The influence of health literacy, anxiety and education on shared decision making and decisional conflict in older adults, and the mediating role of patient participation: A video observational study

OBJECTIVE

To explore the relationship between personal characteristics of older adults with multiple chronic conditions (MCCs) and perceived shared decision making (SDM) resp. decisional conflict.

METHODS

In a video-observational study (N = 213) data were collected on personal characteristics. The main outcomes were perceived level of SDM and decisional conflict. The mediating variable was participation in the SDM process. A twostep mixed effect multilinear regression and a mediation analysis were performed to analyze the data.

RESULTS

The mean age of the patients was 77.3 years and 56.3% were female. Health literacy (β.01, p < .001) was significantly associated with participation in the SDM process. Education (β = -2.43, p = .05) and anxiety (β = -.26, p = .058) had a marginally significant direct effect on the patients' perceived level of SDM. Education (β = 12.12, p = .002), health literacy (β = -.70, p = .005) and anxiety (β = 1.19, p = .004) had a significant direct effect on decisional conflict. The effect of health literacy on decisional conflict was mediated by participation in SDM.

CONCLUSION

Health literacy, anxiety and education are associated with decisional conflict. Participation in SDM during consultations plays a mediating role in the relationship between health literacy and decisional conflict.

PRACTICE IMPLICATIONS

Tailoring SDM communication to health literacy levels is important for high quality SDM.

Assessing dynamical resilience indicators in older adults: a prospective feasibility cohort study

PURPOSE

Measuring dynamical resilience indicators based on time series data may improve the prediction of health deterioration in older adults after hospital discharge. We examined the feasibility of an intensive prospective cohort study examining dynamical resilience indicators based on time series data of symptoms and physical activity in acutely ill older adults who visited the Emergency Department (ED).

METHODS

This is a prospective cohort study with time series data from symptom questionnaires and activity trackers. Thirty older adults (aged 75.9 ± 5.5 years, 37% female) who were discharged from the ED of a tertiary hospital in the Netherlands were included in the study. We monitored self-reported symptoms using a daily online questionnaire, and physical activity using an activity tracker for 30 days. Descriptive data on participant eligibility and adherence to and acceptability of the assessments were collected.

RESULTS

Of 134 older patients visiting the ED, 109/134 (81%) were eligible for inclusion and 30/109 (28%) were included. Twenty-eight (93%) of the included participants completed follow-up. Regarding the adherence rate, 78% of participants filled in the questionnaire and 80% wore the activity tracker. Three (10%) participants completed fewer than three questionnaires. Most participants rated the measurements as acceptable and seven (23%) participants experienced an adverse outcome in the 30 days after discharge.

CONCLUSION

Such an intensive prospective cohort study examining dynamical resilience indicators in older adults was feasible. The quality of the collected data was sufficient, some adjustments to the measurement protocol are recommended. This study is an important first step to study resilience in older adults.

Investigating the Effectiveness of Care Delivery at an Acute Geriatric Community Hospital for Older Adults in the Netherlands: A Prospective Controlled Observational Study

OBJECTIVES

Hospital admission in older adults is associated with unwanted outcomes such as readmission, institutionalization, and functional decline. To reduce these outcomes, the Netherlands introduced an alternative to hospital-based care: the Acute Geriatric Community Hospital (AGCH). The AGCH is an acute care unit situated outside of a hospital focusing on early rehabilitation and comprehensive geriatric assessment. The objective of this study was to evaluate if AGCH care is associated with decreasing unplanned readmissions or death compared with hospital-based care.

DESIGN

Prospective cohort study controlled with a historic cohort.

SETTING AND PARTICIPANTS

A (sub)acute care unit (AGCH) and 6 hospitals in the Netherlands; participants were acutely ill older adults.

METHODS

We used inverse propensity score weighting to account for baseline differences. The primary outcome was 90-day readmission or death. Secondary outcomes included 30-day readmission or death, time to death, admission to long-term residential care, occurrence of falls and functioning over time. Generalized logistic regression models and multilevel regression analyses were used to estimate effects.

RESULTS

AGCH patients (n = 206) had lower 90-day readmission or death rates [odds ratio (OR) 0.39, 95% CI 0.23-0.67] compared to patients treated in hospital (n = 401). AGCH patients had a lower risk of 90-day readmission (OR 0.38, 95% CI 0.21-0.67) but did not differ on all-cause mortality (OR 0.89, 95% CI 0.44-1.79) compared with the hospital control group. AGCH patients had lower 30-day readmission or death rates. Secondary outcomes did not differ.

CONCLUSIONS AND IMPLICATIONS

AGCH patients had lower rates of readmission and/or death than patients treated in a hospital. Our results support further research on the implementation and cost-effectiveness of AGCH in the Netherlands and other countries seeking alternatives to hospital-based care.

Current practice of hospital-based palliative care teams: Advance care planning in advanced stages of disease: A retrospective observational study

BACKGROUND

Specialist palliative care teams are consulted during hospital admission for advice on complex palliative care. These consultations need to be timely to prevent symptom burden and maintain quality of life. Insight into specialist palliative care teams may help improve the outcomes of palliative care.

METHODS

In this retrospective observational study, we analyzed qualitative and quantitative data of palliative care consultations in a six-month period (2017 or 2018) in four general hospitals in the northwestern part of the Netherlands. Data were obtained from electronic medical records.

RESULTS

We extracted data from 336 consultations. The most common diagnoses were cancer (54.8%) and organ failure (26.8%). The estimated life expectancy was less than three months for 52.3% of all patients. Within two weeks after consultation, 53.2% of the patients died, and the median time until death was 11 days (range 191) after consultation. Most patients died in hospital (49.4%) but only 7.5% preferred to die in hospital. Consultations were mostly requested for advance care planning (31.6%). End-of-life preferences focused on last wishes and maintaining quality of life.

CONCLUSION

This study provides detailed insight into consultations of palliative care teams and shows that even though most palliative care consultations were requested for advance care planning, consultations focus on end-of-life care and are more crisis-oriented than prevention-oriented. Death often occurs too quickly after consultation for end-of-life preferences to be met and these preferences tend to focus on dying. Educating healthcare professionals on when to initiate advance care planning would promote a more prevention-oriented approach. Defining factors that indicate the need for timely palliative care team consultation and advance care planning could help timely identification and consultation.

A case vignette study to refine the target group of an intermediate care model: the Acute Geriatric Community Hospital

PURPOSE

To refine the admission criteria of the Acute Geriatric Community Hospital (AGCH) by defining its target group boundaries with (geriatric) hospital care and other bed-based intermediate care models in the Netherlands.

METHODS

A qualitative study consisting of a three-phase refinement procedure with case vignettes. Physicians, medical specialists, nurse practitioners, and physician assistants in hospitals (n = 10) or intermediate care facilities (n = 10) in the Netherlands participated. They collected case vignettes from clinical practice (phase one). The referral considerations and decisions for each case were then documented through surveys (phase two) and two focus groups (phase 3). For thematic data analysis, inductive and deductive approaches were used.

RESULTS

The combination of medical specialist care (MSC) and medical generalist care (MGC), is unique for the AGCH compared to other intermediate care models in the Netherlands. Compared to (geriatric) hospital care, the AGCH offers a more limited scope of MSC. Based on these findings, 13 refined admission criteria were developed such as 'The required diagnostic tests to monitor the effectiveness of treatment are available at the AGCH'. Besides admission criteria, additional clinical and organizational considerations played a role in referral decision-making; 10 themes were identified.

CONCLUSION

This case vignette study defined the target group boundaries between the AGCH and other care models, allowing us to refine the AGCH admission criteria. Our findings may help to determine the required competencies of the interdisciplinary AGCH team and to develop triage instruments. The identified consideration themes can be used as conceptual framework in further research. The findings may also be of interests for healthcare systems outside the Netherlands who aspire to design integrated care for older people closer to home.

More older adults died at their preferred place after implementation of a transmural care pathway for older adults at the end of life: a before-after study

BACKGROUND

To improve transmural palliative care for older adults acutely admitted to hospital, the PalliSupport intervention, comprising an educational programme and transmural palliative care pathway, was developed. This care pathway involves timely identification of palliative care needs, advance care planning, multidisciplinary team meetings, warm handover, and follow-up home visits. With this study, we evaluate changes in patient-related outcomes and transmural collaboration after implementation of the care pathway.

METHODS

We conducted a before-after study, in which we compared 1) unplanned hospital admission and death at place of preference and 2) transmural collaboration before implementation, up to six months, and six to 18 months after implementation. Data from palliative care team consultations were collected between February 2017 and February 2020 in a teaching hospital in the Netherlands.

RESULTS

The palliative care team held 711 first-time consultations. The number of consultation, as well as the number of consultations for patients with non-malignant diseases, and consultations for advance care planning increased after implementation. The implementation of the pathway had no statistically significant effect on unplanned hospitalization but associated positively with death at place of preference more than six months after implementation (during/shortly after adjusted OR: 2.12; 95% CI: 0.84-5.35; p-value: 0.11, long term after adjusted OR: 3.14; 95% CI: 1.49-6.62; p-value: 0.003). Effects on transmural collaboration showed that there were more warm handovers during/shortly after implementation, but not on long term. Primary care professionals attended multidisciplinary team meetings more often during and shortly after implementation, but did not more than six months after implementation.

CONCLUSIONS

The pathway did not affect unplanned hospital admissions, but more patients died at their place of preference after implementation. Implementation of the pathway increased attention to- and awareness for in-hospital palliative care, but did not improve transmural collaboration on long-term. For some patients, the hospital admissions might helped in facilitating death at place of preference.

A causal loop diagram of older persons' emergency department visits and interactions of its contributing factors: a group model building approach

PURPOSE

Understanding the etiology of older persons' emergency department (ED) visits is highly needed. Many contributing factors have been identified, however, the role their interactions play remains unclear. Causal loop diagrams (CLDs), as conceptual models, can visualize these interactions and therefore may elucidate their role. This study aimed to better understand why people older than 65 years of age visit the ED in Amsterdam by capturing the interactions of contributing factors as perceived by an expert group in a CLD through group model building (GMB).

