observation times and rescanning.
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Affiliation(s)
- Henrik Bergenfeldt
- Clinical Research Centre, Department of Clinical Sciences, Skåne University Hospital, Lund University, Box 50332, 20213 Malmö, Sweden
| | - Jakob Lundager Forberg
- Clinical Sciences, Helsingborg General Hospital, Lund University, Svartbrödragränden 3-5, 25187 Helsingborg, Sweden
| | - Riikka Lehtinen
- Clinical Sciences, Helsingborg General Hospital, Lund University, Svartbrödragränden 3-5, 25187 Helsingborg, Sweden
| | - Ebba Anefjäll
- Clinical Sciences, Helsingborg General Hospital, Lund University, Svartbrödragränden 3-5, 25187 Helsingborg, Sweden
| | - Tomas Vedin
- Clinical Research Centre, Department of Clinical Sciences, Skåne University Hospital, Lund University, Box 50332, 20213 Malmö, Sweden
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Conroy S, Brailsford S, Burton C, England T, Lalseta J, Martin G, Mason S, Maynou-Pujolras L, Phelps K, Preston L, Regen E, Riley P, Street A, van Oppen J. Identifying models of care to improve outcomes for older people with urgent care needs: a mixed methods approach to develop a system dynamics model. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-183. [PMID: 37830206 DOI: 10.3310/nlct5104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
Background We aimed to understand urgent and emergency care pathways for older people and develop a decision support tool using a mixed methods study design. Objective(s), study design, settings and participants Work package 1 identified best practice through a review of reviews, patient, carer and professional interviews. Work package 2 involved qualitative case studies of selected urgent and emergency care pathways in the Yorkshire and Humber region. Work package 3 analysed linked databases describing urgent and emergency care pathways identifying patient, provider and pathway factors that explain differences in outcomes and costs. Work package 4 developed a system dynamics tool to compare emergency interventions. Results A total of 18 reviews summarising 128 primary studies found that integrated social and medical care, screening and assessment, follow-up and monitoring of service outcomes were important. Forty patient/carer participants described emergency department attendances; most reported a reluctance to attend. Participants emphasised the importance of being treated with dignity, timely and accurate information provision and involvement in decision-making. Receiving care in a calm environment with attention to personal comfort and basic physical needs were key. Patient goals included diagnosis and resolution, well-planned discharge home and retaining physical function. Participants perceived many of these goals of care were not attained. A total of 21 professional participants were interviewed and 23 participated in focus groups, largely confirming the review evidence. Implementation challenges identified included the urgent and emergency care environment, organisational approaches to service development, staff skills and resources. Work package 2 involved 45 interviews and 30 hours of observation in four contrasting emergency departments. Key themes relating to implementation included: intervention-related staff: frailty mindset and behaviours resources: workforce, space, and physical environment operational influences: referral criteria, frailty assessment, operating hours, transport. context-related links with community, social and primary care organisation and management support COVID-19 pandemic. approaches to implementation service/quality improvement networks engaging staff and building relationships education about frailty evidence. The linked databases in work package 3 comprised 359,945 older people and 1,035,045 observations. The most powerful predictors of four-hour wait and transfer to hospital were age, previous attendance, out-of-hours attendance and call handler designation of urgency. Drawing upon the previous work packages and working closely with a wide range of patient and professional stakeholders, we developed an system dynamics tool that modelled five evidence-based urgent and emergency care interventions and their impact on the whole system in terms of reducing admissions, readmissions, and hospital related mortality. Limitations Across the reviews there was incomplete reporting of interventions. People living with severe frailty and from ethnic minorities were under-represented in the patient/carer interviews. The linked databases did not include patient reported outcomes. The system dynamics model was limited to evidence-based interventions, which could not be modelled conjointly. Conclusions We have reaffirmed the poor outcomes frequently experienced by many older people living with urgent care needs. We have identified interventions that could improve patient and service outcomes, as well as implementation tools and strategies to help including clinicians, service managers and commissioners improve emergency care for older people. Future work Future work will focus on refining the system dynamics model, specifically including patient-reported outcome measures and pre-hospital services for older people living with frailty who have urgent care needs. Study registrations This study is registered as PROSPERO CRD42018111461. WP 1.2: University of Leicester ethics: 17525-spc3-ls:healthsciences, WP 2: IRAS 262143, CAG 19/CAG/0194, WP 3: IRAS 215818, REC 17/YH/0024, CAG 17/CAG/0024. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme [project number 17/05/96 (Emergency Care for Older People)] and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 14. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Simon Conroy
- Geriatrician, George Davies Centre, University of Leicester, Leichester, UK
| | - Sally Brailsford
- Southampton Business School, University of Southampton, Southampton, UK
| | - Christopher Burton
- Academic Unit of Medical Education, University of Sheffield, Sheffield, UK
| | - Tracey England
- Health Sciences, University of Southampton, Southampton, UK
| | - Jagruti Lalseta
- Leicester Older Peoples' Research Forum, University of Leicester, Leicester, UK
| | - Graham Martin
- Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK
| | - Suzanne Mason
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Kay Phelps
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Louise Preston
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Emma Regen
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Peter Riley
- Leicester older peoples' research forum, University of Leicester, Leicester, UK
| | - Andrew Street
- Department of Health Policy, London School of Economics, London, UK
| | - James van Oppen
- Department of Health Sciences, University of Leicester, Leicester, UK
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Meechan C, Navaneetharaja N, Bailey S, Burridge R, Patel M, Loke YK, Mattishent K. EVALUATION OF THE FIRST OLDER PEOPLE'S EMERGENCY DEPARTMENT IN ENGLAND - A RETROSPECTIVE COHORT STUDY. J Emerg Med 2023:S0736-4679(23)00227-5. [PMID: 37355421 DOI: 10.1016/j.jemermed.2023.04.003] [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: 11/24/2022] [Revised: 03/30/2023] [Accepted: 04/10/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND The complexity of older patients along with trends in poorer outcomes in the emergency department (ED) has prompted research into how EDs can adapt to meet the needs of an aging population. A separate Older People's Emergency Department (OPED) has been proposed to improve care at the front door. OBJECTIVE Compare patient flow in a dedicated OPED at a University Hospital in Norfolk, United Kingdom, against that of the main ED. METHODS We carried out a retrospective cohort study to compare older patients attending the ED in 2019 against those attending the newly formed OPED service in 2020. Multivariable logistic regression was performed to estimate adjusted odds ratios (emergency admissions, meeting England's 4-h national target, re-admissions, all-cause 30-day mortality, clinical frailty screening, and discharge to original place of residence). RESULTS Clinical assessment in the OPED did not significantly lower the proportion of patients admitted to the hospital (adjusted odds ratio 0.84; 95% confidence interval 0.61-1.16). There were significant reductions in overall time spent in the department, time to initial clinician review, and time to frailty screening. Patients seen in the OPED were more likely to meet the national 4-h target and more likely to be discharged to their original place of residence. CONCLUSIONS Assessment in the OPED was not associated with a significantly reduced likelihood of hospitalization. However, patients had a shorter wait for clinical assessment, with concomitant reduction in department length of stay.
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Affiliation(s)
- Caitlin Meechan
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | | | - Sarah Bailey
- Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, United Kingdom
| | - Rachel Burridge
- The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, King's Lynn, United Kingdom
| | - Martyn Patel
- Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, United Kingdom
| | - Yoon K Loke
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
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21
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Shafiq S, Haith-Cooper M, Hawkins R, Parveen S. What are lay UK public perceptions of frailty: a scoping review. Age Ageing 2023; 52:7099134. [PMID: 37002930 PMCID: PMC10066724 DOI: 10.1093/ageing/afad045] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Indexed: 04/04/2023] Open
Abstract
RATIONALE AND OBJECTIVE Perceptions of frailty can influence how families cope, quality of life and access to support services. Yet little is known of how lay members of the UK general public perceive frailty. This scoping review aimed to explore how frailty is perceived among the lay public in the United Kingdom. METHODS The established scoping review methodology by Arksey and O'Malley was followed and searches were conducted across eight electronic databases and grey literature websites for articles published between 1990 and August 2022. In total, 6,705 articles were identified, of which six were included in the review. Data were analysed using Braun and Clarke's thematic analysis framework. RESULTS Three key themes were identified; frailty as a normal part of ageing, perceived consequences of frailty and coping with frailty. Overall, frailty has negative connotations and is perceived as linked to a natural part of the ageing process, increased dependency, loss of identity and social exclusion and stigma. However, it is unclear whether these perceptions have a direct bearing on access to support services for communities. CONCLUSION AND IMPLICATIONS This review identifies that it is imperative for health and social care service providers to consider the individual meaning of frailty for older people and families, to understand and integrate their particular needs and preferences when planning and delivering person centred frailty care and support. There is also a need for development of interventions that focus on increasing education and reducing stigma around frailty in order to change frailty perceptions in the UK.
