Assessment of patient capacity to consent to treatment

OBJECTIVE

To compare results of a specific capacity assessment administered by the treating clinician, and a Standardized Mini-Mental Status Examination (SMMSE), with the results of expert assessments of patient capacity to consent to treatment.

DESIGN

Cross-sectional study with independent comparison to expert capacity assessments.

SETTING

Inpatient medical wards at an academic secondary and tertiary referral hospital.

PARTICIPANTS

One hundred consecutive inpatients facing a decision about a major medical treatment or an invasive medical procedure. Participants either were refusing treatment, or were accepting treatment but were not clearly capable according to the treating clinician.

MEASUREMENTS AND MAIN RESULTS

The treating clinician (medical resident or student) conducted a specific capacity assessment on each participant, using a decisional aid called the Aid to Capacity Evaluation. A specific capacity assessment is a semistructured evaluation of the participant's ability to understand relevant information and appreciate reasonably foreseeable consequences with regard to the specific treatment decision. Participants also received a SMMSE administered by a research nurse. Participants then had two independent expert assessments of capacity. If the two expert assessments disagreed, then an independent adjudication panel resolved the disagreement after reviewing videotapes of both expert assessments. Using the two expert assessments and the adjudication panel as the reference standard, we calculated areas under the receiver-operating characteristic curves and likelihood ratios. The areas under the receiver-operating characteristic curves were 0.90 for specific capacity assessment by treating clinician and 0.93 for SMMSE score (2p =.48). For the treating clinician's specific capacity assessment, likelihood ratios for detecting incapacity were as follows: definitely incapable, 20 (95% confidence interval [CI] 3. 6, 120); probably incapable, 6.1 (95% CI 2.6, 15); probably capable, 0.39 (95% CI 0.18, 0.81); and definitely capable, 0.05 (95% CI 0.01, 0.29). For the SMMSE, a score of 0 to 16 had a likelihood ratio of 15 (95% CI 5.3, 44), a score of 17 to 23 had a likelihood ratio of 0. 68 (95% CI 0.35, 1.2), and a score of 24 to 30 had a likelihood ratio of 0.05 (95% CI 0.01, 0.26).

CONCLUSIONS

Specific capacity assessments by the treating clinician and SMMSE scores agree closely with results of expert assessments of capacity. Clinicians can use these practical, flexible, and evaluated measures as the initial step in the assessment of patient capacity to consent to treatment.

Sun exposure and age-related macular degeneration. An Australian case-control study

BACKGROUND

The notion that sun exposure is a risk factor for age-related macular degeneration (AMD) is widespread, but studies have not shown this conclusively.

METHODS

To test the hypothesis that AMD cases have greater ocular sun exposure than control subjects, the authors compared 409 cases with 286 control subjects resident in Newcastle, Australia. Sensitivity to sun and glare of the participants was characterized. Sun exposure was estimated from detailed histories and was validated against sun-seeking or avoidance behavior expected, given sun sensitivity and history of treatment for skin neoplasia.

RESULTS

Contrary to the authors' hypothesis, control subjects had greater median annual ocular sun exposure (865 hours) than cases (723 hours), Mann-Whitney U (U) = 45704, z = -4.9, P > 0.0001. Cases had poorer tanning than did control subjects (mean 2 = 18.2, 4 df, P = 0.001) and as young adults were more sensitive to glare, odds ratio (OR), 2.5; 95% confidence intervals (CIs), 1.8 to 3.5. After stratifying by tanning ability, in the poor-tanning group, the median annual sun exposure of control subjects (685 hours) exceeded that of cases (619 hours), U = 6556, z = -1.9, P = 0.06. Among people who tanned well, control subjects also had significantly greater annual sun exposure than did cases (940 vs. 770 hours), U = 16263, z = -3.7, P = 0.0002.

CONCLUSIONS

Sensitivity to glare and poor tanning ability are markers of increased AMD risk. Sun sensitivity confounds study of the postulated AMD-sunlight link. Despite analyses stratified by sun sensitivity, sun exposure was greater in control subjects than in cases with AMD.