METHODS

Six qualitative online focus group like sessions, known as GMB, were conducted with a purposefully recruited interdisciplinary expert group of nine that resulted in a CLD that depicted their shared view.

RESULTS

The CLD included four direct contributing factors, 29 underlying factors, 66 relations between factors and 18 feedback loops. The direct factors included, 'acute event', 'frailty', 'functioning of the healthcare professional' and 'availability of alternatives for the ED'. All direct factors showed direct as well as indirect contribution to older persons' ED visits in the CLD through interaction.

CONCLUSION

Functioning of the healthcare professional and availability of alternatives for the ED were considered pivotal factors, together with frailty and acute event. These factors, as well as many underlying factors, showed extensive interaction in the CLD, thereby contributing directly and indirectly to older persons' ED visits. This study helps to better understand the etiology of older persons' ED visits and in specific the way contributing factors interact. Furthermore, its CLD can help to find solutions for the increasing numbers of older adults in the ED.

Implementing online group model building to unravel complex geriatric problems, a methodological description

BACKGROUND

Group model building (GMB), is a qualitative focus group like study design from the field of system dynamics, that leads a group of topic experts (often key stakeholders of a problem), through a set of scripted activities to create a conceptual model of their shared view on this problems' key contributing factors and their interactions. By offering a specific step wise approach to the complexity of a problem, GMB has provided better understanding and overview of complex problems across different scientific domains, in addition to traditional research methods. As the development of geriatric syndromes and organization of geriatric care are often complex issues that are difficult to research, understand and resolve, GMB might be a useful methodology to better address these issues. This study aimed to describe the methodology of online GMB using a geriatric case study.

METHODS

Four online GMB sessions were designed by two clinician researchers. A GMB methodology expert was consulted for optimal design. Scriptapedia scripts formed the core of the sessions. These scripts were adapted to the online format. Experts were recruited purposefully and included seven local health care professionals, one patient representative and one healthcare insurance data analyst. The outcome was a conceptual model of older adults' emergency department visits, which was discussed in a separate article.

RESULTS

During implementation of these four sessions, the sessions were adjusted and two extra (non-scripted) sessions were added because defining unambiguous contributing factors to the geriatric case was challenging for the experts. Paraphrasing, categorizing, iterative plenary reflection, and reserving extra time were used to help experts overcome this challenge. All sessions were held in April and May 2021.

CONCLUSION

This study shows that GMB can help unravel complex problems in geriatrics, both pathophysiological as organizational, by creating step wise overview of their key contributing factors and interactions. Furthermore, it shows that GMB can be used by clinicians, researchers and health policy makers to better understand complex geriatric problems. Moreover, this paper can help to overcome specific implementational challenges in the geriatric field.

Avoiding Hospital Admissions and Delayed Transfers of Care by Improved Access to Intermediate Care: A Simulation Study

OBJECTIVE

The current waiting times for intermediate care in the Netherlands prohibit timely access, leading to unwanted and costly hospital admissions. We propose alternative policies for improvement of intermediate care and estimate the effects on the waiting times, hospitalization, and the number of patient replacements.

DESIGN

Simulation study.

SETTING AND PARTICIPANTS

For our case study, data were used of older adults who received intermediate care in Amsterdam, the Netherlands, in 2019. For this target group, in- and outflows and patient characteristics were identified.

METHODS

A process map of the main pathways into and out of the intermediate care was obtained and a discrete event simulation (DES) was built. We demonstrate the use of our DES for intermediate care by evaluating possible policy changes for a real-life case study in Amsterdam.

RESULTS

By means of a sensitivity analysis with the DES, we show that in Amsterdam the waiting times are not a result of a lack in bed capacity but are due to an inefficient triage and application process. Older adults have to wait a median of 1.8 days for admission, leading to hospitalization. If the application process becomes more efficient and evening and weekend admissions are allowed, we find that unwanted hospitalization can be decreased substantially.

CONCLUSION AND IMPLICATIONS

In this study, a simulation model is developed for intermediate care that can serve as a basis for policy decisions. Our case study shows that the waiting times for health care facilities are not always solved by increasing bed capacity. This underlines the necessity for a data-driven approach to identify logistic bottlenecks and find the best ways to solve them.

Acute hospital use in older adults following the 2015 Dutch reform of long-term care: an interrupted time series analysis

BACKGROUND

In 2015, the Dutch government implemented a long-term care (LTC) reform primarily designed to promote older adults to age-in-place. Increased proportions of older adults living in the community might have resulted in more and longer acute hospitalisations. The aims of this study were to evaluate whether the Dutch 2015 LTC reform was associated with immediate and longitudinal increases in the monthly rate of acute clinical hospitalisation and monthly average hospital length of stay (LOS) in adults aged 65 years or older.

METHODS

In this interrupted time series analysis of national hospital data (2009-18), we evaluated the association of the Dutch 2015 LTC reform with the monthly rate of acute clinical hospitalisation and monthly average LOS for older adults (aged ≥65 years). Patient-level episodic hospital data were provided by Dutch Hospital Data. Records were included that were defined as an acute clinical hospital admission for which a medical specialist decided treatment was necessary within 24 h. The analysis controlled for population growth (Dutch population data was provided by Statistics Netherlands) and seasonality, and calculated adjusted incident rate ratios (IRR).

FINDINGS

Before the 2015 LTC reform, the rate of acute monthly hospitalisation was increasing (IRR 1·002 [95% CI 1·001-1·002]). A positive average reform effect was observed (1·116 [1·070-1·165]), accompanied by a negative change in trend (0·997 [0·996-0·998]) that resulted in a decreasing trend over the post-reform period (0·998 [0·998-0·999]). The pre-reform trend of LOS was decreasing (0·998 [0·997-0·998]), and the 2015 reform exhibited a positive change in trend (1·002 [1·002-1·003]) that resulted in a stabilisation of LOS in the post-reform period (0·999 [0·999-1·000]).

INTERPRETATION

Our findings suggest that the increase in the rate of acute hospitalisation after the reform implementation was temporary, whereas the increase in LOS post-reform appeared to last longer than expected. These results have the potential to inform policy makers about effects of ageing-in-place LTC strategies on health and curative care.

FUNDING

The Netherlands Organization for Health Research and Development, the Yale Claude Pepper Center, and the National Center for Advancing Translational Sciences, National Institutes of Health.

TRANSLATION

For the Dutch translation of the abstract see Supplementary Materials section.

Post-discharge light physical activity indicates recovery in acutely hospitalized older adults - the Hospital-ADL study

BACKGROUND

Physical activity (PA) levels might be a simple overall physical function indicator of recovery in acutely hospitalized older adults; however it is unknown which amount and level of PA is associated with recovery. Our objective was to evaluate the amount and level of post discharge PA and its optimum cut-off values associated with recovery among acutely hospitalized older adults and stratified for frailty.

METHODS

We performed a prospective observational cohort study including acutely hospitalized older adults (≥ 70 years). Frailty was assessed using Fried's criteria. PA was assessed using Fitbit up to one week post discharge and quantified in steps and minutes light, moderate or higher intensity. The primary outcome was recovery at 3-months post discharge. ROC-curve analyses were used to determine cut-off values and area under the curve (AUC), and logistic regression analyses to calculate odds ratios (ORs).

RESULTS

The analytic sample included 174 participants with a mean (standard deviation) age of 79.2 (6.7) years of whom 84/174 (48%) were frail. At 3-months, 109/174 participants (63%) had recovered of whom 48 were frail. In all participants, determined cut-off values were 1369 steps/day (OR: 2.7, 95% confidence interval [CI]: 1.3-5.9, AUC 0.7) and 76 min/day of light intensity PA (OR: 3.9, 95% CI: 1.8-8.5, AUC 0.73). In frail participants, cut-off values were 1043 steps/day (OR: 5.0, 95% CI: 1.7-14.8, AUC 0.72) and 72 min/day of light intensity PA (OR: 7.2, 95% CI: 2.2-23.1, AUC 0,74). Determined cut-off values were not significantly associated with recovery in non-frail participants.

CONCLUSIONS

Post-discharge PA cut-offs indicate the odds of recovery in older adults, especially in frail individuals, however are not equipped for use as a diagnostic test in daily practice. This is a first step in providing a direction for setting rehabilitation goals in older adults after hospitalization.

Effects of a shared decision making intervention for older adults with multiple chronic conditions: the DICO study

BACKGROUND

To evaluate the effects of a shared decision making (SDM) intervention for older adults with multiple chronic conditions (MCCs).

METHODS

A pragmatic trial evaluated the effects of the SDM^MCC intervention, existing of SDM training for nine geriatricians in two hospitals and a preparatory tool for patients. A prospective pre-intervention post-intervention multi-center clinical study was conducted in which an usual care group of older patients with MCC and their informal caregivers was included before the implementation of the intervention and a new cohort of patients and informal caregivers after the implementation of the intervention. SDM was observed using the OPTION^MCC during video-recorded consultations. Patient- and caregivers reported outcomes regarding their role in SDM, involvement, perceived SDM and decisional conflict were measured. The differences between groups regarding the level of observed SDM (OPTION^MCC) were analyzed with a mixed model analysis. Dichotomous patient-reported outcomes were analyzed with a logistic mixed model.

RESULTS

From two outpatient geriatric clinics 216 patients with MCCs participated. The mean age was 77.3 years, and 56.3% of patients were female. No significant difference was found in the overall level of SDM as measured with the OPTION^MCC or in patient-reported outcomes. However, at item level the items discussing 'goals', 'options', and 'decision making' significantly improved after the intervention. The items discussing 'partnership' and 'evaluating the decision-making process' showed a significant decrease. Fifty-two percent of the patients completed the preparatory tool, but the results were only discussed in 12% of the consultations.