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Affiliation(s)
| | - Melanie Haith-Cooper
- Centre for Applied Dementia Studies, Faculty of Health Studies, University of Bradford, Bradford BD7 1DP, UK
| | - Rebecca Hawkins
- Leeds Institute of Health Sciences, University of Leeds, Leeds, LS2 9LH, UK
| | - Sahdia Parveen
- Centre for Applied Dementia Studies, Faculty of Health Studies, University of Bradford, Bradford BD7 1DP, UK
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22
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Meredith SJ, Roberts H, Grocott MPW, Jack S, Murphy J, Varkonyi-Sepp J, Bates A, Lim SER. Frail2Fit study protocol: a feasibility and acceptability study of a virtual multimodal intervention delivered by volunteers to improve functional outcomes in older adults with frailty after discharge from hospital. BMJ Open 2023; 13:e069533. [PMID: 36927597 PMCID: PMC10030662 DOI: 10.1136/bmjopen-2022-069533] [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] [Indexed: 03/18/2023] Open
Abstract
INTRODUCTION Physical activity (PA) and replete nutritional status are key to maintaining independence and improving frailty status among frail older adults. In response to the COVID-19 pandemic, healthcare has increasingly turned to virtual modes of delivery and there is interest in the use of trained volunteers to deliver PA and nutrition interventions. We aim to evaluate the feasibility and acceptability of training hospital volunteers to deliver an online intervention, comprising exercise, behaviour change and nutrition support, to older people with frailty after discharge from hospital. METHODS We will use a quasi-experimental mixed methods approach. Hospital volunteers (n=6) will be trained to deliver an online, 3-month, multimodal intervention to frail (Clinical Frailty Scale ≥5) adults ≥65 years (n=30) after discharge from hospital. Feasibility will be assessed by determining the number of volunteers recruited, trained and retained at the end of the study; the proportion of intervention sessions delivered; participant recruitment, retention and adherence to the intervention. To determine the acceptability of the intervention, interviews will be conducted among a purposive sample of older adults, and volunteers. Secondary outcomes will include physical function, appetite, well-being, quality of life, anxiety and depression, self-efficacy for managing chronic disease and PA. Outcomes will be measured at baseline, 3 months and 6 months. ANALYSIS Descriptive statistics will be used to describe feasibility and adherence to the intervention. Secondary outcomes at baseline will be compared at 3 and 6 months. Interviews will be transcribed verbatim and analysed using thematic analysis. ETHICS AND DISSEMINATION Health Research Authority ethical approval was obtained on 30 May 2022 (reference: 22/WA/0155). Results will be disseminated through peer-reviewed journal articles, volunteer organisations, National Health Service communication systems and social media platforms. A toolkit will be developed to facilitate roll out of volunteer training. TRIAL REGISTRATION NUMBER NCT05384730.
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Affiliation(s)
- Samantha Jane Meredith
- Academic Geriatric Medicine, University of Southampton Faculty of Medicine, Southampton, Hampshire, UK
- NIHR ARC Wessex, University of Southampton, Southampton, UK
| | - Helen Roberts
- Academic Geriatric Medicine, University of Southampton Faculty of Medicine, Southampton, Hampshire, UK
- NIHR ARC Wessex, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton / University of Southampton, Southampton, UK
| | - Michael P W Grocott
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton / University of Southampton, Southampton, UK
- Clinical and Experimental Science, University of Southampton, Southampton, UK
| | - Sandy Jack
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton / University of Southampton, Southampton, UK
- Clinical and Experimental Science, University of Southampton, Southampton, UK
| | - Jane Murphy
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, UK
| | - Judit Varkonyi-Sepp
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton / University of Southampton, Southampton, UK
- Clinical and Experimental Science, University of Southampton, Southampton, UK
- Clinical Health Psychology Service, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Andrew Bates
- Clinical and Experimental Science, University of Southampton, Southampton, UK
- Nursing, Midwifery, and Health, University of Southampton, Southampton, UK
| | - Stephen Eu Ruen Lim
- Academic Geriatric Medicine, University of Southampton Faculty of Medicine, Southampton, Hampshire, UK
- NIHR ARC Wessex, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton / University of Southampton, Southampton, UK
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23
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van Oppen J, Conroy S. Improving outcomes for older people with emergency care needs. Br J Hosp Med (Lond) 2023; 29:1-7. [PMID: 36989154 DOI: 10.12968/hmed.2022.0495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
This article describes work on emergency care for older people. It summarises patient experience in emergency care settings, the evidence base relating to improvement of outcomes and emerging interventions and describes tools that can support teams as they work on service improvement. Finally, it calls for the measurement of outcomes that matter to older people, as a mechanism to drive more person-centred approaches to emergency care.
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Affiliation(s)
- James van Oppen
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Simon Conroy
- MRC Unit for Lifelong Health and Ageing at UCL, University College London, London, UK
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24
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Markofski MM, Johnston CA. Virtual Programming for Physical Activity Interventions: Integration of Behavioral Components. Am J Lifestyle Med 2023; 17:198-201. [PMID: 36896040 PMCID: PMC9989496 DOI: 10.1177/15598276221142753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The SARS-Cov-2 pandemic changed many contemporary experiences, including how healthcare and exercise programming are delivered. As a result of the pandemic, there was an increase in virtual services and programming and there continues to be a demand for virtual options. The results from Desir et al support the use of virtual visits to successfully change lifestyle factors, specifically nutrition and physical activity. The use of individualized dietary and exercise goals were important to the success of the intervention, and should not be disregarded. As virtual healthcare and exercise continues to evolve, to maximize behavior change, we should also consider how to include the social and community aspects of exercise. Regardless, it is encouraging to see that significant advances are being made in virtual programming and that the needed engagement can occur in a virtual setting.
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Affiliation(s)
- Melissa M Markofski
- Department of Health and Human Performance, University of Houston, Houston, TX, USA
| | - Craig A Johnston
- Department of Health and Human Performance, University of Houston, Houston, TX, USA
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25
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Clinical frailty scale score during geriatric rehabilitation predicts short-term mortality: RESORT cohort study. Ann Phys Rehabil Med 2023; 66:101645. [PMID: 35151896 DOI: 10.1016/j.rehab.2022.101645] [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: 08/03/2021] [Revised: 12/25/2021] [Accepted: 01/03/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND Frailty is associated with poor health outcomes, such as functional decline and institutionalization. The Clinical Frailty Scale (CFS) is a judgement-based frailty assessment tool developed to identify frail adults and assess level of frailty. OBJECTIVES We aimed to determine the association between CFS at admission and discharge, admission-discharge change, and mortality in individuals admitted to geriatric rehabilitation. METHODS REStORing health of acutely unwell adulTs (RESORT) is a longitudinal, observational inception cohort of consecutive individuals admitted to geriatric rehabilitation at the Royal Melbourne Hospital, Melbourne, Australia. The CFS was assessed at admission and discharge from geriatric rehabilitation. Logistic regression was used to examine the association between CFS score at admission and in-hospital mortality. Cox proportional hazards regression analysis was used to analyse associations between CFS at admission and discharge, admission-to-discharge change, and 3-month and 1-year mortality. RESULTS A total of 1766 participants were included: median age was 83.4 years (Interquartile range [IQR] 77.6-88.4), 57% were female, median length of stay in geriatric rehabilitation was 20 days (13.8-31.7) and median CFS score was 6 (5-7) at both admission and discharge. Increased CFS score was associated with in-hospital mortality (odds ratio [OR] 1.8, 95% CI 1.4-2.4), 3-month mortality and 1-year mortality (admission CFS: hazard ratio [HR] 1.4, 95% CI 1.2-1.6; discharge CFS: HR 1.4, 95% CI 1.2-1.7). Risk of 3-month mortality was increased when CFS score increased from admission to discharge (HR 2.1, 95% CI 1.2-3.8) as compared with when it decreased. CONCLUSION CFS score at admission and discharge was associated with post-discharge mortality in individuals admitted to geriatric rehabilitation. These findings support the use of the CFS in clinical settings to assist clinical characterisation and decision making.
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26
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van Oppen JD, Coats TJ, Conroy SP, Lalseta J, Richardson V, Riley P, Valderas JM, Mackintosh N. Co-creation of a Patient-Reported Outcome Measure for Older People Living with Frailty Receiving Acute Care (PROM-OPAC). J Patient Exp 2023. [DOI: 10.1177/23743735231158941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023] Open
Abstract
Older people living with frailty emphasize autonomy and function as acute healthcare outcome goals. Existing Patient-Reported Outcome Measures (PROMs) measure function but do not comprehensively address autonomy. This initial development of a novel autonomy outcome measure used co-creation and cognitive interviews, working toward a PROM for Older People living with frailty receiving Acute Care (“PROM-OPAC”). Novel item question stems and responses considering autonomy were devised with lay research partners. Items were examined for content by lay volunteers, and then selected based on relevance, completeness, and accessibility. Retained items were cognitively tested with patient participants. Item selection considered content validity and feasibility and was undertaken collaboratively with lay research partners. The study involved 3 lay research partners and 4 further lay collaborators throughout all stages, and 14 patient participants were recruited for the cognitive interviews. Twenty-two novel items were appraised. Seven were selected for retention. This preliminary PROM-OPAC comprised 7 items to measure autonomy and was intended for administration alongside a function measure to capture meaningful acute healthcare outcomes. Development will continue with quantitative testing and validation.