Integrated geriatric assessment and treatment (INTEGERATE) in older people with cancer planned for systemic anticancer therapy

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Background: Older people experience significant adverse effects of cancer and anti-cancer therapy due to age-related vulnerabilities, including medical, functional, cognitive, nutritional and psychosocial issues. Comprehensive geriatric assessment and management (CGAM) provides a powerful framework to assess an older person’s health status and offers a coordinated, person-centered approach to care. Despite its effectiveness, the uptake of CGAM in oncology has been limited due to a lack of randomized evidence in this setting. This study evaluated the effectiveness of CGAM in older people with cancer. Methods: INTEGERATE is a prospective, randomized, parallel group, open-label study in patients aged >70 years with cancer planned for chemotherapy, targeted therapy or immunotherapy. Patients were randomly assigned (1:1) to receive either geriatrician-led CGAM integrated with usual care (integrated oncogeriatric care) or usual care alone, using minimization to balance treatment intent, cancer type, age, sex and performance status. Health-related quality of life (HRQOL) was assessed using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-ELD14 at 0, 12, 18 and 24 weeks. The primary outcome was HRQOL measured by the validated Elderly Functional Index (ELFI) score. Major secondary outcomes included function, mood, nutrition, health utility, treatment delivery, healthcare utilization and survival. Results: Of the 154 patients who underwent randomization, 13 died by week 12 and 130 (92.2% of the remaining patients) completed at least two primary outcome assessments. For the primary outcome, patients in the intervention group had significantly better ELFI score than the usual care group across all followup timepoints, with a maximal difference at week 18 (estimated marginal mean ELFI score 72.0 vs 58.7, p= 0.001). In addition, significant differences favoring the intervention group over the usual care group were seen in HRQOL (domains: physical, role and social functioning; mobility, burden of illness and future worries), unplanned hospital admissions (-1.2 admissions per person-years, p< 0.001) and early treatment discontinuation (32.9% vs 53.2%, p = 0.01). Conclusions: Integrated oncogeriatric care led to improvements in HRQOL, unplanned hospital admissions and treatment discontinuation in older people receiving systemic anti-cancer therapy. Older people (>70 years) planned for anti-cancer therapy should receive CGAM to optimize their clinical care and health outcomes. Clinical trial information: ACTRN12614000399695 .

Measuring capacity to complete an advance directive

OBJECTIVE

To validate reference standards for the assessment of capacity to complete an advance directive and to develop and test three simple screening instruments.

METHODS

We administered five measures of capacity to 96 older subjects from nursing homes, retirement homes, and homes for the aged. The measures included two reference standard evaluations: an assessment by a specially trained nurse in collaboration with a multidisciplinary team (Competency Clinic assessment) and geriatrician assessment using a decisional aid. Three screening instruments were also included: a Generic Instrument designed for any advance directive, a Specific Instrument designed for the "Let Me Decide" advance directive, and the Standardized Mini-Mental Status Examination (SMMSE). The screening instruments and the geriatrician's assessment were administered twice to half of the respondents to determine interrater agreement.

RESULTS

The chance-corrected agreement for the assessment by two geriatricians was 0.78, and for agreement between the geriatricians and Competency Clinic assessments it was 0.82. Agreement for the Generic and Specific screening instrument assessments by two observers was 0.77 and 0.90, respectively. The areas under the Receiver Operating Characteristic curve relating the results of the three screening instruments to the Competency Clinic assessment were 0.82 for the Generic Instrument, 0.90 for the Specific Instrument, and 0.94 for the SMMSE; chance is an unlikely explanation for the difference between these three values (P < or = .01).

CONCLUSIONS

Using rigorous methods, health workers can make reproducible and valid assessments of capacity to complete an advance directive. The SMMSE accurately differentiates people who can learn about and ultimately complete advance directives from those who cannot.

Predicting driving performance in older adults: we are not there yet!

OBJECTIVE

We set up this study to determine the predictive value of approaches for which a statistical association with driving performance has been documented.

METHODS

We determined the statistical association (magnitude of association and probability of occurrence by chance alone) between four different predictors (the Mini-Mental State Examination, Trails A test, Useful Field of View [UFOV], and a composite measure of past driving incidents) and driving performance. We then explored the predictive value of these measures with receiver operating characteristic (ROC) curves and various cutoff values.