CONCLUSION

This study provides scope for improvement of SDM in geriatrics. Engaging older adults with MCCs and informal caregivers in the decision making process should be an essential part of SDM training for geriatricians, beyond the SDM steps of explaining options, benefits and harms. More attention should be paid to the integration of preparatory work in the consultation.

Facilitators and barriers to implementing an acute geriatric community hospital in the Netherlands: a qualitative study

BACKGROUND

there is a trend across Europe to enable more care at the community level. The Acute Geriatric Community Hospital (AGCH) in the Netherlands in an acute geriatric unit situated in a skilled nursing facility (SNF). It provides hospital-level care for older adults with acute medical conditions. The aim of this study is to identify barriers and facilitators associated with implementing the AGCH in a SNF.

METHODS

semi-structured interviews (n = 42) were carried out with clinical and administrative personnel at the AGCH and university hospital and stakeholders from the partnering care organisations and health insurance company. Data were analysed using thematic analysis.

RESULTS

facilitators to implementing the AGCH concept were enthusiasm for the AGCH concept, organising preparatory sessions, starting with low-complex patients, good team leadership and ongoing education of the AGCH team. Other facilitators included strong collaboration between stakeholders, commitment to shared investment costs and involvement of regulators.Barriers to implementation were providing hospital care in an SNF, financing AGCH care, difficulties selecting patients at the emergency department, lack of protocols and guidelines, electronic health records unsuited for hospital care, department layout on two different floors and complex shared business operations. Furthermore, transfer of acute care to the community care meant that some care was not reimbursed.

CONCLUSIONS

the AGCH concept was valued by all stakeholders. The main facilitators included the perceived value of the AGCH concept and enthusiasm of stakeholders. Structural financing is an obstacle to the expansion and continuation of this care model.

Effectiveness of transmural team-based palliative care in prevention of hospitalizations in patients at the end of life: A systematic review and meta-analysis

BACKGROUND

Team-based palliative care interventions have shown positive results for patients at the end of life in both hospital and community settings. However, evidence on the effectiveness of transmural, that is, spanning hospital and home, team-based palliative care collaborations is limited.

AIM

To systematically review whether transmural team-based palliative care interventions can prevent hospital admissions and increase death at home.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE (Ovid), Embase (Ovid), CINAHL (Ebsco), PsychINFO (Ovid), and Cochrane Library (Wiley) were systematically searched until January 2021. Studies incorporating teams in which hospital and community professionals co-managed patients, hospital-based teams with community follow-up, and case-management interventions led by palliative care teams were included. Data was extracted by two researchers independently.

RESULTS

About 19 studies were included involving 6614 patients, of whom 2202 received an intervention. The overall pooled odds ratio of at least one hospital (re)admissions was 0.46 (95% confidence interval (CI) 0.34-0.68) in favor of the intervention group. The highest reduction in admission was in the hospital-based teams with community follow-up: OR 0.21 (95% CI 0.07-0.66). The pooled effect on home deaths was 2.19 (95% CI 1.26-3.79), favoring the intervention, with also the highest in the hospital-based teams: OR 4.77 (95% CI 1.23-18.47). However, studies had high heterogeneity regarding intervention, study population, and follow-up time.

CONCLUSION

Transmural team-based palliative care interventions, especially hospital-based teams that follow-up patients at home, show an overall effect on lowering hospital admissions and increasing the number of patients dying at home. However, broad clinical and statistical heterogeneity of included studies results in uncertainty about the effect size.

Recommendations for an exercise intervention and core outcome set for older patients after hospital discharge: Results of an international Delphi study

For older adults, acute hospitalization is a high-risk event with poor health outcomes, including functional decline. In absence of practical guidelines and high quality randomized controlled trials, this Delphi study was conducted. The aim of this study was to obtain consensus on an exercise intervention program, a core outcome set (COS) and handover information to prevent functional decline or restore physical function in acutely hospitalized older patients transitioning from hospital to home. An internal panel of experts in the field of exercise interventions for acutely hospitalized older adults were invited to join the study. In the Delphi study, relevant topics were recognized, statements were formulated and ranked on a 9-point Likert scale in two additional rounds. To reaching consensus, a score of 7-9 was classified as essential. Results were expressed as median and semi-interquartile range (SIQR), and consensus threshold was set at SIQR≤0.5. Fifteen international experts from eight countries participated in the panel. The response rate was 93%, 93% and 80% for the three rounds respectively. After three rounds, consensus was reached on 167 of the 185 (90.3%) statements, of which ninety-five (51.4%) were ranked as essential (median Likert-score ≥7.0, SIQR ≤0.5). This Delphi study provides starting points for developing an exercise intervention, a COS and handover information. The results of this Delphi study can assist physical therapists to provide a tailored exercise intervention for older patients with complex care needs after hospital discharge, to prevent functional decline and/or restore physical function.

Reduced Waiting Times by Preference-Based Allocation of Patients to Nursing Homes

OBJECTIVES

The long waiting times for nursing homes can be reduced by applying advanced waiting-line management. In this article, we implement a preference-based allocation model for older adults to nursing homes, evaluate the performance in a simulation setting for 2 case studies, and discuss the implementation in practice.

DESIGN

Simulation study.

SETTING AND PARTICIPANTS

Older adults requiring somatic nursing home care, from an urban region (Rotterdam) and a rural region (Twente) in the Netherlands.

METHODS

Data about nursing homes and capacities for the 2 case studies were identified. A set of preference profiles was defined with aims regarding waiting time preferences and flexibility. Guidelines for implementation of the model in practice were obtained by addressing the tasks of all stakeholders. Thereafter, the simulation was run to compare the current practice with the allocation model based on specified outcome measures about waiting times and preferences.

RESULTS

We found that the allocation model decreased the waiting times in both case studies. Compared with the current practice policy, the allocation model reduced the waiting times until placement by at least a factor of 2 (from 166 to 80 days in Rotterdam and 178 to 82 days in Twente). Moreover, more of the older adults ended up in their preferred nursing home and the aims of the distinct preference profiles were satisfied.

CONCLUSIONS AND IMPLICATIONS

The results show that the allocation model outperforms commonly used waiting-line policies for nursing homes, while meeting individual preferences to a larger extent. Moreover, the model is easy to implement and of a generic nature and can, therefore, be extended to other settings as well (eg, to allocate older adults to home care or daycare). Finally, this research shows the potential of mathematical models in the care domain for older adults to face the increasing need for cost-effective solutions.

Challenges in the implementation and evaluation of a transmural palliative care pathway for acutely hospitalized older adults; lessons from the PalliSupport program: A qualitative process evaluation study

OBJECTIVES

To improve transmural palliative care for acutely admitted older patients, the PalliSupport transmural care pathway was developed. Implementation of this care pathway was challenging. The aim of this study was to improve understanding why the implementation partly failed.

DESIGN

A qualitative process evaluation study.

SETTING/PARTICIPANTS

17 professionals who were involved in the PalliSupport program were interviewed.

METHODS

Online semi-structured interviews. Thematic analysis to create themes according to the implementation framework of Grol & Wensing.

RESULTS

From this study, themes within four levels of implementation emerged: 1) The innovation: challenges in current palliative care, the setting of the pathway and boost for improvement; 2) Individual professional: feeling (un)involved and motivation; 3) Organizational level: project management; 4) Political and economic level: project plan and evaluation.

CONCLUSION AND IMPLICATIONS

We learned that the challenges involved in implementing a transmural care pathway in palliative care should not be underestimated. For successful implementation, we emphasize the importance of creating a program that fits the complexity of transmural palliative care. We suggest starting on a small scale and invest in project management. This could help to involve all stakeholders and anticipate current challenges in palliative care. To increase acceptance, create one care pathway that can start and be used in all care settings. Make sure that there is sufficient flexibility in time and room to adjust the project plan, so that a second pilot study can possibly be performed, and choose a scientific evaluation with both rigor and practical usefulness to evaluate effectiveness.

Post-discharge light physical activity indicates recovery in acutely hospitalized older adults

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Netherlands Organization for Health Research and DevelopmentThe Dutch Research Council

Introduction

Physical activity levels might be a simple overall physical marker of recovery in acutely hospitalized older adults; however, cut-off values post discharge are lacking.

Purpose

We aim to identify cut-off values for post-discharge physical activity that indicate recovery among acutely hospitalized older adults and stratified for frailty.

Methods

Prospective observational cohort study including acutely hospitalized older adults (≥70 years) during hospitalization and at home. Frailty was assessed using Fried’s criteria. Steps and intensity of physical activity were assessed using Fitbit up to one week post discharge. The primary outcome was recovery at 3-months post discharge. ROC-curve analyses were used to determine cut-off values, and logistic regression analyses to calculate odds ratios (ORs).

Results

The analytic sample included 174 participants with a mean (standard deviation) age of 79.2 (6.7) years of whom 84/174 (48%) were frail and 67 (39%) had cardiac disease. At 3-months, 109/174 participants (63%) had recovered. In all participants, determined cut-off values were 1369 steps/day (OR: 2.5, 95% confidence interval [CI]: 1.3–4.6) and 76 minutes/day of light intensity activity (OR: 3.0, 95% CI: 1.6–5.8). In frail participants, cut-off values were 1043 steps/day (OR: 3.3, 95% CI: 1.3–8.4) and 72 minutes/day of light intensity activity (OR: 4.2, 95% CI: 1.6–10.8). Determined cut-off values were not significantly associated with recovery in non-frail participants.

Conclusions

We recommend at least 1369 steps per day and 76 minutes of light activity to help older patients’ recovery from an acute hospitalization.

The Cardiac Care Bridge transitional care program for the management of older high-risk cardiac patients: An economic evaluation alongside a randomized controlled trial

Objective

To evaluate the cost-effectiveness of the Cardiac Care Bridge (CCB) nurse-led transitional care program in older (≥70 years) cardiac patients compared to usual care.