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Affiliation(s)
- James D. van Oppen
- Department of Population Health Sciences, University of Leicester, Leicester, UK
- Emergency & Specialist Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Timothy J. Coats
- Emergency & Specialist Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Simon P. Conroy
- MRC Unit for Lifelong Health and Ageing, University College London, London, UK
| | - Jagruti Lalseta
- Leicester, Leicestershire and Rutland Older Persons Patient and Public Involvement Forum, Leicester, UK
| | - Vivien Richardson
- Leicester, Leicestershire and Rutland Older Persons Patient and Public Involvement Forum, Leicester, UK
| | - Peter Riley
- Leicester, Leicestershire and Rutland Older Persons Patient and Public Involvement Forum, Leicester, UK
| | - Jose M. Valderas
- Department of Family Medicine, National University Health System, Singapore, Singapore
| | - Nicola Mackintosh
- Department of Population Health Sciences, University of Leicester, Leicester, UK
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27
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Summerfield C, Smith L, Todd O, Renzi C, Lyratzopoulos G, Neal RD, Jones D. The Effect of Older Age and Frailty on the Time to Diagnosis of Cancer: A Connected Bradford Electronic Health Records Study. Cancers (Basel) 2022; 14:5666. [PMID: 36428757 PMCID: PMC9688630 DOI: 10.3390/cancers14225666] [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: 10/25/2022] [Revised: 11/12/2022] [Accepted: 11/16/2022] [Indexed: 11/19/2022] Open
Abstract
Over 60% of cancer diagnoses in the UK are in patients aged 65 and over. Cancer diagnosis and treatment in older adults is complicated by the presence of frailty, which is associated with lower survival rates and poorer quality of life. This population-based cohort study used a longitudinal database to calculate the time between presentation to primary care with a symptom suspicious of cancer and a confirmed cancer diagnosis for 7460 patients in the Bradford District. Individual frailty scores were calculated using the electronic frailty index (eFI) and categorised by severity. The median time from symptomatic presentation to cancer diagnosis for all patients was 48 days (IQR 21-142). 23% of the cohort had some degree of frailty. After adjustment for potential confounders, mild frailty added 7 days (95% CI 3-11), moderate frailty 23 days (95% CI 4-42) and severe frailty 11 days (95% CI -27-48) to the median time to diagnosis compared to not frail patients. Our findings support use of the eFI in primary care to identify and address patient, healthcare and system factors that may contribute to diagnostic delay. We recommend further research to explore patient and clinician factors when investigating cancer in frail patients.
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Affiliation(s)
| | - Lesley Smith
- Clinical and Population Science Department, School of Medicine, University of Leeds, Leeds LS2 9JT, UK
| | - Oliver Todd
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds LS2 9JT, UK
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Trust, Bradford BD9 6RJ, UK
| | - Cristina Renzi
- Epidemiology of Cancer Healthcare Outcomes (ECHO) Research Group, Research Department of Behavioural Science and Health, University College London, London WC1E 6BT, UK
- Faculty of Medicine, University Vita-Salute San Raffaele, Milan, Via Olgettina 58, 20132 Milan, Italy
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare Outcomes (ECHO) Research Group, Research Department of Behavioural Science and Health, University College London, London WC1E 6BT, UK
| | - Richard D. Neal
- Department of Health and Community Sciences, Faculty of Health and Life Sciences, University of Exeter, Exeter EX4 4PY, UK
| | - Daniel Jones
- Academic Unit of Primary Care, University of Leeds, Leeds LS2 9JT, UK
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28
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Eldehni MT. Frailty, multimorbidity and sarcopaenia in haemodialysis patients. Curr Opin Nephrol Hypertens 2022; 31:560-565. [PMID: 36172855 DOI: 10.1097/mnh.0000000000000834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW It is well recognised that haemodialysis patients have higher levels of multimorbidity, frailty and sarcopaenia. This review examines the current understanding of the three concepts in relation to the general population and haemodialysis patients, and the methods used to quantify them. It also looks at the interaction between multimorbidity, frailty and sarcopaenia in this patient group and proposes a new model that utilises muscle mass index and fat mass index as a surrogate representation of the three concepts. RECENT FINDINGS Multimorbidity in on the rise in the general population and this is one of the contributing factors to higher rates of chronic kidney disease, progression to end-stage renal disease and multimorbidity in haemodialysis patients. Malnutrition and haemodialysis induced end organ damage further contributes to muscle loss and frailty in this patient group. There is a significant overlap and interaction between multimorbidity, frailty and sarcopaenia in haemodialysis and their presence carries a significant impact on quality of life and survival. There are multiple scores for measuring multimorbidity, frailty and sarcopenia and there is no consensus on their utilisation in haemodialysis patients. We propose the use of fat mass index and muscle mass index model as a surrogate method for clinically quantifying multimorbidity, frailty and sarcopaenia. SUMMARY Effective public health policies are likely to have an impact on reducing the prevalence of multimorbidity and the development of end stage renal disease. Future research is required to develop interventions that are targeted at maintaining muscle mass and function in haemodialysis patients.
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Affiliation(s)
- Mohamed Tarek Eldehni
- Department of Renal Medicine, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, Derbyshire
- Centre for Kidney Research and Innovation, Academic Unit for Translational Medical Sciences School of Medicine, University of Nottingham, Nottingham, UK
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29
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Johnstone G, Joe A, Dickins M, Lowthian JA. Use of home care services by older Veterans and dependants in Melbourne, Australia, 2007-2016. JOURNAL OF MILITARY, VETERAN AND FAMILY HEALTH 2022. [DOI: 10.3138/jmvfh-2021-0120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
LAY SUMMARY Military service has an impact on health and well-being across the life course. However, there is little research on older Veterans and dependants who use home care to enable them to remain living in the community. The authors analysed data from a Melbourne, Australia, home care organization’s electronic care records to explore the differences between clients supported by the Department of Veterans’ Affairs and clients in the general home nursing population. Results showed the greater needs of and complexity of care utilized by Veterans and dependants. Funding structures and support services need to account for these needs in older age.
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Affiliation(s)
- Georgina Johnstone
- Bolton Clarke Research Institute, Bolton Clarke, Melbourne, Victoria, Australia
| | - Angela Joe
- Bolton Clarke Research Institute, Bolton Clarke, Melbourne, Victoria, Australia
| | - Marissa Dickins
- Bolton Clarke Research Institute, Bolton Clarke, Melbourne, Victoria, Australia
| | - Judy A. Lowthian
- Bolton Clarke Research Institute, Bolton Clarke, Melbourne, Victoria, Australia
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30
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Cowley A, Goldberg SE, Gordon AL, Logan PA. A non-randomised feasibility study of the Rehabilitation Potential Assessment Tool (RePAT) in frail older people in the acute healthcare setting. BMC Geriatr 2022; 22:785. [PMID: 36207681 PMCID: PMC9541000 DOI: 10.1186/s12877-022-03420-w] [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: 02/28/2022] [Accepted: 08/24/2022] [Indexed: 11/13/2022] Open
Abstract
Background Rehabilitation potential involves predicting who will benefit from rehabilitation. Decisions about rehabilitation potential must take into account personal, clinical and contextual factors, a process which is complicated in the presence of acute ill-health and frailty. This study aimed to evaluate the feasibility and acceptability of the Rehabilitation Potential Assessment Tool (RePAT) – a 15 item holistic, person-centred assessment tool and training package – in the acute hospital setting. Methods A non-randomised feasibility study with nested semi-structured interviews explored whether RePAT was feasible and acceptable. Feasibility was tested by recruiting physiotherapy and occupational therapy participants delivering the RePAT intervention to patients alongside usual clinical care. Acceptability was tested by conducting semi-structured interviews with staff, patient and carer participants. Staff and patient characteristics were analysed using descriptive statistics. Interview data were analysed thematically. Fidelity of completed RePAT items was assessed against a priori criteria on how closely they matched tool guidance by two researchers. Mean values of the two scores were calculated. RePAT content was analysed and supported with verbatim quotes. Results Six staff participants were recruited and trained. They assessed 26 patient participants using RePAT. Mean (SD) patient age was 86.16 (±6.39) years. 32% were vulnerable or mildly frail, 42% moderately frail and 26% severely or very severely frail using the Clinical Frailty Scale. Mean (SD) time to complete RePAT was 32.7 (±9.6) minutes. RePAT fidelity was good where 13 out of 15 items achieved a priori fidelity. RePAT was acceptable and tolerated by staff and patients. Staff participants reported RePAT enabled them to consider rehabilitation decisions in a more structured and consistent way. Patients and carer participants, although unable to comment directly on RePAT, reported being satisfied with their rehabilitation assessments which were found to embrace a person-centred approach. Conclusions RePAT was found to be acceptable and feasible by staff, carers and patients. It allowed clinicians to make explicit their reasoning behind rehabilitation assessments and encouraged them to become more cognisant of factors which affected their clinical decision-making. Trial registration ID ISRCTN31938453. Registered 05/10/2021. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03420-w.