RESULTS

We identified associations between the predictors and driving performance well beyond the play of chance (p < .01). Nonetheless, the predictors had limited predictive value with areas under the curve ranging from .51 to .82.

CONCLUSIONS

Statistical associations are not sufficient to infer adequate predictive value, especially when crucial decisions such as whether one can continue driving are at stake. The predictors we examined have limited predictive value if used as stand-alone screening tests.

Factors associated with unplanned readmissions in a major Australian health service

Objective The aim of the present study was to gain an understanding of the factors associated with unplanned hospital readmission within 28 days of acute care discharge from a major Australian health service. Methods A retrospective study of 20575 acute care discharges from 1 August to 31 December 2015 was conducted using administrative databases. Patient, index admission and readmission characteristics were evaluated for their association with unplanned readmission in ≤28 days. Results The unplanned readmission rate was 7.4% (n=1528) and 11.1% of readmitted patients were returned within 1 day. The factors associated with increased risk of unplanned readmission in ≤28 days for all patients were age ≥65 years (odds ratio (OR) 1.3), emergency index admission (OR 1.6), Charlson comorbidity index >1 (OR 1.1-1.9), the presence of chronic disease (OR 1.4) or complications (OR 1.8) during the index admission, index admission length of stay (LOS) >2 days (OR 1.4-1.8), hospital admission(s) (OR 1.7-10.86) or emergency department (ED) attendance(s) (OR 1.8-5.2) in the 6 months preceding the index admission and health service site (OR 1.2-1.6). However, the factors associated with increased risk of unplanned readmission ≤28 days changed with each patient group (adult medical, adult surgical, obstetric and paediatric). Conclusions There were specific patient and index admission characteristics associated with increased risk of unplanned readmission in ≤28 days; however, these characteristics varied between patient groups, highlighting the need for tailored interventions. What is known about the topic? Unplanned hospital readmissions within 28 days of hospital discharge are considered an indicator of quality and safety of health care. What does this paper add? The factors associated with increased risk of unplanned readmission in ≤28 days varied between patient groups, so a 'one size fits all approach' to reducing unplanned readmissions may not be effective. Older adult medical patients had the highest rate of unplanned readmissions and those with Charlson comorbidity index ≥4, an index admission LOS >2 days, left against advice and hospital admission(s) or ED attendance(s) in the 6 months preceding index admission and discharge from larger sites within the health service were at highest risk of unplanned readmission. What are the implications for practitioners? One in seven discharges resulted in an unplanned readmission in ≤28 days and one in 10 unplanned readmissions occurred within 1 day of discharge. Although some patient and hospital characteristics were associated with increased risk of unplanned readmission in ≤28 days, statistical modelling shows there are other factors affecting the risk of readmission that remain unknown and need further investigation. Future work related to preventing unplanned readmissions in ≤28 days should consider inclusion of health professional, system and social factors in risk assessments.

Age-related changes in microvascular blood flow and transcutaneous oxygen tension under Basal and stimulated conditions

BACKGROUND

Adequate cutaneous microvascular blood flow and tissue oxygen tension are important prerequisites for successful tissue repair. The efficacy of tissue repair decreases with age and is linked to the age-related functional decline of unmyelinated sensory neurons that are important for inflammation and tissue repair. However, available information on the effect of these neuronal changes on microvascular blood flow and tissue oxygen tension is limited, particularly under control and injury conditions. The authors had two aims in this study: (a) to assess age-related changes in the relationship between microvascular blood flow and tissue oxygen perfusion under basal and two different stimulated conditions (sensory dependent and sensory independent), and (b) to clarify the biological meaning of transcutaneous partial pressure of oxygen (tcPO2) measurements.

METHODS

The effects of a sensory-independent vasodilator (acetylcholine) and a sensory-dependent vasodilator (capsaicin) on microvascular blood flow and oxygen perfusion in persons of different ages were measured. Laser Doppler flowmetry and a commercially available transcutaneous oxygen monitor (with sensors set at 39 degrees C and 44 degrees C) were used. Healthy volunteers were recruited: 11 young, 14 middle aged, and 19 older.