Methods

The intervention group (n = 153) received the CCB program consisting of case management, disease management and home-based cardiac rehabilitation in the transition from hospital to home on top of usual care and was compared with the usual care group (n = 153). Outcomes included a composite measure of first all-cause unplanned hospital readmission or mortality, Quality Adjusted Life Years (QALYs) and societal costs within six months follow-up. Missing data were imputed using multiple imputation. Statistical uncertainty surrounding Incremental Cost-Effectiveness Ratios (ICERs) was estimated by using bootstrapped seemingly unrelated regression.

Results

No significant between group differences in the composite outcome of readmission or mortality nor in societal costs were observed. QALYs were statistically significantly lower in the intervention group, mean difference -0.03 (95% CI: -0.07; -0.02). Cost-effectiveness acceptability curves showed that the maximum probability of the intervention being cost-effective was 0.31 at a Willingness To Pay (WTP) of €0,00 and 0.14 at a WTP of €50,000 per composite outcome prevented and 0.32 and 0.21, respectively per QALY gained.

Conclusion

The CCB program was on average more expensive and less effective compared to usual care, indicating that the CCB program is dominated by usual care. Therefore, the CCB program cannot be considered cost-effective compared to usual care.

Implementation of a national testing policy in Dutch nursing homes during SARS-CoV-2 outbreaks

Background

To evaluate how a national policy of testing for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) regardless of symptoms was implemented during outbreaks in Dutch nursing homes in the second wave of the pandemic and to explore barriers and facilitators to serial testing.

Methods

We conducted a mixed‐method study of nursing homes in the Netherlands with a SARS‐CoV‐2 outbreak after 15 September 2020. Direct care staff and management from 355 healthcare organizations were invited to participate in a digital survey. A total of 74 out of 355 (20.9%) healthcare organizations participated and provided information about 117 nursing homes. We conducted 26 in‐depth interviews on the outbreak and the testing strategy used. We also conducted four focus group meetings involving managers, physicians, nurses, and certified health assistants. Recordings were transcribed and data were thematically analyzed.

Results

One hundred and four nursing homes (89%) tested residents regardless of their symptoms during the outbreak, and 85 nursing homes (73%) tested the staff regardless of their symptoms. However, interviews showed testing was sometimes implemented during later stages of the outbreak and was not always followed up with serial testing. Barriers to serial testing regardless of symptoms were lack of knowledge of local leaders with decisional making authority, lack of a cohort ward or skilled staff, and insufficient collaboration with laboratories or local public health services. Important facilitators to serial testing were staff willingness to undergo testing and the availability of polymerase chain reaction (PCR) tests.

Conclusions

Serial testing regardless of symptoms was only partially implemented. The response rate of 21% of nursing home organizations gives a risk of selection bias. Barriers to testing need to be addressed. A national implementation policy that promotes collaboration between public health services and nursing homes and educates management and care staff is necessary.

[Home sweat hospital-at-home]

This article discusses the outcomes of a randomized controlled trial by Shepperd et al in the UK on comprehensive geriatric assessment and hospital-at-home (HaH) for older adults, compared to hospitalization and the implications for the Dutch health care system. The authors found that older adults have comparable outcomes in terms of living at home and mortality at six months, but older adults were more satisfied with the HaH care, less often experienced a delirium and less older adults were admitted to the nursing home. The hospital-at-home model has some other advantages, as it minimizes transitions, older adults are more active in their own environment and experience more autonomy and self-management. To implement this model in the Netherlands it is important to sharply define the target group for HaH, to have a team with nurse practitioners and geriatrician who is able to provide the care 24/7 and to build an acute geriatric infrastructure in primary care, so the HaH is a serious alternative to hospital care.

The Impact of COVID-19 from the Perspectives of Dutch District Nurses: A Mixed-Methods Study

Little is known about how COVID-19 affects older patients living at home or how it affects district nursing teams providing care to these patients. This study aims to (1) explore, from the perspectives of Dutch district nurses, COVID-19's impact on patients receiving district nursing care, district nursing teams, and their organisations during the first outbreak in March 2020 as well as one year later; and (2) identify the needs of district nurses regarding future outbreaks. A mixed-methods, two-phase, sequential exploratory design was followed. In total, 36 district nurses were interviewed during the first outbreak (March 2020), of which 18 participated in the follow-up questionnaire in April 2021. Thirteen themes emerged, which showed that the COVID pandemic has substantially impacted patient care and district nursing teams. During the first outbreak, nurses played a crucial role in organising care differently and worked under high pressure, leading to exhaustion, tiredness, and psychosocial problems, including fear of infection. A year later, nurses were better prepared to provide COVID care, but problems regarding work pressure and mental complaints remained. The identified needs focus on a sustainable implementation of leadership roles for district nurses. At the organisational and national levels, more support and appreciation are needed in terms of trust and appropriate policies.

Symptoms of depression, anxiety, and perceived mastery in older adults before and during the COVID-19 pandemic: Results from the Longitudinal Aging Study Amsterdam

OBJECTIVE

Governmental measures to protect older adults from COVID-19 are hypothesized to cause anxiety and depression. Previous studies are heterogeneous and showed small effects. This study aims to assess depressive and anxiety symptoms and perceived mastery just after the first wave of the COVID-19 pandemic compared to previous years in community-dwelling older adults and to identify potential risk groups according to the comprehensive geriatric assessment framework.

METHODS

Data were used from 1068 Dutch older adults (aged 55-93 at baseline in 2011-2013) participating in the Longitudinal Aging Study Amsterdam, including 4 follow-ups spanning 9 years. Depressive symptoms, anxiety symptoms and feelings of mastery were assessed with the short Center for Epidemiologic Studies Depression scale (CES-D-10), the Hospital Anxiety Depression Scale - Anxiety subscale (HADS-A) and the Pearlin Mastery Scale. Linear mixed regression was used to compare outcomes in June-August 2020 to previous years and to examine predictors to identify risk groups.

RESULTS

Slight increases in CES-D-10 (1.37, 95% Confidence interval [CI] 1.12;1.62), HADS-A (0.74, 95% CI 0.56;0.94) and mastery (1.10, 95% CI 0.88;1.31) occurred during the COVID year compared to previous years. Older adults with functional limitations or with frailty showed a smaller increase in feelings of mastery in the COVID-year.

CONCLUSION

Our results suggest limited mental health effects on older adults from the first COVID-19 wave. Older adults have perhaps better coping strategies than younger adults, or preventive measures did not have extensive consequences for the daily life of older adults. Further monitoring of depression, anxiety and perceived mastery is recommended.

Symptom- and Prevention-Based Testing of COVID-19 in Nursing Home Residents: A Retrospective Cohort Study

Nursing homes (NH) residents with COVID-19 can either be tested because of presence of core symptoms (S-based) or because of transmission prevention (TP-based). The investigated study sample included all NH residents who underwent SARS-CoV-2 RT-PCR testing between March 16, 2020 and May 31, 2020 (n = 380). Clinical symptoms, temperature, and oxygen saturation were extracted from medical records, 7 days before to 14 days after testing. COVID-19 was confirmed in 81 (21%) residents; 36 (44%) S-based and 45 (56%) TP-based: 45. Cycle threshold (CT) values did not differ between the groups. In the 7 days prior to the test falling (32%), somnolence (25%) and fatigue (21%) occurred in both groups. Two days before the test, we observed a stronger decrease in oxygen saturation and an increase in temperature for the S-based group compared to the T-based group that remained up to 10 days after testing. Residents within the S-based group were 2.5 times more likely to increased mortality within 30 days than residents in the TP-based group (HR, 2.56; 95% 1.3–5.2). Although, 73% of the T-based group did eventually develop core symptoms. Thus, attention to falling and daily measures of temperature and oxygen saturation can contribute to earlier detection.

The nurse-coordinated cardiac care bridge transitional care programme: a randomised clinical trial

Background

after hospitalisation for cardiac disease, older patients are at high risk of readmission and death.

Objective

the cardiac care bridge (CCB) transitional care programme evaluated the impact of combining case management, disease management and home-based cardiac rehabilitation (CR) on hospital readmission and mortality.

Design

single-blind, randomised clinical trial.

Setting

the trial was conducted in six hospitals in the Netherlands between June 2017 and March 2020. Community-based nurses and physical therapists continued care post-discharge.

Subjects

cardiac patients ≥ 70 years were eligible if they were at high risk of functional loss or if they had had an unplanned hospital admission in the previous 6 months.

Methods

the intervention group received a comprehensive geriatric assessment-based integrated care plan, a face-to-face handover with the community nurse before discharge and follow-up home visits. The community nurse collaborated with a pharmacist and participants received home-based CR from a physical therapist. The primary composite outcome was first all-cause unplanned readmission or mortality at 6 months.

Results

in total, 306 participants were included. Mean age was 82.4 (standard deviation 6.3), 58% had heart failure and 92% were acutely hospitalised. 67% of the intervention key-elements were delivered. The composite outcome incidence was 54.2% (83/153) in the intervention group and 47.7% (73/153) in the control group (risk differences 6.5% [95% confidence intervals, CI −4.7 to 18%], risk ratios 1.14 [95% CI 0.91–1.42], P = 0.253). The study was discontinued prematurely due to implementation activities in usual care.

Conclusion

in high-risk older cardiac patients, the CCB programme did not reduce hospital readmission or mortality within 6 months.

Trial registration

Netherlands Trial Register 6,316, https://www.trialregister.nl/trial/6169

Patients' preferred place of death: patients are willing to consider their preferences, but someone has to ask them

Background

end-of-life care is not always in line with end-of-life preferences, so patients do not always die at their preferred place of death (PPD). This study aims to identify factors associated with patients’ PPD and changes in PPD.