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Affiliation(s)
- Alison Cowley
- Research and Innovation, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Hucknall Road, Nottingham, NG5 1PB, UK. .,Academic Unit of Injury, Inflammation and Recovery Sciences, School of Medicine, University of Nottingham, Nottingham, UK.
| | - Sarah E Goldberg
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Adam L Gordon
- Academic Unit of Injury, Inflammation and Recovery Sciences, School of Medicine, University of Nottingham, Nottingham, UK.,University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK.,NIHR Applied Research Collaboration East Midlands (ARC-EM), Nottingham, UK
| | - Pip A Logan
- Academic Unit of Injury, Inflammation and Recovery Sciences, School of Medicine, University of Nottingham, Nottingham, UK.,NIHR Applied Research Collaboration East Midlands (ARC-EM), Nottingham, UK.,Nottingham CityCare Partnership CIC, Nottingham, UK
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31
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Towards new definitions of avoidable hospital admissions. Br J Gen Pract 2022. [PMCID: PMC9512436 DOI: 10.3399/bjgp22x720725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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32
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Phelps K, Regen E, van Oppen JD, Riley P, Lalseta J, Martin G, Mason S, Conroy S. What are the goals of care for older people living with frailty when they access urgent care? Are those goals attained? A qualitative view of patient and carer perspectives. Int Emerg Nurs 2022; 63:101189. [DOI: 10.1016/j.ienj.2022.101189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 05/04/2022] [Accepted: 05/25/2022] [Indexed: 11/05/2022]
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33
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Morley DA, Kilgore C, Edwards M, Collins P, Scammell JME, Fletcher K, Board M. The changing role of Advanced Clinical Practitioners working with older people during the COVID- 19 pandemic: A qualitative research study. Int J Nurs Stud 2022; 130:104235. [PMID: 35427944 PMCID: PMC8956343 DOI: 10.1016/j.ijnurstu.2022.104235] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 03/11/2022] [Accepted: 03/12/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND COVID-19 was identified as a pandemic by the World Health Organisation (WHO) in December 2020. Advanced Clinical Practitioners (ACPs) in England working with older people with frailty, experienced their clinical role changing in response to the emergency health needs of this complex population group. In contrast to other countries, in England Advanced Clinical Practitioners are drawn from both nursing and allied health professions. Whilst much of the literature emphasises the importance of ensuring the sustainability of the Advanced Clinical Practitioners' role, the pandemic threw further light on its potential and challenges. However, an initial review of the literature highlighted a lack of research of Advanced Clinical Practitioners' capabilities working with uncertainty in disaster response situations. AIM To capture the lived experience of how English Advanced Clinical Practitioners working with older people adapted their roles in response to the COVID-19 pandemic (October 2020-January 2021). DESIGN, SETTING AND PARTICIPANTS A qualitative research design was used. Following ethical approval, 23 Advanced Clinical Practitioner volunteer participants from across England with varied health professional backgrounds were recruited from Advanced Clinical Practitioners' professional and social media networks on Twitter using a snowballing technique. METHODS Depending on preference or availability, 23 participants (nurses (18), physiotherapists (2), paramedics (2) and a pharmacist (1)) were interviewed singularly (n = 9) or as part of 3 focus groups (n = 14) using Zoom video communication. Audio recordings were transcribed and using qualitative data analysis software, NVivo 12 pro, coded for an essentialist thematic analysis of Advanced Clinical Practitioners' responses using an inductive approach. 27 codes were identified and collated into five themes. For the purposes of this paper, four themes are discussed: experiencing different work, developing attributes, negotiating barriers and changing future provision. FINDINGS Advanced Clinical Practitioners successfully transferred their advanced practice skills into areas of clinical need during the pandemic. Their autonomous and generic, high level of expertise equipped them for management and leadership positions where speed of change, and the dissolution of traditional professional boundaries, were prioritised. Barriers to progress included a lack of knowledge of the Advanced Clinical Practitioner role and friction between Advanced Clinical Practitioners and physicians. DISCUSSION AND CONCLUSION The study demonstrated the successful adaption of the Advanced Clinical Practitioner role to enable more creative, personalised and sustainable solutions in the care of older people living with frailty during the pandemic. The potential of Advanced Clinical Practitioner development is in a juxtaposition to the threat of pandemic services being dismantled once the emergency nature of care has passed. Healthcare organisations have a vital part to play in considering the enablers and barriers of Advanced Clinical Practitioner capability-based practice when responding to uncertainty.
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Affiliation(s)
- Dawn A. Morley
- Department of Nursing Science, Faculty of Health and Social Science (FHSS), Bournemouth University, Bournemouth Gateway Building, St Pauls Lane, Bournemouth BH8 8AJ, United Kingdom,Corresponding author
| | - Cliff Kilgore
- Dorset Healthcare Universities NHS Foundation Trust, United Kingdom
| | - Mary Edwards
- Dorset Healthcare Universities NHS Foundation Trust, United Kingdom
| | - Pippa Collins
- Dorset Healthcare Universities NHS Foundation Trust, United Kingdom
| | - Janet ME Scammell
- Department of Nursing Science, Faculty of Health and Social Science (FHSS), Bournemouth University, Bournemouth Gateway Building, St Pauls Lane, Bournemouth BH8 8AJ, United Kingdom
| | - Kelsie Fletcher
- Department of Nursing Science, Faculty of Health and Social Science (FHSS), Bournemouth University, Bournemouth Gateway Building, St Pauls Lane, Bournemouth BH8 8AJ, United Kingdom
| | - Michele Board
- Department of Nursing Science, Faculty of Health and Social Science (FHSS), Bournemouth University, Bournemouth Gateway Building, St Pauls Lane, Bournemouth BH8 8AJ, United Kingdom
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Horner RL. The role of the district nurse in screening and assessment for frailty. Br J Community Nurs 2022; 27:226-230. [PMID: 35522451 DOI: 10.12968/bjcn.2022.27.5.226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
An ageing population is leading to greater demands on healthcare services; investments are being made to allow complex care to be given in patient's homes by community care staff, as highlighted in the NHS Long Term Plan (2019). Frailty is often identified in secondary care when acute crisis is hit; frailty does not suddenly occur and will happen over time. This article aims to explore community screening, the assessment processes of frailty and the role the district nurse has. It also addresses how working collaboratively with the wider multidisciplinary team to earlier identify service users with frailty can assist in improving patient outcomes by empowering and supporting service users to remain at home. Recognising continual improvement to service users' care and changes in practice should be considered and disseminated. based upon best available evidence.
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Rueegg M, Nissen SK, Brabrand M, Kaeppeli T, Dreher T, Carpenter CR, Bingisser R, Nickel CH. The clinical frailty scale predicts 1-year mortality in emergency department patients aged 65 years and older. Acad Emerg Med 2022; 29:572-580. [PMID: 35138670 PMCID: PMC9320818 DOI: 10.1111/acem.14460] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/13/2021] [Accepted: 12/28/2021] [Indexed: 12/22/2022]
Abstract
Objective To validate the Clinical Frailty Scale (CFS) for prediction of 1‐year all‐cause mortality in the emergency department (ED) and compare its performance to the Emergency Severity Index (ESI). Methods Prospective cohort study at the ED of a tertiary care center in Northwestern Switzerland. All patients aged ≥65 years were included from March 18 to May 20, 2019, after informed consent. Frailty status was assessed using CFS, excluding level 9 (palliative). Acuity level was assessed using ESI. Both CFS and ESI were adjusted for age, sex and presenting condition in multivariable logistic regression. Prognostic performance was assessed for discrimination and calibration separately. Estimates were internally validated by Bootstrapping. Restricted mean survival time (RMST) was determined for all levels of CFS. Results In the final study population of 2191 patients, 1‐year all‐cause mortality was 17% (n = 372). RMST values ranged from 219 days for CFS 8 to 365 days for CFS 1. The adjusted CFS model had an area under receiver operating characteristic of 0.767 (95% confidence interval [CI]: 0.741–0.793), compared to 0.703 (95% CI: 0.673–0.732) for the adjusted ESI model. Conclusion The CFS predicts 1‐year all‐cause mortality for older ED patients and predicts survival time in a graded manner. The CFS is superior to the ESI when adjusted for age, sex, and presenting condition.