RESULTS

Under basal conditions (skin temperature, 37 degrees C to 39 degrees C), both basal blood flow and tcPO2 increased with increasing age. However, with the sensor set at 44 degrees C, tcPO2 showed a significant decrease with age. Acetylcholine increased blood flow approximately equally in the three age groups. Capsaicin increased blood flow and tcPO2 in all age groups, with the young showing a greater increase compared with the older participants.

CONCLUSIONS

The age-associated changes in basal and stimulated microvascular blood flow and tcPO2 could be attributed in part to altered neuronal function. Measuring tcPO2 at 39 degrees C showed a trend toward an increase with age. In contrast, a decrease with age was observed when tcPO2 was measured at 44 degrees C, a temperature sufficient to activate sensory nerve endings. The results may reflect a decline in sensory nerve function with age rather than a decrease in oxygen delivery for vascular reasons. This is supported by the complementary data showing a significant age-related decrease in stimulated blood flow in response to capsaicin, with no change in the response to the sensory-independent vasodilator acetylcholine. Thus, for clinical purposes, data obtained using the tcPO2 monitor should be interpreted with full knowledge of the conditions under which the measurements were made. Furthermore, for scientific purposes, the tcPO2 monitor could be used to assess sensory nerve function when sensors are heated to 44 degrees C.

Understanding the patient experience of early unplanned hospital readmission following acute care discharge: a qualitative descriptive study

OBJECTIVES

To understand from a patient and carer perspective: (1) what features of the discharge process could be improved to avoid early unplanned hospital readmission (within 72 hours of acute care discharge) and (2) what elements of discharge planning could have enhanced the discharge experience.

DESIGN

A qualitative descriptive design was used. Study data were collected using semi-structured interviews that were transcribed verbatim and analysed using inductive thematic analysis. Data related to participant characteristic were collected by medical record audit and summarised using descriptive statistics.

SETTING

Three acute care hospitals from one health service in Australia.

PARTICIPANTS

Patients who had an early unplanned hospital readmission and/or their carers, if present during the interviews and willing to participate, with patient permission.

FINDINGS

Thirty interviews were conducted (23 patients only; 6 patient and carer dyads; 1 carer only). Five themes were constructed: 'experiences of care', 'hearing and being heard', 'what's wrong with me', 'not just about me' and 'all about going home'. There was considerable variability in patients' and carers' experiences of hospital care, discharge processes and early unplanned hospital readmission. Features of the discharge process that could be improved to potentially avoid early unplanned hospital readmission were better communication, optimal clinical care including ensuring readiness for discharge and shared decision-making regarding discharge timing and goals on returning home. The discharge experience could have been enhanced by improved communication between patients (and carers) and the healthcare team, not rushing the discharge process and a more coordinated approach to patient transport home from hospital.

CONCLUSIONS

The study findings highlight the complexities of the discharge process and the importance of effective communication, shared decision-making and carer engagement in optimising hospital discharge and reducing early unplanned hospital readmissions.

Findings from the Candrive/Ozcandrive study: Low mileage older drivers, crash risk and reduced fitness to drive

Previous research has found that only older drivers with low annual driving mileages had a heightened crash risk relative to other age groups. These drivers tend to drive mainly in urban areas, where the prevalence of complex traffic situations increases crash risk. However it might also be that some drivers may have reduced their driving due to perceived or actual declines in driving fitness. This paper uses Canadian and Australian data from the Candrive/Ozcandrive older driver study to investigate the association between annual driving distances and a set of driving-related factors, including fitness to drive. All drivers in the Candrive/Ozcandrive older driver cohort study were allocated to one of three groups according to their self-reported annual driving distances: <5001km; >5000 and <15,000km; and 15,000km or greater. Relationships between these driving-distance categories and: (a) self-reported crash data; (b) various Year 1 'fitness to drive' performance measures; and (c) self-perceptions of driving ability and of comfort while driving, were determined. Results confirmed the previously reported association between low mileage and heightened crash risk. Further, low mileage drivers performed relatively poorly on a wide range of performance measures, perceived their own driving ability as lower, and reported lower comfort levels when driving in challenging situations, compared to the higher mileage drivers. In most instances, these differences were statistically significant. The paper provides further evidence that the so-called 'older driver problem' is most pertinent to low mileage drivers, and that this is due in part to low mileage drivers tending to have reduced fitness to drive. This higher risk group represented a fairly small proportion of the sample in this study.