Methods

we prospectively collected data on PPD at four time points within 6 months from 230 acutely hospitalised older patients who were part of the control group in a stepped-wedge randomised controlled trial. Associations between patient characteristics and preferences were calculated using multivariable (multinomial) logistic regression analysis.

Results

the mean age of participants was 80.7 years. 47.8% of the patients had no PPD at hospital admission. Patients previously admitted to hospital preferred to die at home (home versus no preference: odds ratio [OR] 2.38, 95% confidence interval [CI] 1.15–4.92; home versus healthcare facility: OR 3.25, 95% CI 1.15–9.16). Patients with more chronic diseases preferred the healthcare facility as their PPD (healthcare facility versus no preference: OR 1.33, 95% CI 1.09–1.61; healthcare facility versus home: OR 1.21, 95% CI 1.00–1.47). 32 of 65 patients changed their preference during follow-up, and most of these had no PPD at hospital admission (home versus no preference: OR 0.005, 95% CI ≤0.001–0.095) and poorer self-rated well-being (OR 1.82, 95% CI 1.07–3.08).

Conclusions

almost half of the patients had no PPD at baseline. Previous hospital admission, having more chronic diseases and living alone are associated with having a PPD. Introducing PPD could make older people aware of PPD and facilitate optimal palliative care.

The implementation of a professional practice model to improve the nurse work environment in a Dutch hospital: A quasi-experimental study

Aims

To evaluate the effects of the implementation of a professional practice model based on Magnet principles on the nurse work environment in a Dutch teaching hospital.

Design

A quasi‐experimental study.

Methods

Data were collected from registered nurses working on the clinical wards and outpatient clinics of the hospital in June/July 2016 (baseline) and in June/September 2019 (measurement of effects). Participants completed the Dutch Essentials of Magnetism II survey, which was used to measure their perception of their work environment. After baseline measurements were collected, interventions based on a professional practice model incorporating Magnet principles were implemented to improve the nurse work environment. Descriptive statistics and independent t‐tests were conducted to examine differences between survey outcomes in 2016 and 2019.

Results

Survey outcomes revealed significant changes in the nurse work environment between 2016 and 2019. Seven of the eight subscales (essentials of magnetism) improved significantly. Score for overall job satisfaction increased from 7.3 to 8.0 and score for quality of care increased from 7.0 to 7.6. On unit level, 17 of the 19 units showed improvement in the nurse work environment.

Conclusion

The implementation of a professional practice model positively affects the nurse work environment, job satisfaction and quality of care.

Impact

Nowadays, the quality of care is threatened by workload pressure and the low autonomy experienced by nurses. Considering the global shortage of nurses and growing complexity of healthcare, it is important to invest in improving the nurse work environment. The Magnet concept created a work environment in which nurses can deliver optimal quality of care. Knowledge of how Magnet principles affect the nurse work environment in the Netherlands is missing. These study results, including the description of how the interventions were implemented, will assist other hospitals to develop improvement strategies by focusing on the nurse work environment.

Older patients' perspectives on factors contributing to frequent visits to the emergency department: a qualitative interview study

BACKGROUND

Older patients are at high risk of unplanned revisits to the emergency department (ED) because of their medical complexity. To reduce the number of ED visits, we need more knowledge about the patient-level, environmental, and healthcare factors involved. The aim of this study was to describe older patients' perspectives and experiences before and after an ED visit, and to identify factors that possibly contribute to frequent ED revisits.

METHODS

This was a qualitative description study. We performed semi-structured individual interviews with older patients who frequently visited the ED and were discharged home after an acute visit. Patients were enrolled in the ED of a university medical centre using purposive sampling. Interviews were recorded, transcribed, and coded independently by two researchers. Theoretical analysis was used to identify recurring patterns and themes in the data. Interviews were conducted until thematic saturation was reached.

RESULTS

In-depth interviews were completed with 13 older patients. Three main themes emerged: 1) medical events leading to feelings of crisis, 2) patients' untreated health problems, and 3) persistent problems in health and daily functioning post discharge. Participants identified problems before and after their ED visit that possibly contributed to further ED visits. These problems included increasing symptoms leading to feelings of crisis, the relationship with the general practitioner, incomplete discharge information at the ED, and inadequate follow-up and lack of recovery after an ED visit.

CONCLUSIONS

This qualitative study identified multiple factors that may contribute to frequent ED visits among older patients. Older patients in need of acute care might benefit from hospital-at-home interventions, or acute care provided by geriatric emergency teams in the primary care setting. Identifying frailty in the ED is needed to improve discharge communication and adequate follow-up is needed to improve recovery after an acute ED visit.

Physical Resilience in Daily Functioning Among Acutely Ill Hospitalized Older Adults: The Hospital-ADL Study

OBJECTIVES

Insight into older adults' physical resilience is needed to predict functional recovery after hospitalization. We assessed functional trajectories in response to acute illness and subsequent hospitalization and investigated baseline variables and dynamic variables associated with these trajectories.

DESIGN

Prospective observational cohort study (Hospitalization-Associated Disability and impact on daily Life Study).

SETTING AND PARTICIPANTS

This study included 207 older adults (aged 79.8 ± 6.9 years, 49% female, 57% frail) acutely hospitalized in 6 Dutch hospitals.

METHODS

Functional disability was assessed using the 15-item modified activities of daily living index retrospectively 2 weeks before admission, and prospectively from admission up to 3 months after discharge. Baseline variables including frailty, somatic, physical, and psychosocial factors were assessed at admission. Dynamic variables (step count, pain, fatigue, and fear of falling) were continuously or repeatedly assessed during hospitalization. We performed individual spline modeling using random effects. Baseline variables and within-person mean levels and variability in the dynamic variables were assessed as predictors of functional trajectories.

RESULTS

Functional disability significantly increased before admission and decreased from admission to 3 months post discharge. Frail participants had a significantly higher increase in functional disability before admission compared with nonfrail participants. Lower step count, higher pain scores, and higher within-person variability in fear of falling were significantly associated with higher increase in functional disability before admission. Higher within-person variability in fear of falling was associated with more recovery.

CONCLUSIONS AND IMPLICATIONS

Older adults increase in functional disability before hospitalization and start to recover from admission onward. Frailty and dynamic variables are associated with a higher increase in functional disability after acute illness. Our findings give more insight into older adults' physical resilience, which may improve the prediction of functional recovery and may improve therapeutic decision-making and rehabilitation strategies to improve functional recovery after acute hospitalization.

Are presymptomatic SARS-CoV-2 infections in nursing home residents unrecognised symptomatic infections? Sequence and metadata from weekly testing in an extensive nursing home outbreak

BACKGROUND

Sars-CoV-2 outbreaks resulted in a high case fatality rate in nursing homes (NH) worldwide. It is unknown to which extent presymptomatic residents and staff contribute to the spread of the virus.

AIMS

To assess the contribution of asymptomatic and presymptomatic residents and staff in SARS-CoV-2 transmission during a large outbreak in a Dutch NH.

METHODS

Observational study in a 185-bed NH with two consecutive testing strategies: testing of symptomatic cases only, followed by weekly facility-wide testing of staff and residents regardless of symptoms. Nasopharyngeal and oropharyngeal testing with RT-PCR for SARs-CoV-2, including sequencing of positive samples, was conducted with a standardised symptom assessment.

RESULTS

185 residents and 244 staff participated. Sequencing identified one cluster. In the symptom-based test strategy period, 3/39 residents were presymptomatic versus 38/74 residents in the period of weekly facility-wide testing (P-value < 0.001). In total, 51/59 (91.1%) of SARS-CoV-2 positive staff was symptomatic, with no difference between both testing strategies (P-value 0.763). Loss of smell and taste, sore throat, headache or myalga was hardly reported in residents compared to staff (P-value <0.001). Median Ct-value of presymptomatic residents was 21.3, which did not differ from symptomatic (20.8) or asymptomatic (20.5) residents (P-value 0.624).

CONCLUSIONS

Symptoms in residents and staff are insufficiently recognised, reported or attributed to a possible SARS-CoV-2 infection. However, residents without (recognised) symptoms showed the same potential for viral shedding as residents with symptoms. Weekly testing was an effective strategy for early identification of SARS-Cov-2 cases, resulting in fast mitigation of the outbreak.

Effects of a transitional care programme on medication adherence in an older cardiac population: A randomized clinical trial

AIMS

Medication non-adherence post-discharge is common among patients, especially those suffering from chronic medical conditions, and contributes to hospital admissions and mortality. This study aimed to evaluate the effect of the Cardiac Care Bridge (CCB) intervention on medication adherence post-discharge.

METHODS

We performed a secondary analysis of the CCB randomized single-blind trial, a study in patients ≥70 years, at high risk of functional loss and admitted to cardiology departments in six hospitals. In this multi-component intervention study, community nurses performed medication reconciliation and observed medication-related problems (MRPs) during post-discharge home visits, and pharmacists provided recommendations to resolve MRPs. Adherence to high-risk medications was measured using the proportion of days covered (PDC), using pharmacy refill data. Furthermore, MRPs were assessed in the intervention group.

RESULTS

For 198 (64.7%) of 306 CCB patients, data were available on adherence (mean age: 82 years; 58.9% of patients used a multidose drug dispensing [MDD] system). The mean PDC before admission was 92.3% in the intervention group (n = 99) and 88.5% in the control group (n = 99), decreasing to 85.2% and 84.1% post-discharge, respectively (unadjusted difference: -2.6% (95% CI -9.8 to 4.6, P = .473); adjusted difference -3.3 (95% CI -10.3 to 3.7, P = .353)). Post-hoc analysis indicated that a modest beneficial intervention effect may be restricted to MDD non-users (P_interaction  = .085). In total, 77.0% of the patients had at least one MRP post-discharge.

CONCLUSIONS

Our findings indicate that a multi-component intervention, including several components targeting medication adherence in older cardiac patients discharged from hospital back home, did not benefit their medication adherence levels. A modest positive effect on adherence may potentially exist in those patients not using an MDD system. This finding needs replication.