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Affiliation(s)
- Marco Rueegg
- Emergency Department University Hospital Basel, University of Basel Basel Switzerland
| | - Søren Kabell Nissen
- Institute of Regional Health Research, Centre South‐West Jutland University of Southern Denmark Odense Denmark
| | - Mikkel Brabrand
- Institute of Regional Health Research, Centre South‐West Jutland University of Southern Denmark Odense Denmark
- Department of Emergency Medicine Odense University Hospital, University of Southern Denmark Odense Denmark
| | - Tobias Kaeppeli
- Emergency Department University Hospital Basel, University of Basel Basel Switzerland
| | - Thomas Dreher
- Emergency Department University Hospital Basel, University of Basel Basel Switzerland
| | - Christopher R. Carpenter
- Department of Emergency MedicineWashington University in St. Louis School of Medicine, Emergency Care Research CoreSt. LouisMichiganUSA
| | - Roland Bingisser
- Emergency Department University Hospital Basel, University of Basel Basel Switzerland
| | - Christian H. Nickel
- Emergency Department University Hospital Basel, University of Basel Basel Switzerland
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A systematic review and recommendations for prom instruments for older people with frailty in emergency care. J Patient Rep Outcomes 2022; 6:30. [PMID: 35362836 PMCID: PMC8975986 DOI: 10.1186/s41687-022-00438-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 03/18/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction The current service metrics used to evaluate quality in emergency care do not account for specific healthcare outcome goals for older people living with frailty. These have previously been classified under themes of ‘Autonomy’ and ‘Functioning’. There is no person-reported outcome measure (PROM) for older people with frailty and emergency care needs. This study aimed to identify and co-produce recommendations for instruments potentially suitable for use in this population.
Methods In this systematic review, we searched six databases for PROMs used between 2010 and 2021 by older people living with frailty receiving acute hospital care. Studies were reviewed against predefined eligibility criteria and appraised for quality using the COSMIN Risk of Bias checklist. Data were extracted to map instrument constructs against an existing framework of acute healthcare outcome goals. Instrument face and content validity were assessed by lay collaborators. Recommendations for instruments with potential emergency care suitability were formed through co-production. Results Of 9392 unique citations screened, we appraised the full texts of 158 studies. Nine studies were identified, evaluating nine PROMs. Quality of included studies ranged from ‘doubtful’ to ‘very good’. Most instruments had strong evidence for measurement properties. PROMs mainly assessed ‘Functioning’ constructs, with limited coverage of ‘Autonomy’. Five instruments were considered too burdensome for the emergency care setting or too specific for older people living with frailty. Conclusions Four PROMs were recommended as potentially suitable for further validation with older people with frailty and emergency care needs: COOP/WONCA charts, EuroQol, McGill Quality of Life (Expanded), and Palliative care Outcome Scale. Supplementary Information The online version contains supplementary material available at 10.1186/s41687-022-00438-x.
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van Oppen JD, Coats TJ, Conroy SP, Lalseta J, Phelps K, Regen E, Riley P, Valderas JM, Mackintosh N. What matters most in acute care: an interview study with older people living with frailty. BMC Geriatr 2022; 22:156. [PMID: 35216550 PMCID: PMC8880299 DOI: 10.1186/s12877-022-02798-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 01/11/2022] [Indexed: 11/24/2022] Open
Abstract
Background Healthcare outcome goals are central to person-centred acute care, however evidence among older people is scarce. Older people who are living with frailty have distinct requirements for healthcare delivery and have distinct risk for adverse outcomes from healthcare. There is insufficient evidence for whether those living with frailty also have distinct healthcare outcome goals. This study explored the nature of acute care outcome goals in people living with frailty. Methods Healthcare outcome goals were explored using semi-structured patient interviews. Participants aged over 65 with Clinical Frailty Score 5-8 (mild to very severe frailty) were recruited during their first 72 hours in a UK hospital. Purposive, maximum variation sampling was guided by lay partners from a Patient and Public Involvement Forum specialising in ageing-related research. Qualitative analysis used a blended approach based on framework and constant comparative methodologies for the identification of themes. Findings were validated through triangulation with participant, lay partner, and technical expert review. Results The 22 participants were aged 71 to 98 and had mild to very severe frailty. One quarter were living with dementia. Most participants had reflected on their situation and considered their outcome goals. Theme categories (and corresponding sub-categories) were ‘Autonomy’ (information, control, and security) and ‘Functioning’ (physical, psychosocial, and relief). A novel ‘security’ theme was identified, whereby participants sought to feel safe in their usual living place and with their health problems. Those living with milder frailty were concerned to maintain ability to support loved ones, while those living with most severe frailty were concerned about burdening others. Conclusions Outcome goals for acute care among older participants living with frailty were influenced by the insecurity of their situation and fear of deterioration. Patients may be supported to feel safe and in control through appropriate information provision and functional support.
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Affiliation(s)
- James David van Oppen
- Department of Health Sciences, University of Leicester, Leicester, UK. .,Emergency & Specialist Medicine, University Hospitals Leicester NHS Trust, Leicester, UK.
| | - Timothy John Coats
- Emergency & Specialist Medicine, University Hospitals Leicester NHS Trust, Leicester, UK.,Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Simon Paul Conroy
- MRC Unit for Lifelong Health and Ageing, University College London, London, UK
| | - Jagruti Lalseta
- Leicester, Leicestershire and Rutland Older Persons Patient and Public Involvement Forum, Leicester, UK
| | - Kay Phelps
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Emma Regen
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Peter Riley
- Leicester, Leicestershire and Rutland Older Persons Patient and Public Involvement Forum, Leicester, UK
| | - Jose Maria Valderas
- Department of Family Medicine, National University Health System, Singapore, Singapore
| | - Nicola Mackintosh
- Department of Health Sciences, University of Leicester, Leicester, UK
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Gené Huguet L, Kostov B, Navarro González M, Hervás Docon A, Colungo Francia C, Vilaseca Llobet JM, Benavent Àreu J, González de Paz L, Sisó-Almirall A. Long-Term Effects on Preventing Frailty and Health Care Costs Associated with a Multifactorial Intervention in the Elderly: Three-Year Follow-Up Data from the Pre-Frail 80 Study. Gerontology 2022; 68:1121-1131. [DOI: 10.1159/000521497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 12/14/2021] [Indexed: 11/19/2022] Open
Abstract
<b><i>Introduction:</i></b> Preventing or delaying frailty has important benefits. Studies show the effectiveness of multifactorial interventions in the frail and pre-frail elderly, but few have evaluated their long-term effectiveness. Frailty and its consequences have been shown to increase the use of health resources. The main aim was to evaluate the long-term effect of a multifactorial primary healthcare intervention in pre-frail elderly people at 36 months and determine the health resources used and their cost. <b><i>Methods:</i></b> A follow-up of a cohort study of patients who participated in a randomized clinical trial in an urban primary care centre in Barcelona was carried out. We included 200 non-institutionalized people aged ≥80 years who met the Fried pre-frailty criteria. The intervention group (IG) received a 6-month interdisciplinary intervention based on physical exercise, Mediterranean diet advice, assessment of inadequate prescribing in polypharmacy patients, and social assessment, while the control group (CG) received standard of care primary healthcare treatment. Sociodemographic variables were collected at baseline. The Fried criteria, comorbidities, and geriatric syndromes were collected at baseline and 12 and 36 months. For the analysis of health costs, data were collected on visits, complementary tests, hospital admissions, and surgical interventions in the last 36 months. Complexity, the rate of expected emergency admission, and the rate of expected mortality were collected at 36 months. Between-group characteristics were compared at baseline and 36 months using the χ<sup>2</sup> test and the <i>t</i> test for independent samples. The post-intervention (12-month follow-up) versus longitudinal follow-up (36-month follow-up) comparison used McNemar’s test for each group. The nonparametric Mann-Whitney test was used to compare health costs. <b><i>Results:</i></b> Of the 200 patients initially included, we evaluated 135 (67.5%) patients who completed the 36-month follow-up. The mean age was 88.5 years and 64.4% were female. At 36 months, the transition to frailty was much lower in the IG than in the CG (22.1% vs. 32.8%, <i>p</i> = 0.013). The total mean health cost at 36 months was 3,110 EUR in the CG and 2,679 EUR in the IG. No significant between-group differences were observed according to Clinical Risk Groups. <b><i>Conclusions:</i></b> A multifactorial, interdisciplinary intervention carried out in primary care prevented frailty in pre-frail elderly people at 36-month follow-up. Although the IG was grouped into higher grade Clinical Risk Groups and therefore had greater morbidity, the cost was lower than that in the CG.
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The Diagnostic Accuracy and Clinimetric Properties of Screening Instruments to Identify Frail Older Adults Attending Emergency Departments: A Protocol for a Mixed Methods Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19031380. [PMID: 35162397 PMCID: PMC8834939 DOI: 10.3390/ijerph19031380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/17/2022] [Accepted: 01/19/2022] [Indexed: 01/23/2023]
Abstract
Background: Prompt and efficient identification and stratification of patients who are frail is important, as this cohort are at high risk of adverse healthcare outcomes. Numerous frailty screening tools have been developed to support their identification across different settings, yet relatively few have emerged for use in emergency departments (EDs). This protocol provides details for a systematic review aiming to synthesize the accumulated evidence regarding the diagnostic accuracy and clinimetric properties of frailty screening instruments to identify frail older adults in EDs. Methods: Six electronic databases will be searched from January 2000 to March 2021. Eligible studies will include adults aged ≥60 years screened in EDs with any available screening instrument to identify frailty (even if not originally designed for this purpose). Studies, including case-control, longitudinal, and cohort studies, will be included, where instruments are compared to a reference standard to explore diagnostic accuracy. Predictive accuracy for a selection of outcomes, including mortality, institutionalization, and readmission, will be assessed. Clinical and methodological heterogeneity will be examined, and a random effects meta-analysis performed if appropriate. Conclusion: Understanding whether frailty screening on presentation to EDs is accurate in identifying frailty, and predicting these outcomes is important for decision-making and targeting appropriate management.