Development of the Handicap Assessment and Resource Tool (HART)

An important determinant of whether people can live in community settings is the absence of significant handicap. People with considerable disabilities can live without handicap if they have adequate supports. Handicap, rather than disability, limits peoples' residence options. Disability assessment tools are commonly used to guide where people can live--these assess neither the resources available nor the personal-care handicap present. The Handicap Assessment and Resource Tool (HART) was designed to provide information about the personal-care issues (clothing, hygiene, nutrition, mobility, safety, residence and supports) relevant to choice of residence. The HART was tested by occupational therapists who are frequently expected to provide recommendations regarding disabled clients' residence options. It is a client-centred tool that addresses key occupational performance components of personal care. Pilot testing in hospital and community settings shows the HART is a comprehensive and practical tool that is acceptable to users and clients.

The Driver Behaviour Questionnaire for older drivers: Do errors, violations and lapses change over time?

The aim of the current study was to examine how self-reported aberrant driving behaviours change across a three time-points in a group of older drivers. Two hundred and twenty-seven older drivers (males = 69.6%) from the Candrive/Ozcandrive longitudinal study completed the Driving Behaviour Questionnaire (DBQ) each yearacross three time-points (i.e., Year 1, Year 2, Year 3). At the third time-point, older drivers ranged in age from 77 to 96 years (M = 81.74 years; SD = 3.44 years). A longitudinal confirmatory factor analysis showed that a modified 21-item, 3-factor (errors, lapses and violations) DBQ was invariant across the time period, suggesting that the structure of the questionnaire was stable across each time-point. Further, multiple domain latent growth analysis on the resultant factors for errors, lapses and violations showed that the frequency of errors remained similar across the three-year period, while violations and lapses showed very marginal decreases in frequency. These changes were independent of the absolute number of these behaviours; Drivers with higher violations or lapses in Year one, showed similar decreases in frequency as those who self-reported lower frequencies of the behaviours. These results suggest that the DBQ is a reliable tool to measure older drivers' self-reported aberrant driving behaviours, and that these behaviours do not show much change across time. Future research should validate the self-reported responses from the DBQ with more objective measures such as those collected through naturalistic driving study (NDS) methodology or on-road driving tasks.

On-road driving assessment and route design for drivers with dementia

Introduction

Dementia causes the progressive loss of cognitive capacities and thus impairs social and daily living skills. Dementia, to varying degrees, influences driver performance and safety. Eventually drivers affected by dementia must stop driving so they do not harm themselves or others. However, having to stop driving can result in loss of mobility and social connections. Therefore, assessing drivers with dementia is important. Driving assessment is susceptible to possible biases, including unreliable driving performance measures or driving routes that are inconsistent in the levels of difficulty of the driving tasks and manoeuvres. The aim of the study was to determine what measures of driving performance could optimally be applied to occupational therapy on-road driving assessments.

Method

All drivers with dementia underwent a 60 minute, set route on-road driving assessment that consisted of 110 pre-programmed observation points.

Results

The study identified 80 sufficiently challenging driving tasks and described the relationship of driving error to that task, for example, critical errors at unguided intersections.

Conclusion

The results of the task-demand by error type analysis identified a list of task items that can be applied to assessment route design to increase consistency of on-road assessment for people with dementia.

Direct supervision of physiotherapists improves compliance with clinical practice guidelines for patients with hip fracture: a controlled before-and-after study