Experiences of frail older cardiac patients with a nurse-coordinated transitional care intervention - a qualitative study

BACKGROUND

Older cardiac patients are at high risk of readmission and mortality. Transitional care interventions (TCIs) might contribute to the prevention of adverse outcomes. The Cardiac Care Bridge program was a randomized nurse-coordinated TCI combining case management, disease management and home-based rehabilitation for hospitalized frail older cardiac patients. This qualitative study explored the experiences of patients' participating in this study, as part of a larger process evaluation as this might support interpretation of the neutral study outcomes. In addition, understanding these experiences could contribute to the design and application of future transitional care interventions for frail older cardiac patients.

METHODS

A generic qualitative approach was used. Semi-structured interviews were performed with 16 patients ≥70 years who participated in the intervention group. Participants were selected by gender, diagnosis, living arrangement and hospital of inclusion. Data were analysed using thematic analysis. In addition, quantitative data about intervention delivery were analysed.

RESULTS

Three themes emerged from the data: 1) appreciation of care continuity; 2) varying experiences with recovery and, 3) the influence of an existing care network. Participants felt supported by the transitional care intervention as they experienced post-discharge support and continuity of care. The perceived contribution of the program in participants' recovery varied. Some participants reported physical improvements while others felt impeded by comorbidities or frailty. The home visits by the community nurse were appreciated, although some participants did not recognize the added value. Participants with an existing healthcare provider network preferred to consult these providers instead of the providers who were involved in the transitional care intervention.

CONCLUSION

Our results contribute to an explanation of the neutral study of a nurse-coordinated transitional care intervention. For future purpose, it is important to identify which patients might benefit most from TCIs. Furthermore, the intensity and content of TCIs could be more personalized by tailoring interventions to older cardiac patients' needs, considering their frailty, self-management skills and existing formal and informal caregiver networks.

'Patients come with two garbage bags full of problems and we have to sort them.' A qualitative study of the experiences of healthcare professionals on patients admitted to short-term residential care in the Netherlands

BACKGROUND

Short-term residential care (STRC) facilities were recently implemented in the Netherlands to provide temporary care to older adults with general health problems. The aim of STRC is to allow the individual to return home. However, 40% of patients are discharged to long-term care facilities. In-depth data about characteristics of patients admitted and challenges in providing STRC are missing.

OBJECTIVE

To obtain perspectives of STRC professionals on the patient journey from admission to discharge.

DESIGN

Qualitative study.

SETTING

Eight nursing homes and three hospitals.

SUBJECTS

A total of 28 healthcare professionals.

METHODS

A total of 13 group interviews with in-depth reviews of 39 pseudonymised patient cases from admission to discharge. Interviews were analysed thematically.

RESULTS

Many patients had complex problems that were underestimated at handover, making returning to home nearly impossible. The STRC eligibility criteria that patients have general health problems and can return home do not fit with current practice. This results in a mismatch between patient needs and the STRC that is provided. Therefore, planning care before and after discharge, such as advance care planning, social care and home adaptations, is important.

CONCLUSIONS

STRC is used by patients with complex health problems and pre-existing functional decline. Evidence-based guidelines, appropriate staffing and resources should be provided to STRC facilities. We need to consider the environmental context of the patient and healthcare system to enable older adults to live independently at home for longer.

The course of readmission in frail older cardiac patients

AIM

The aim of this study is to explore patients' and (in)formal caregivers' perspectives on their role(s) and contributing factors in the course of unplanned hospital readmission of older cardiac patients in the Cardiac Care Bridge (CCB) program.

DESIGN

This study is a qualitative multiple case study alongside the CCB randomized trial, based on grounded theory principles.

METHODS

Five cases within the intervention group, with an unplanned hospital readmission within six months after randomization, were selected. In each case, semi-structured interviews were held with patients (n = 4), informal caregivers (n = 5), physical therapists (n = 4), and community nurses (n = 5) between April and June 2019. Patients' medical records were collected to reconstruct care processes before the readmission. Thematic analysis and the six-step analysis of Strauss & Corbin have been used.

RESULTS

Three main themes emerged. Patients experienced acute episodes of physical deterioration before unplanned hospital readmission. The involvement of (in)formal caregivers in adequate observation of patients' health status is vital to prevent rehospitalization (theme 1). Patients and (in)formal caregivers' perception of care needs did not always match, which resulted in hampering care support (theme 2). CCB caregivers experienced difficulties in providing care in some cases, resulting in limited care provision in addition to the existing care services (theme 3).

CONCLUSION

Early detection of deteriorating health status that leads to readmission was often lacking, due to the acuteness of the deterioration. Empowerment of patients and their informal caregivers in the recognition of early signs of deterioration and adequate collaboration between caregivers could support early detection. Patients' care needs and expectations should be prioritized to stimulate participation.

IMPACT

(In)formal caregivers may be able to prevent unplanned hospital readmission of older cardiac patients by ensuring: (1) early detection of health deterioration, (2) empowerment of patient and informal caregivers, and (3) clear understanding of patients' care needs and expectations.

The performance of the Dutch Safety Management System frailty tool to predict the risk of readmission or mortality in older hospitalised cardiac patients

Background

Early identification of older cardiac patients at high risk of readmission or mortality facilitates targeted deployment of preventive interventions. In the Netherlands, the frailty tool of the Dutch Safety Management System (DSMS-tool) consists of (the risk of) delirium, falling, functional impairment, and malnutrition and is currently used in all older hospitalised patients. However, its predictive performance in older cardiac patients is unknown.

Aim

To estimate the performance of the DSMS-tool alone and combined with other predictors in predicting hospital readmission or mortality within 6 months in acutely hospitalised older cardiac patients.

Methods

An individual patient data meta-analysis was performed on 529 acutely hospitalised cardiac patients ≥70 years from four prospective cohorts. Missing values for predictor and outcome variables were multiply imputed. We explored discrimination and calibration of: (1) the DSMS-tool alone; (2) the four components of the DSMS-tool and adding easily obtainable clinical predictors; (3) the four components of the DSMS-tool and more difficult to obtain predictors. Predictors in model 2 and 3 were selected using backward selection using a threshold of p = 0.157. We used shrunk c-statistics, calibration plots, regression slopes and Hosmer-Lemeshow p-values (P_HL) to describe predictive performance in terms of discrimination and calibration.

Results

The population mean age was 82 years, 52% were males and 51% were admitted for heart failure. DSMS-tool was positive in 45% for delirium, 41% for falling, 37% for functional impairments and 29% for malnutrition. The incidence of hospital readmission or mortality gradually increased from 37 to 60% with increasing DSMS scores. Overall, the DSMS-tool discriminated limited (c-statistic 0.61, 95% 0.56–0.66). The final model included the DSMS-tool, diagnosis at admission and Charlson Comorbidity Index and had a c-statistic of 0.69 (95% 0.63–0.73; P_HL was 0.658).

Discussion

The DSMS-tool alone has limited capacity to accurately estimate the risk of readmission or mortality in hospitalised older cardiac patients. Adding disease-specific risk factor information to the DSMS-tool resulted in a moderately performing model. To optimise the early identification of older hospitalised cardiac patients at high risk, the combination of geriatric and disease-specific predictors should be further explored.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02243-5.

Emergency department management of older people living with frailty: a guide for emergency practitioners

Emergency Departments (EDs) are increasingly seeing more seriously unwell older people living with frailty. In the context of limited resources and increasing demand it's the ED practitioner's challenge to unpick this constellation of physical, psychological, functional and social issues.To properly assess older people living with frailty at the ED it is crucial to use an holistic approach. This consists of triage with algorithms sensitive to the higher risk of older people living with frailty, a frailty assessment, and an assessment with the help of the principles of Comprehensive Geriatric Assessment. Multi-disciplinary care, a tailor-made treatment plan, based on what the person values most, will help the ED practitioner to deliver appropriate and valuable care during the ED stay, but also in transition from hospital to home.

A European Research Agenda for Geriatric Emergency Medicine: a modified Delphi study

PURPOSE

Geriatric Emergency Medicine (GEM) focuses on delivering optimal care to (sub)acutely ill older people. This involves a multidisciplinary approach throughout the whole healthcare chain. However, the underpinning evidence base is weak and it is unclear which research questions have the highest priority. The aim of this study was to provide an inventory and prioritisation of research questions among GEM professionals throughout Europe.

METHODS

A two-stage modified Delphi approach was used. In stage 1, an online survey was administered to various professionals working in GEM both in the Emergency Department (ED) and other healthcare settings throughout Europe to make an inventory of potential research questions. In the processing phase, research questions were screened, categorised, and validated by an expert panel. Subsequently, in stage 2, remaining research questions were ranked based on relevance using a second online survey administered to the same target population, to identify the top 10 prioritised research questions.

RESULTS

In response to the first survey, 145 respondents submitted 233 potential research questions. A total of 61 research questions were included in the second stage, which was completed by 176 respondents. The question with the highest priority was: Is implementation of elements of CGA (comprehensive geriatric assessment), such as screening for frailty and geriatric interventions, effective in improving outcomes for older patients in the ED?

CONCLUSION

This study presents a top 10 of high-priority research questions for a European Research Agenda for Geriatric Emergency Medicine. The list of research questions may serve as guidance for researchers, policymakers and funding bodies in prioritising future research projects.

The Cardiac Care Bridge randomized trial in high-risk older cardiac patients: A mixed-methods process evaluation

Aim

To evaluate healthcare professionals' performance and treatment fidelity in the Cardiac Care Bridge (CCB) nurse‐coordinated transitional care intervention in older cardiac patients to understand and interpret the study results.

Design

A mixed‐methods process evaluation based on the Medical Research Council Process Evaluation framework.