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Gilbert T, Cordier Q, Polazzi S, Bonnefoy M, Keeble E, Street A, Conroy S, Duclos A. External validation of the Hospital Frailty Risk Score in France. Age Ageing 2022; 51:6310130. [PMID: 34185827 PMCID: PMC8753041 DOI: 10.1093/ageing/afab126] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The Hospital Frailty Risk Score (HFRS) has made it possible internationally to identify subgroups of patients with characteristics of frailty from routinely collected hospital data. OBJECTIVE To externally validate the HFRS in France. DESIGN A retrospective analysis of the French medical information database. SETTING 743 hospitals in Metropolitan France. SUBJECTS All patients aged 75 years or older hospitalised as an emergency in 2017 (n = 1,042,234). METHODS The HFRS was calculated for each patient based on the index stay and hospitalisations over the preceding 2 years. Main outcome measures were 30-day in-patient mortality, length of stay (LOS) >10 days and 30-day readmissions. Mixed logistic regression models were used to investigate the association between outcomes and HFRS score. RESULTS Patients with high HFRS risk were associated with increased risk of mortality and prolonged LOS (adjusted odds ratio [aOR] = 1.38 [1.35-1.42] and 3.27 [3.22-3.32], c-statistics = 0.676 and 0.684, respectively), while it appeared less predictive of readmissions (aOR = 1.00 [0.98-1.02], c-statistic = 0.600). Model calibration was excellent. Restricting the score to data prior to index admission reduced discrimination of HFRS substantially. CONCLUSIONS HFRS can be used in France to determine risks of 30-day in-patient mortality and prolonged LOS, but not 30-day readmissions. Trial registration: Reference ID on clinicaltrials.gov: ID: NCT03905629.
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Affiliation(s)
- Thomas Gilbert
- Service de médecine gériatrique, Hospices Civils de Lyon, Groupement Hospitalier Sud, 69495 Pierre-Bénite, France
- Research on Healthcare professionals and Performance (RESHAPE, inserm U1290), université Claude Bernard Lyon1, Lyon, France
| | - Quentin Cordier
- Health Data Department, Hospices Civils de Lyon, Lyon, France
| | - Stéphanie Polazzi
- Research on Healthcare professionals and Performance (RESHAPE, inserm U1290), université Claude Bernard Lyon1, Lyon, France
- Health Data Department, Hospices Civils de Lyon, Lyon, France
| | - Marc Bonnefoy
- Service de médecine gériatrique, Hospices Civils de Lyon, Groupement Hospitalier Sud, 69495 Pierre-Bénite, France
- U1060 INSERM, CarMeN, 69921 Oullins, France
| | | | - Andrew Street
- Department of Health Policy, London School of Economics, London WC2A 2AE, UK
| | - Simon Conroy
- Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester LE1 7HA, UK
| | - Antoine Duclos
- Research on Healthcare professionals and Performance (RESHAPE, inserm U1290), université Claude Bernard Lyon1, Lyon, France
- Health Data Department, Hospices Civils de Lyon, Lyon, France
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Frailty assessment and acute frailty service provision in the UK: results of a national 'day of care' survey. BMC Geriatr 2022; 22:19. [PMID: 34979956 PMCID: PMC8721940 DOI: 10.1186/s12877-021-02679-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 11/05/2021] [Indexed: 11/18/2022] Open
Abstract
Background The incorporation of acute frailty services into the acute care pathway is increasingly common. The prevalence and impact of acute frailty services in the UK are currently unclear. Methods The Society for Acute Medicine Benchmarking Audit (SAMBA) is a day of care survey undertaken annually within the UK. SAMBA 2019 (SAMBA19) took place on Thursday 27th June 2019. A questionnaire was used to collect hospital and patient-level data on the structure and organisation of acute care delivery. SAMBA19 sought to establish the frequency of frailty assessment tool use and describe acute frailty services nationally. Hospitals were classified based on the presence of acute frailty services and metrics of performance compared. Results A total of 3218 patients aged ≥70 admitted to 129 hospitals were recorded in SAMBA19. The use of frailty assessment tools was reported in 80 (62.0%) hospitals. The proportion of patients assessed for the presence of frailty in individual hospitals ranged from 2.2 to 100%. Bedded Acute Frailty Units were reported in 65 (50.3%) hospitals. There was significant variation in admission rates between hospitals. This was not explained by the presence of a frailty screening policy or presence of a dedicated frailty unit. Conclusion Two fifths of participating UK hospitals did not have a routine frailty screening policy: where this existed, rates of assessment for frailty were variable and most at-risk patients were not assessed. Responses to positive results were poorly defined. The provision of acute frailty services is variable throughout the UK. Improvement is needed for the aspirations of national policy to be fully realised.
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van Oppen J, Conroy S. Are Emergency Departments Responding to the Aging Demography? Ann Emerg Med 2021; 79:364-366. [PMID: 34952730 DOI: 10.1016/j.annemergmed.2021.11.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Indexed: 11/17/2022]
Affiliation(s)
- James van Oppen
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Simon Conroy
- Medical Research Council Unit for Lifelong Health and Ageing at University College London, University College London, London, United Kingdom.
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Wray F, Coleman S, Clarke D, Hudson K, Forster A, Teale E. Risk factors for manifestations of frailty in hospitalized older adults: A qualitative study. J Adv Nurs 2021; 78:1688-1703. [PMID: 34850424 PMCID: PMC9299686 DOI: 10.1111/jan.15120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 09/02/2021] [Accepted: 11/10/2021] [Indexed: 01/03/2023]
Abstract
Aims To explore the experiences of older people and ward staff to identify modifiable factors (risk factors) which have the potential to reduce development or exacerbation of manifestations of frailty during hospitalization. To develop a theoretical framework of modifiable risk factors. Design Qualitative descriptive study. Methods Qualitative interviews with recently discharged older people (n = 18) and focus groups with ward staff (n = 22) were undertaken between July and October 2019. Data were analysed using directed content analysis. Results Themes identified related to attitude to risk, communication and, loss of routine, stimulation and confidence. Using findings from this study and previously identified literature, we developed a theoretical framework including 67 modifiable risk factors. Risk factors are grouped by patient risk factor domains (pain, medication, nutritional/fluid intake, mobility, elimination, infection, additional patient risk factors) and linked care management sub‐domains (including risk factors relating to the ward environment, process of care, ward culture or broader organizational set up). Many of the additional 36 risk factors identified by this study were related to care management sub‐domains. Conclusion A co‐ordinated approach is needed to address modifiable risk factors which lead to the development or exacerbation of manifestations of frailty in hospitalized older people. Risk assessment and management practices should not be duplicative and, should recognize and address modifiable risk factors which occur at the ward and organizational level. Impact Some older people leave hospital more dependent than when they come in and this is, in part, due to the environment and process of care and not just the severity of their presenting illness. Many of the risk factors identified need to be addressed at an organizational rather than individual level. Findings will inform a programme of research to develop and test a novel system of care aimed at preventing loss of independence in hospitalized older people.
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Affiliation(s)
- Faye Wray
- University of Leeds, Leeds, UK.,Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | | | - David Clarke
- University of Leeds, Leeds, UK.,Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Kristian Hudson
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Anne Forster
- University of Leeds, Leeds, UK.,Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Elizabeth Teale
- University of Leeds, Leeds, UK.,Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
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Using explainable machine learning to characterise data drift and detect emergent health risks for emergency department admissions during COVID-19. Sci Rep 2021; 11:23017. [PMID: 34837021 PMCID: PMC8626460 DOI: 10.1038/s41598-021-02481-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 11/15/2021] [Indexed: 01/11/2023] Open
Abstract
A key task of emergency departments is to promptly identify patients who require hospital admission. Early identification ensures patient safety and aids organisational planning. Supervised machine learning algorithms can use data describing historical episodes to make ahead-of-time predictions of clinical outcomes. Despite this, clinical settings are dynamic environments and the underlying data distributions characterising episodes can change with time (data drift), and so can the relationship between episode characteristics and associated clinical outcomes (concept drift). Practically this means deployed algorithms must be monitored to ensure their safety. We demonstrate how explainable machine learning can be used to monitor data drift, using the COVID-19 pandemic as a severe example. We present a machine learning classifier trained using (pre-COVID-19) data, to identify patients at high risk of admission during an emergency department attendance. We then evaluate our model’s performance on attendances occurring pre-pandemic (AUROC of 0.856 with 95%CI [0.852, 0.859]) and during the COVID-19 pandemic (AUROC of 0.826 with 95%CI [0.814, 0.837]). We demonstrate two benefits of explainable machine learning (SHAP) for models deployed in healthcare settings: (1) By tracking the variation in a feature’s SHAP value relative to its global importance, a complimentary measure of data drift is found which highlights the need to retrain a predictive model. (2) By observing the relative changes in feature importance emergent health risks can be identified.