Purpose: To determine if the addition of direct supervision to usual clinical supervision practice of physiotherapists can improve compliance with clinical practice guidelines and post-surgical outcomes for inpatients with hip fracture.Methods: A controlled before-and-after study was conducted on two acute orthopedic wards. Junior and mid-level physiotherapists on one ward were provided with direct supervision during their post-operative management of patients with hip fracture. Physiotherapists on the comparison ward received usual reflective supervision. The primary outcome was patient compliance with the hip fracture guideline to mobilize on the day following surgery. Secondary patient outcomes included physical function on the fifth post-operative day.Results: Data were collected from 290 patients with acute hip fracture. Patients at the direct supervision site were more likely to mobilize on the day after surgery [OR 3.14, 95% confidence interval (CI) 1.41-7.01; p = 0.005] and by the second post-operative day (OR 4.62, 95% CI 2.31-9.23; p < 0.001) compared to patients at the comparison site. Patients walked further on the fifth post-operative day (p < 0.001) with less assistance from therapists (p = 0.044).Conclusions: The addition of direct supervision improved physiotherapists' compliance with hip fracture guidelines and walking endurance and independence in hospitalized patients with hip fracture.Implications for rehabilitationThe addition of a direct supervision model, where physiotherapists are directly observed in their management of patients with hip fracture, to usual practice supervision improved early mobilization of patients with hip fractureDirect supervision appears to be an effective guideline implementation strategy that can improve care and outcomes for hospitalized patients with hip fracture.

The use of sensory nerve stimulation and compression bandaging to improve sensory nerve function and healing of chronic venous leg ulcers

Low frequency transcutaneous sensory nerve stimulation (LF-SNS) [International Patent PCT/AU2004/001079: "nerve function and tissue healing" (Khalil, Z.)] improves sensory nerve function and accelerates wound healing of older animals.

INTERVENTION

Double blind, placebo controlled randomised trial of LF-SNS for 5 minutes, twice daily for up to 12 weeks, on healing of chronic venous leg ulcers in older people. Four layer compression bandaging was the standard therapy. OUTCOME MEASURES (METHODS): Wound healing and the rate of epithelialisation (calculated from serial wound area estimation), microvascular blood flow (measured using LASER Doppler flowmetry), transcutaneous oxygen tension (measured using a transcutaneous oxygen monitor, TCM400 Radiometer). Sensory nerve activity (assessed via measuring electrical cutaneous perception threshold using the Neurometer((R))CPT and the flare response to 5% capsaicin (a selective activator of C fibres).

PARTICIPANTS

14 older people with chronic venous ulcers randomly allocated to active (mean age 74.8+/-2.3 years) and 15 to Sham nerve stimulation (mean age 76.5+/-2.6 years).

RESULTS

Microvascular blood flow improved in all participants. A high proportion of wounds healed ( approximately 60%). There were trends for better C-fibre function and faster healing rates in the Active group (1.1+/-0.3 cm(2)/wk) compared to the Sham group (0.6+/-0.2 cm(2)/wk) but failed to reach statistical significance due to the small sample size.

CONCLUSIONS

The improvement in microvascular blood flow in both groups was an unexpected finding that has not previously been described. Most likely this was due to the four layer compression bandaging provided to all participants. Improved microvascular blood flow may be a significant contributor to wound healing. The observed trends to increased healing rates and improvements in C-fibre function in the actively stimulated group compared to the sham group warrant further studies of LF-SNS as an adjunct therapy for chronic venous leg ulcers. An exploration of the possibility that LF-SNS induced-improvement in C-fibre function could protect against future ulceration is also warranted.

Use of the sensory nerve stimulator to accelerate healing of a venous leg ulcer with sensory nerve dysfunction: a case study

A new therapy using sensory nerve stimulation [International Patent Application Number PCT/AU2004/001079: "nerve function and tissue healing" (Khalil, Z)] has been developed in our vascular physiology laboratory. This treatment has been found to improve the deficient sensory nerve function and associated deficient wound healing of older persons to levels seen in young people. An 82-year-old man with a small but persistent venous leg ulcer for 18 months, despite apparently appropriate wound dressings and compression therapy, was seen in a specialist wound management service. The patient's sensory and microvascular function was assessed in great detail using the vascular physiology laboratory techniques, and he was provided the sensory nerve stimulation therapy in addition to conventional therapy. His wound healed after 4 weeks. We report the case here. Prior to nerve stimulation therapy, cutaneous sensation, microvascular blood flow and oxygen tension were found to be reduced near the ulcer when compared with the opposite, non ulcerated leg. After therapy, oxygen tension and microvascular blood flow had improved. This case provides further evidence that sensory nerve stimulation therapy at the stipulated parameters improves wound healing. The observation that sensory nerve function improved provides support for the notion that improvement in healing is mediated by improved nerve function.