Methods

Quantitative data on intervention key elements were collected from 153 logbooks of all intervention patients. Qualitative data were collected using semi‐structured interviews with 19 CCB professionals (cardiac nurses, community nurses and primary care physical therapists), from June 2017 until October 2018. Qualitative data‐analysis is based on thematic analysis and integrated with quantitative key element outcomes. The analysis was blinded to trial outcomes. Fidelity was defined as the level of intervention adherence.

Results

The overall intervention fidelity was 67%, ranging from severely low fidelity in the consultation of in‐hospital geriatric teams (17%) to maximum fidelity in the comprehensive geriatric assessment (100%). Main themes of influence in the intervention performance that emerged from the interviews are interdisciplinary collaboration, organizational preconditions, confidence in the programme, time management and patient characteristics. In addition to practical issues, the patient's frailty status and limited motivation were barriers to the intervention.

Conclusion

Although involved healthcare professionals expressed their confidence in the intervention, the fidelity rate was suboptimal. This could have influenced the non‐significant effect of the CCB intervention on the primary composite outcome of readmission and mortality 6 months after randomization. Feasibility of intervention key elements should be reconsidered in relation to experienced barriers and the population.

Impact

In addition to insight in effectiveness, insight in intervention fidelity and performance is necessary to understand the mechanism of impact. This study demonstrates that the suboptimal fidelity was subject to a complex interplay of organizational, professionals' and patients' issues. The results support intervention redesign and inform future development of transitional care interventions in older cardiac patients.

Insight Into the Posthospital Syndrome: A 3-Month Longitudinal Follow up on Geriatric Syndromes and Their Association With Functional Decline, Readmission, and Mortality

Background

Acute hospitalization may lead to posthospital syndrome, but no studies have investigated how this syndrome manifests and geriatric syndromes are often used as synonym. However, studies on longitudinal associations between syndromes and adverse outcomes are scarce. We aimed to analyze longitudinal associations between geriatric syndromes and functional decline (FD), readmission, and mortality.

Methods

Prospective cohort study, including 401 acutely hospitalized patients (aged ≥ 70). We performed: (i) logistic regression analyses to assess associations between patterns of geriatric syndromes as they develop over time (between admission and 1 month postdischarge), and FD and readmission; (ii) generalized estimating equations to assess longitudinal associations between geriatric syndromes over five time points (admission, discharge, 1, 2, and 3 months postdischarge) and FD, mortality, and readmission at 3 months postdischarge.

Results

After syndrome absent, syndrome present at both admission and 1 month postdischarge was most prevalent. Persistent patterns of apathy (odds ratio [OR] = 4.35, 95% confidence interval [CI] = 1.54–12.30), pain (OR = 3.26, 95% CI = 1.21–8.8), malnutrition (OR = 3.4, 95% CI = 1.35–8.56), mobility impairment (OR = 6.65, 95% CI = 1.98–22.38), and fear of falling (OR = 3.17, 95% CI = 1.25–8.02) were associated with FD. Developing cognitive impairment (OR = 6.40, 95% CI = 1.52–26.84), fatigue (OR = 4.71, 95% CI = 1.03–21.60), and fall risk (OR = 4.30, 95% CI = 1.21–16.57) postdischarge, was associated with readmission; however, only 4%–6% developed these syndromes. Over the course of five time points, mobility impairment, apathy, and incontinence were longitudinally associated with FD; apathy, malnutrition, fatigue, and fall risk with mortality; malnutrition with readmission.

Conclusion

Most geriatric syndromes are present at admission and patients are likely to retain them postdischarge. Several geriatric syndromes are longitudinally associated with mortality and, particularly, persistently present syndromes place persons are at risk of FD. Although few persons develop syndromes postdischarge, those developing cognitive impairment, fatigue, and fall risk were at increased readmission risk.

Barriers and facilitators for shared decision making in older patients with multiple chronic conditions: a systematic review

Background

The aim of this study was to describe barriers and facilitators for shared decision making (SDM) as experienced by older patients with multiple chronic conditions (MCCs), informal caregivers and health professionals.

Methods

A structured literature search was conducted with 5 databases. Two reviewers independently assessed studies for eligibility and performed a quality assessment. The results from the included studies were summarized using a predefined taxonomy.

Results

Our search yielded 3838 articles. Twenty-eight studies, listing 149 perceived barriers and 67 perceived facilitators for SDM, were included. Due to poor health and cognitive and/or physical impairments, older patients with MCCs participate less in SDM. Poor interpersonal skills of health professionals are perceived as hampering SDM, as do organizational barriers, such as pressure for time and high turnover of patients. However, among older patients with MCCs, SDM could be facilitated when patients share information about personal values, priorities and preferences, as well as information about quality of life and functional status. Informal caregivers may facilitate SDM by assisting patients with decision support, although informal caregivers can also complicate the SDM process, for example, when they have different views on treatment or the patient’s capability to be involved. Coordination of care when multiple health professionals are involved is perceived as important.

Conclusions

Although poor health is perceived as a barrier to participate in SDM, the personal experience of living with MCCs is considered valuable input in SDM. An explicit invitation to participate in SDM is important to older adults. Health professionals need a supporting organizational context and good communication skills to devise an individualized approach for patient care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02050-y.

Two European Examples of Acute Geriatric Units Located Outside of a General Hospital for Older Adults With Exacerbated Chronic Conditions

OBJECTIVE

Throughout Europe, the number of older adults requiring acute hospitalization is increasing. Admission to an acute geriatric unit outside of a general hospital could be an alternative. In this model of acute medical care, comprehensive geriatric assessment and rehabilitation are provided to selected older patients. This study aims to compare patients' diagnoses, characteristics, and outcomes of 2 European sites where this care occurs.

DESIGN

Exploratory cohort study.

SETTING AND PARTICIPANTS

Subacute Care Unit (SCU), introduced in 2012 in Barcelona, Spain, and the Acute Geriatric Community Hospital (AGCH), introduced in 2018 in Amsterdam, the Netherlands. The main admission criteria for older patients were acute events or exacerbations of chronic conditions, hemodynamic stability on admission, and no requirement for complex diagnostics.

MEASURES

We compared setting, characteristics, and outcomes between patients admitted to the 2 units.

RESULTS

Data from 909 patients admitted to SCU and 174 to AGCH were available. Patients were admitted from the emergency department or from home. The mean age was 85.8 years [standard deviation (SD) = 6.7] at SCU and 81.9 years (SD = 8.5) (P < .001) at AGCH. At SCU, patients were more often delirious (38.7% vs 22.4%, P < .001) on admission. At both units, infection was the main admission diagnosis. Other diagnoses included heart failure or chronic obstructive pulmonary disease. Five percent or less of patients were readmitted to general hospitals. Average length of stay was 8.8 (SD = 4.4) days (SCU) and 9.9 (SD = 7.5) days (AGCH).

CONCLUSIONS AND IMPLICATIONS

These acute geriatric units are quite similar and both provide an alternative to admission to a general hospital. We encourage the comparison of these units to other examples in Europe and suggest multicentric studies comparing their performance to usual hospital care.

Longitudinal Changes in Muscle Mass, Muscle Strength, and Physical Performance in Acutely Hospitalized Older Adults

OBJECTIVES

Acute hospitalization may lead to a decrease in muscle measures, but limited studies are reporting on the changes after discharge. The aim of this study was to determine longitudinal changes in muscle mass, muscle strength, and physical performance in acutely hospitalized older adults from admission up to 3 months post-discharge.

DESIGN

A prospective observational cohort study was conducted.

SETTING AND PARTICIPANTS

This study included 401 participants aged ≥70 years who were acutely hospitalized in 6 hospitals. All variables were assessed at hospital admission, discharge, and 1 and 3 months post-discharge.

METHODS

Muscle mass in kilograms was assessed by multifrequency Bio-electrical Impedance Analysis (MF-BIA) (Bodystat; Quadscan 4000) and muscle strength by handgrip strength (JAMAR). Chair stand and gait speed test were assessed as part of the Short Physical Performance Battery (SPPB). Norm values were based on the consensus statement of the European Working Group on Sarcopenia in Older People.

RESULTS

A total of 343 acute hospitalized older adults were included in the analyses with a mean (SD) age of 79.3 (6.6) years, 49.3% were women. From admission up to 3 months post-discharge, muscle mass (-0.1 kg/m²; P = .03) decreased significantly and muscle strength (-0.5 kg; P = .08) decreased nonsignificantly. The chair stand (+0.7 points; P < .001) and gait speed test (+0.9 points; P < .001) improved significantly up to 3 months post-discharge. At 3 months post-discharge, 80%, 18%, and 43% of the older adults scored below the cutoff points for muscle mass, muscle strength, and physical performance, respectively.

CONCLUSIONS AND IMPLICATIONS

Physical performance improved during and after acute hospitalization, although muscle mass decreased, and muscle strength did not change. At 3 months post-discharge, muscle mass, muscle strength, and physical performance did not reach normative levels on a population level. Further research is needed to examine the role of exercise interventions for improving muscle measures and physical performance after hospitalization.

Asymptomatic Cases and Limited Transmission of SARS-CoV-2 in Residents and Healthcare Workers in Three Dutch Nursing Homes

We aimed to assess the contribution of a- and presymptomatic residents and healthcare workers in transmission of SARS-CoV-2 in nursing homes. We conducted two serial point-prevalence surveys, including standardized symptom assessment and nasopharyngeal and oropharyngeal testing for SARS-CoV-2, among 297 residents and 542 healthcare workers of three Dutch nursing homes (NHs) with recent SARS-CoV-2 introduction. At the first point-prevalence survey, 15 residents tested positive of which one was presymptomatic and three remained asymptomatic. At the second point-prevalence survey one resident and one healthcare worker tested SARS-CoV-2 positive and both remained asymptomatic. Although a limited number of SARS-CoV-2 positive cases were identified, this study confirms a- and presymptomatic occurrence of Covid-19. We additionally describe factors that may contribute to the prevention of transmission. Taken together, our study complements the discussion on effective SARS-CoV-2 screening in NHs.