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Rezaei-Shahsavarloo Z, Atashzadeh-Shoorideh F, Ebadi A, Gobbens RJJ. Factors affecting missed nursing care in hospitalized frail older adults in the medical wards: a qualitative study. BMC Geriatr 2021; 21:555. [PMID: 34649518 PMCID: PMC8515677 DOI: 10.1186/s12877-021-02524-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 10/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Frail older adults who are hospitalized, are more likely to experience missed nursing care (MNC) due to high care needs, communication problems, and complexity of nursing care. We conducted a qualitative study to examine the factors affecting MNC among hospitalized frail older adults in the medical units. METHODS This qualitative study was carried using the conventional content analysis approach in three teaching hospitals. Semi-structured interviews were conducted with 17 nurses through purposive and snowball sampling. The inclusion criteria for the nurses were: at least two years of clinical work experience on a medical ward, caring for frail older people in hospital and willingness to participate. Data were analyzed in accordance with the process described by Graneheim and Lundman. In addition, trustworthiness of the study was assessed using the criteria proposed by Lincoln and Guba. RESULTS In general, 20 interviews were conducted with nurses. A total of 1320 primary codes were extracted, which were classified into two main categories: MNC aggravating and moderating factors. Factors such as "age-unfriendly structure," "inefficient care," and "frailty of older adults" could increase the risk of MNC. In addition, factors such as "support capabilities" and "ethical and legal requirements" will moderate MNC. CONCLUSIONS Hospitalized frail older adults are more at risk of MNC due to high care needs, communication problems, and nursing care complexity. Nursing managers can take practical steps to improve the quality of care by addressing the aggravating and moderating factors of MNC. In addition, nurses with a humanistic perspective who understand the multidimensional problems of frail older adults and pay attention to their weakness in expressing needs, can create a better experience for them in the hospital and improve patient safety.
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Affiliation(s)
- Zahra Rezaei-Shahsavarloo
- Student Research Committee, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Foroozan Atashzadeh-Shoorideh
- Department of Psychiatric Nursing & Management, School of Nursing and Midwifery, Shahid Labbafinezhad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Abbas Ebadi
- Behavioral Sciences Research Center, Life Style Institute, Baqiyatallah University of Medical Sciences, Tehran, IR, Iran
- Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, IR, Iran
| | - Robbert J J Gobbens
- Faculty of Health, Sports and Social Work, Inholland University of Applied Sciences, Amsterdam, the Netherlands
- Zonnehuisgroep Amstelland, Amstelveen, The Netherlands
- Department of Family Medicine and Population Health, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
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Tabinor M, Crowley LE, Godlee A, Flanagan D, Rashid RM, Baharani J, Ferro CJ, Eddington H. End-stage kidney disease patients from ethnic minorities and mortality in coronavirus disease 2019. Hemodial Int 2021; 26:83-93. [PMID: 34378315 PMCID: PMC8444789 DOI: 10.1111/hdi.12976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 07/19/2021] [Accepted: 07/23/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Coronavirus disease 2019 (COVID-19) adversely affects patients who are older, multimorbid, and from Black, Asian or minority ethnicities (BAME). We assessed whether being from BAME is independently associated with mortality in end-stage kidney disease (ESKD) patients with COVID-19. METHODS Prospective observational study in a single UK renal center. A study was conducted between March 10, 2020 and April 30, 2020. Demographics, socioeconomic deprivation (index of multiple deprivation), co-morbidities (Charlson comorbidity index [CCI]), and frailty data (clinical frailty score) were collected. The primary outcome was all-cause mortality. Data were censored on the 1st June 2020. FINDINGS Overall, 191 of our 3379 ESKD patients contracted COVID-19 in the 8-week observation period; 84% hemodialysis, 5% peritoneal dialysis, and 11% kidney transplant recipients (KTR). Of these, 57% were male and 67% were from BAME groups (43% Asian, 17% Black, 2% mixed race, and 5% other). Mean CCI was 7.45 (SD 2.11) and 3.90 (SD 2.10) for dialysis patients and KTR, respectively. In our cohort, 60% of patients lived in areas classified as being in the most deprived 20% in the United Kingdom, and of these, 77% of patients were from BAME groups. The case fatality rate was 29%. Multivariable cox regression demonstrated that BAME (hazard ratio [HR]: 2.37, 95% CI: 1.22-4.61) was associated with all-cause mortality after adjustment for age, deprivation, co-morbidities, and frailty. Associations with all-cause mortality persisted in sensitivity analyses in patients from South Asian (HR: 2.52, 95% CI: 1.24-5.12) and Black (HR: 2.43, 95% CI: 1.04-5.67) ethnic backgrounds. DISCUSSION BAME ESKD patients with COVID-19 are just over twice as likely to die compared to White patients, despite adjustment for age, deprivation, comorbidity, and frailty. This study highlights the need to develop strategies to improve BAME patient outcomes in future outbreaks of COVID-19.
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Affiliation(s)
- Matthew Tabinor
- Department of Renal Medicine, University Hospitals of Birmingham NHS Trust, Birmingham, UK
| | - Lisa Emma Crowley
- Department of Renal Medicine, University Hospitals of Birmingham NHS Trust, Birmingham, UK
| | - Alexandra Godlee
- Department of Renal Medicine, University Hospitals of Birmingham NHS Trust, Birmingham, UK
| | - Daisy Flanagan
- Department of Renal Medicine, University Hospitals of Birmingham NHS Trust, Birmingham, UK
| | - Raja Muhammad Rashid
- Department of Renal Medicine, University Hospitals of Birmingham NHS Trust, Birmingham, UK
| | - Jyoti Baharani
- Department of Renal Medicine, University Hospitals of Birmingham NHS Trust, Birmingham, UK
| | - Charles Joseph Ferro
- Department of Renal Medicine, University Hospitals of Birmingham NHS Trust, Birmingham, UK
| | - Helen Eddington
- Department of Renal Medicine, University Hospitals of Birmingham NHS Trust, Birmingham, UK
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Meid AD, Gonzalez-Gonzalez AI, Dinh TS, Blom J, van den Akker M, Elders P, Thiem U, Küllenberg de Gaudry D, Swart KMA, Rudolf H, Bosch-Lenders D, Trampisch HJ, Meerpohl JJ, Gerlach FM, Flaig B, Kom G, Snell KIE, Perera R, Haefeli WE, Glasziou P, Muth C. Predicting hospital admissions from individual patient data (IPD): an applied example to explore key elements driving external validity. BMJ Open 2021; 11:e045572. [PMID: 34348947 PMCID: PMC8340284 DOI: 10.1136/bmjopen-2020-045572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To explore factors that potentially impact external validation performance while developing and validating a prognostic model for hospital admissions (HAs) in complex older general practice patients. STUDY DESIGN AND SETTING Using individual participant data from four cluster-randomised trials conducted in the Netherlands and Germany, we used logistic regression to develop a prognostic model to predict all-cause HAs within a 6-month follow-up period. A stratified intercept was used to account for heterogeneity in baseline risk between the studies. The model was validated both internally and by using internal-external cross-validation (IECV). RESULTS Prior HAs, physical components of the health-related quality of life comorbidity index, and medication-related variables were used in the final model. While achieving moderate discriminatory performance, internal bootstrap validation revealed a pronounced risk of overfitting. The results of the IECV, in which calibration was highly variable even after accounting for between-study heterogeneity, agreed with this finding. Heterogeneity was equally reflected in differing baseline risk, predictor effects and absolute risk predictions. CONCLUSIONS Predictor effect heterogeneity and differing baseline risk can explain the limited external performance of HA prediction models. With such drivers known, model adjustments in external validation settings (eg, intercept recalibration, complete updating) can be applied more purposefully. TRIAL REGISTRATION NUMBER PROSPERO id: CRD42018088129.
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Affiliation(s)
- Andreas Daniel Meid
- Department of Clinical Pharmacology & Pharmacoepidemiology, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Ana Isabel Gonzalez-Gonzalez
- Institute of General Practice, Goethe University, Frankfurt am Main, Hessen, Germany
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain
| | - Truc Sophia Dinh
- Institute of General Practice, Goethe University, Frankfurt am Main, Hessen, Germany
| | - Jeanet Blom
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Marjan van den Akker
- Institute of General Practice, Goethe University, Frankfurt am Main, Hessen, Germany
- School of CAPHRI, Department of Family Medicine, Maastricht University, Maastricht, The Netherlands
| | - Petra Elders
- Department of General Practice and Elderly Care Medicine, Amsterdam UMC, Vrije Universiteit, Amstedarm Public Health Research Institute, Amsterdam, The Netherlands
| | - Ulrich Thiem
- Chair of Geriatrics and Gerontology, University Clinic Eppendorf, Hamburg, Germany
| | - Daniela Küllenberg de Gaudry
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Karin M A Swart
- Department of General Practice and Elderly Care Medicine, Amsterdam UMC, Vrije Universiteit, Amstedarm Public Health Research Institute, Amsterdam, The Netherlands
| | - Henrik Rudolf
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum, Bochum, Nordrhein-Westfalen, Germany
| | - Donna Bosch-Lenders
- School of CAPHRI, Department of Family Medicine, Maastricht University, Maastricht, The Netherlands
| | - Hans J Trampisch
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum, Bochum, Nordrhein-Westfalen, Germany
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ferdinand M Gerlach
- Institute of General Practice, Goethe University, Frankfurt am Main, Hessen, Germany
| | - Benno Flaig
- Institute of General Practice, Goethe University, Frankfurt am Main, Hessen, Germany
| | | | - Kym I E Snell
- Centre for Prognosis Research, School of Primary Care Research, Community and Social Care, Keele University, Keele, UK
| | - Rafael Perera
- Nuffield Department of Primary Care, University of Oxford, Oxford, UK
| | - Walter Emil Haefeli
- Department of Clinical Pharmacology & Pharmacoepidemiology, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Paul Glasziou
- Centre for Research in Evidence-Based Practice, Bond University, Robina, Queensland, Australia
| | - Christiane Muth
- Institute of General Practice, Goethe University, Frankfurt am Main, Hessen, Germany
- Department of General Practice and Family Medicine, Medical Faculty OWL, University of Bielefeld, Bielefeld, Germany
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48
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Affiliation(s)
- Ivan Aprahamian
- Geriatrics Division, Department of Internal Medicine, Jundiai Medical School, Jundiai, Sao Paulo, Brazil
| | - Qian-Li Xue
- Department of Medicine Division of Geriatric Medicine and Gerontology, School of Medicine, and the Center on Aging and Health, Johns Hopkins University, Baltimore, MD, USA.
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49
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Bion J, Aldridge C, Beet C, Boyal A, Chen YF, Clancy M, Girling A, Hofer T, Lord J, Mannion R, Rees P, Roseveare C, Rowan L, Rudge G, Sun J, Sutton E, Tarrant C, Temple M, Watson S, Willars J, Lilford R. Increasing specialist intensity at weekends to improve outcomes for patients undergoing emergency hospital admission: the HiSLAC two-phase mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background
NHS England’s 7-day services policy comprised 10 standards to improve access to quality health care across all days of the week. Six standards targeted hospital specialists on the assumption that their absence caused the higher mortality associated with weekend hospital admission: the ‘weekend effect’. The High-intensity Specialist-Led Acute Care (HiSLAC) collaboration investigated this using the implementation of 7-day services as a ‘natural experiment’.
Objectives
The objectives were to determine whether or not increasing specialist intensity at weekends improves outcomes for patients undergoing emergency hospital admission, and to explore mechanisms and cost-effectiveness.
Design
This was a two-phase mixed-methods observational study. Year 1 focused on developing the methodology. Years 2–5 included longitudinal research using quantitative and qualitative methods, and health economics.
Methods
A Bayesian systematic literature review from 2000 to 2017 quantified the weekend effect. Specialist intensity measured over 5 years used self-reported annual point prevalence surveys of all specialists in English acute hospital trusts, expressed as the weekend-to-weekday ratio of specialist hours per 10 emergency admissions. Hospital Episode Statistics from 2007 to 2018 provided trends in weekend-to-weekday mortality ratios. Mechanisms for the weekend effect were explored qualitatively through focus groups and on-site observations by qualitative researchers, and a two-epoch case record review across 20 trusts. Case-mix differences were examined in a single trust. Health economics modelling estimated costs and outcomes associated with increased specialist provision.
Results
Of 141 acute trusts, 115 submitted data to the survey, and 20 contributed 4000 case records for review and participated in qualitative research (involving interviews, and observations using elements of an ethnographic approach). Emergency department attendances and admissions have increased every year, outstripping the increase in specialist numbers; numbers of beds and lengths of stay have decreased. The reduction in mortality has plateaued; the proportion of patients dying after discharge from hospital has increased. Specialist hours increased between 2012/13 and 2017/18. Weekend specialist intensity is half that of weekdays, but there is no relationship with admission mortality. Patients admitted on weekends are sicker (they have more comorbid disease and more of them require palliative care); adjustment for severity of acute illness annuls the weekend effect. In-hospital care processes are slightly more efficient at weekends; care quality (errors, adverse events, global quality) is as good at weekends as on weekdays and has improved with time. Qualitative researcher assessments of hospital weekend quality concurred with case record reviewers at trust level. General practitioner referrals at weekends are one-third of those during weekdays and have declined further with time.
Limitations
Observational research, variable survey response rates and subjective assessments of care quality were compensated for by using a difference-in-difference analysis over time.
Conclusions
Hospital care is improving. The weekend effect is associated with factors in the community that precede hospital admission. Post-discharge mortality is increasing. Policy-makers should focus their efforts on improving acute and emergency care on a ‘whole-system’ 7-day approach that integrates social, community and secondary health care.
Future work
Future work should evaluate the role of doctors in hospital and community emergency care and investigate pathways to emergency admission and quality of care following hospital discharge.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 13. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Julian Bion
- University Department of Anaesthesia & Critical Care, University of Birmingham, Birmingham, UK
| | - Cassie Aldridge
- University Department of Anaesthesia & Critical Care, University of Birmingham, Birmingham, UK
| | - Chris Beet
- Intensive Care Medicine, Royal Derby Hospital NHS Trust, Derby, UK
| | - Amunpreet Boyal
- Research & Development, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Yen-Fu Chen
- Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Michael Clancy
- Emergency Medicine, University of Southampton, Southampton, UK
| | - Alan Girling
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Timothy Hofer
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Joanne Lord
- Southampton Health Technology Assessments Centre, University of Southampton, Southampton, UK
| | - Russell Mannion
- Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Peter Rees
- Patient & Lay Committee, Academy of Medical Royal Colleges, London, UK
| | - Chris Roseveare
- General Internal Medicine, Southern Health NHS Foundation Trust, Southampton, UK
| | - Louise Rowan
- University Department of Anaesthesia & Critical Care, University of Birmingham, Birmingham, UK
| | - Gavin Rudge
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jianxia Sun
- Informatics, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | | | | | - Mark Temple
- Nephrology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Sam Watson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Janet Willars
- Health Sciences, University of Leicester, Leicester, UK
| | - Richard Lilford
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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50
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Hollinghurst J, Housley G, Watkins A, Clegg A, Gilbert T, Conroy SP. A comparison of two national frailty scoring systems. Age Ageing 2021; 50:1208-1214. [PMID: 33252680 DOI: 10.1093/ageing/afaa252] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The electronic Frailty Index (eFI) has been developed in primary care settings. The Hospital Frailty Risk Score (HFRS) was derived using secondary care data. OBJECTIVE Compare the two different tools for identifying frailty in older people admitted to hospital. DESIGN AND SETTING Retrospective cohort study using the Secure Anonymised Information Linkage Databank, comprising 126,600 people aged 65+ who were admitted as an emergency to hospital in Wales from January 2013 up until December 2017. METHODS Pearson's correlation coefficient and weighted kappa were used to assess the correlation between the tools. Cox and logistic regression were used to estimate hazard ratios (HRs) and odds ratios (ORs). The Concordance statistic and area under the receiver operating curves (AUROC) were estimated to determine discrimination. RESULTS Pearson's correlation coefficient was 0.26 and the weighted kappa was 0.23. Comparing the highest to the least frail categories in the two scores the HRs for 90-day mortality, 90-day emergency readmission and care home admissions within 1-year using the HFRS were 1.41, 1.69 and 4.15 for the eFI 1.16, 1.63 and 1.47. Similarly, the ORs for inpatient death, length of stay greater than 10 days and readmission within 30-days were 1.44, 2.07 and 1.52 for the HFRS, and 1.21, 1.21 and 1.44 for the eFI. AUROC was determined as having no clinically relevant difference between the tools. CONCLUSIONS The eFI and HFRS have a low correlation between their scores. The HRs and ORs were higher for the increasing frailty categories for both the HFRS and eFI.
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Affiliation(s)
- Joe Hollinghurst
- Health Data Research UK (HDR-UK), Data Science Building, Swansea University, Swansea SA2 8PP, UK
| | - Gemma Housley
- East Midlands Academic Science Health Network, Nottingham, UK
| | - Alan Watkins
- Health Data Research UK (HDR-UK), Data Science Building, Swansea University, Swansea SA2 8PP, UK
| | | | - Thomas Gilbert
- Department Geriatric Medicine, Lyon University Teaching Hospital, Lyon, France
| | - Simon P Conroy
- Department of Health Sciences, University of Leicester, University Road, Leicester, LE1 7RH
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