Feasibility of the PalliSupport care pathway: results from a mixed-method study in acutely hospitalized older patients at the end of life

BACKGROUND

A transitional care pathway (TCP) could improve care for older patients in the last months of life. However, barriers exist such as unidentified palliative care needs and suboptimal collaboration between care settings. The aim of this study was to determine the feasibility of a TCP, named PalliSupport, for older patients at the end of life, prior to a stepped-wedge randomized controlled trial.

METHODS

A mixed-method feasibility study was conducted at one hospital with affiliated primary care. Patients were ≥ 60 years and acutely hospitalized. The intervention consisted of (1) training on early identification of the palliative phase and end of life conversations, (2) involvement of a transitional palliative care team during admission and post-discharge and (3) intensified collaboration between care settings. Outcomes were feasibility of recruitment, data collection, patient burden and protocol adherence. Experiences of 14 professionals were assessed through qualitative interviews.

RESULTS

Only 16% of anticipated participants were included which resulted in difficulty assessing other feasibility criteria. The qualitative analysis identified misunderstandings about palliative care, uncertainty about professionals' roles and difficulties in initiating end of life conversations as barriers. The training program was well received and professionals found the intensified collaboration beneficial for patient care. The patients that participated experienced low burden and data collection on primary outcomes and protocol adherence seems feasible.

DISCUSSION

This study highlights the importance of performing a feasibility study prior to embarking on effectiveness studies. Moving forward, the PalliSupport care pathway will be adjusted to incorporate a more active recruitment approach, additional training on identification and palliative care, and further improvement on data collection.

Motivational factors mediate the association of general self-efficacy and performance outcomes in acutely hospitalised older patients

Objectives

To study (i) the association of general self-efficacy (GSE) on the course of subjective (i.e. basic and instrumental activities of daily living (ADLs and IADLs) and objective physical performance outcomes (short physical performance battery (SPPB)) among older persons from discharge up to 3 months post-discharge and (ii) the extent to whether motivational factors such as depressive symptoms, apathy and fatigue mediate this association.

Methods

Prospective multi-centre cohort of acutely hospitalised patients aged ≥70 (Hospital-ADL study). Structural equation modelling was used to analyse the structural relationships.

Results

The analytic sample included 236 acutely hospitalised patients. GSE had a significant total effect on the course of subjective and objective performance outcomes (ADLs: β = −0.21, P < 0.001, IADLs: β = −0.24, P < 0.001 and SPPB: β = 0.17, P < 0.001). However, when motivational factors as mediator were included into the same model, motivational factors (IADLs: β = 0.51, P < 0.001; SPPB: β = 0.49, P < 0.001) but not GSE remained significantly associated with IADLs (β = −0.06, P = 0.16) and SPPB (β = 0.002, P = 0.97). Motivational factors partially mediated the relationship between GSE and ADLs (β = −0.09, P = 0.04). The percentage of mediation was 55, 74 and 99% for ADLs, IADLs and SPPB, respectively.

Conclusions

Motivational factors and GSE are both associated with subjective and objective performance outcomes. However, the relationship between GSE and subjective and objective performance outcomes was highly mediated by motivational factors. Taken together, this suggests that GSE is important to being physically active but not sufficient to becoming more physical active in acutely hospitalised older patients; motivation is important to improving both subjective and objective performance.

Health Care Providers' Views on the Transition Between Hospital and Primary Care in Patients in the Palliative Phase: A Qualitative Description Study

CONTEXT

Inadequate handovers between hospital and home can lead to adverse health outcomes. A group particularly at risk is patients at the end of life because of complex health problems, frequent care transitions, and involvement of many professionals.

OBJECTIVES

To investigate health care providers' views and experiences with regard to the transition from hospital to primary care in palliative care.

METHODS

This was a descriptive qualitative study. Three focus group discussions were held with 28 nurses and two focus groups with nine physicians. Participants were recruited from primary and hospital care. The focus groups were audiorecorded, transcribed verbatim, and analyzed thematically.

RESULTS

The following themes emerged from the data: lack of identification of and communication about the last phase of life; incomplete and insufficient handover; and uncertainty about responsibilities. Professionals emphasize the importance of proper handovers and transitional processes in these vulnerable patients. The transition between hospital to primary care is hindered by a lack of identification of the palliative phase and uncertainties about patient awareness. Direct communication between professionals is needed but lacking. The handover itself is currently primarily focused on physical aspects where psychosocial aspects were also found necessary. Furthermore, uncertainties with regard to physicians' responsibility for the patient seem to further hinder professionals in the transitional process.

CONCLUSION

Efforts should be made to enhance knowledge and skills around identification of palliative needs and communication with patients about the end of life, especially in the hospital setting.

The longitudinal association between depressive symptoms and functional abilities in older patients

OBJECTIVES

To investigate the course of depressive symptoms, and basic and instrumental activities of daily living (collectively described as, (I)ADL functioning) from acute admission until one year post-discharge, the longitudinal association between depressive symptoms and (I)ADL functioning, and to disaggregate between- and within-person effects to examine whether changes in depressive symptoms are associated with changes in (I)ADL functioning.

METHODS

Prospective multicenter cohort of acutely hospitalized patients aged ≥70. Data gathered over a one-year period were assessed using validated measures of depressive symptoms (GDS-15) and physical functioning (Katz-ADL index). A Poisson mixed model analysis was used to examine the association between the courses and a hybrid model was used to disentangle between- and within-subject effects.

RESULTS

The analytic sample included 398 patients (mean age = 79.6 years, SD = 6.6). Results showed an improvement in depressive symptoms and physical functions over time, whereby changes in depressive symptoms were significantly associated with the course of ADL function (rate ratio (RR) = 0.91, p < .001) and IADL function (RR = 0.94, p < .001), even after adjustment for confounding variables. Finally, both between- and within-person effects of depressive symptoms were significantly associated with the course of ADL function (between-person: RR = 0.85, p < .001; within-person: RR = 0.94, p < .001) and IADL function (between-person: RR = 0.87, p < .001; within-person: RR = 0.97, p < .001).

CONCLUSION

The course of depressive symptoms and physical functions improved over time, whereby changes in depressive symptoms were significantly associated with changes in physical functions, both at group and individual level. These changes in (I)ADL functioning lie mostly above the estimated minimally important change for both scales, implying clinically relevant changes.

Medication-related interventions delivered both in hospital and following discharge: a systematic review and meta-analysis

BACKGROUND

Harm due to medications is common during the transition from hospital to home. Approaches that seek to prevent harm often involve isolated medication-related interventions and show conflicting results. However, until now, no review has focused on the effect of intervention components delivered both in hospital and following discharge from hospital to home.

OBJECTIVE

To examine effects of medication-related interventions on hospital readmissions, medication-related problems (MRPs), medication adherence and mortality.

METHODS

For this systematic review and meta-analysis, we searched the PubMed, Embase, CINAHL and CENTRAL databases without language restrictions. Citations of included articles were checked through Web of Science and Scopus from inception to 20 June 2019. We included prospective studies that examined effects of medication-related interventions delivered both in hospital and following discharge from hospital to home compared with usual care. Three authors independently extracted data and assessed study quality in pairs.

RESULTS

Fourteen original studies were included, comprising 8182 patients. Interventions consisted mainly of patient education and medication reconciliation in the hospital, and patient education following discharge. Nine studies were included in the meta-analysis; compared with usual care (n=3376 patients), medication-related interventions (n=1820 patients) reduced hospital readmissions by 3.8 percentage points within 30 days of discharge (number needed to treat=27, risk ratio (RR) 0.79 (95% CI 0.65 to 0.96)). Meta-regression analysis suggested that readmission rates were reduced by 17% per additional intervention component (RR 0.83 (95% Cl 0.75 to 0.91)). Medication adherence and MRPs may be improved. Effects on mortality were unclear.

CONCLUSIONS

Studied medication-related interventions reduce all-cause hospital readmissions within 30 days. The treatment effect appears to increase with higher intervention intensities. More evidence is needed for recommendations on adherence, mortality and MRPs.

Video-based tools to enhance nurses' geriatric knowledge: A development and pilot study

BACKGROUND

The need for health care professionals with geriatric knowledge is expected to increase due to aging of society. Educational tools that fit the specific learning styles of nurses and nursing students might be useful for this. Serioussoap.nl (available in Dutch and English) is an educational tool that integrates video-based gaming and storytelling, and it might be an effective way to improve the geriatric knowledge of nurses or nursing students.

OBJECTIVES

To investigate the effect of Serioussoap.nl on the geriatric knowledge of nurses and nursing students, and to evaluate its usability.

DESIGN

We conducted a development and an explorative pilot study, using a pretest posttest quantitative design to investigate the effect of Serioussoap.nl on geriatric knowledge. A qualitative approach was used to evaluate its usability.

PARTICIPANTS AND SETTING

Three vocational nursing schools (n = 119 second/third year students), one baccalaureate nursing university (n = 77 first year vocational nurses) and one home-care organization (n = 44 vocational nurses) in the Netherlands participated in the quantitative study, and 94 vocational students participated in the qualitative study.

METHODS

We measured the effect on geriatric knowledge with the Knowledge of Older People Questionnaire (KOP-Q, score 0-30). The qualitative study included observations of 94 participants while they played Serioussoap.nl, four semi-structured focus groups and eleven individual interviews.

RESULTS

The study demonstrated a significant increase of geriatric knowledge of 7.8% (+2.3 score on the KOP-Q, 95% Confidence Interval (1.4-3.2, p < 0.001). The qualitative data showed that Serioussoap.nl contributed to the reflective learning-style and enhanced meaningful learning.

CONCLUSION

Serioussoap.nl increased the students' geriatric knowledge and was perceived as a suitable and effective educational tool for vocational nursing students and nurses.