Factors associated with unplanned readmissions within 1 day of acute care discharge: a retrospective cohort study

BACKGROUND

Unplanned hospital readmissions are a quality and safety indicator. In Australian, 8% to 11.1% of unplanned readmissions occur ≤1 day of acute care discharge. The aim of this study was to explore the reasons for unplanned hospital readmissions ≤1 day of acute care discharge, and determine what proportion of such unplanned hospital readmissions were potentially preventable.

METHODS

A retrospective exploratory cohort design was used to conduct this two phase study. In Phase 1, organisational data from 170 readmissions ≤1 day and 1358 readmissions between 2 and 28 days were compared using the Cochran-Mantel-Haenszel test. Binary logistic regression was used to examine factors associated with unplanned readmission ≤1 day. In Phase 2, a medical record audit of 162 Phase 1 readmissions ≤1 day was conducted and descriptive statistics used to summarise the study data. Index discharges occurred between 1 August and 31 December 2015.

RESULTS

In Phase 1, unplanned readmissions ≤1 day were more likely in paediatric patients (< 0.001); index discharges on weekends (p = 0.006), from short stay unit (SSU) (p < 0.001) or against health professional advice (p = 0.010); or when the readmission was for a Diagnosis Related Group (p < 0.001). The significant predictors of unplanned readmission ≤1 day were index discharge against advice or from SSU, and 1-5 hospital admissions in the 6 months preceding index admission. In Phase 2, 88.3% readmissions were unpreventable and 11.7% were preventable. The median patient age was 57 years and comorbidities were uncommon (3.1%). Most patients (94.4%) lived at home and with others (78.9%). Friday was the most common day of index discharge (17.3%) and Saturday was the most common day of unplanned readmission (19.1%). The majority (94.4%) of readmissions were via the emergency department: 58.5% were for a like diagnosis and pain was the most common reason for readmission.

CONCLUSIONS

Advanced age, significant comorbidities and social isolation did not feature in patients with an unplanned readmission ≤1 day. One quarter of patients were discharged on a Friday or weekend, one quarter of readmissions occurred on a weekend, and pain was the most common reason for readmission raising issues about access to services and weekend discharge planning.

Clinical evaluation of the national hospital acquired complication program

OBJECTIVE

Health services are encouraged to evaluate data from the national hospital acquired complications (HAC) program and identify strategies to mitigate them.

DESIGN

Retrospective chart review compared with HAC extracted from administrative data.

SETTING

430-bed university-affiliated metropolitan hospital.

PARTICIPANTS

260 records with, and 462 without, reported HAC from 2,619 multi-day stay adults.

MAIN OUTCOME MEASURES

Prevalence and positive predictive value (PPV) of HAC methodology.

RESULTS

No errors of HAC coding or classification were identified. 423 HAC events were reported in 260 records; most commonly delirium (n =57, 13.4%), pneumonia (n =46, 10.9%), blood stream infection (n =39, 9.2%), hypoglycaemia (n =33, 7.8%) and cardiac arrhythmias (n =33, 7.8%). 108 (25.5%) "HAC" events in 69 separations (95%CI = 2.05 - 3.33 per 100 separations) were false positive, and 43 of 462 (95%CI = 6.72 - 12.22) per 100 separations false negative. Prevalence of total "HAC" was 16.06 (95%CI = 14.02 - 19.52); "reported HAC" 9.93 (95% CI = 8.76 - 11.21); "potentially preventable" HAC 1.68 (95%CI = 1.22 - 2.26); and healthcare errors 0.31 (95%CI = 0.13-1.30) per 100 separations. PPV of HAC for true clinical events was 0.74 (0.68 - 0.79); preventable events 0.18 (0.13 - 0.23); and healthcare error 0.03 (0.01-0.06).

CONCLUSIONS

Rate of HAC events was higher than expected, but positive predictive value for healthcare errors was low, suggesting provision of care is a less common cause of HAC events than patient factors. HAC may be an indicator of hospital admission complexity rather than hospital acquired complications. This article is protected by copyright. All rights reserved.

Reliability of an Online Geriatric Assessment Procedure Using the interRAI Acute Care Assessment System

OBJECTIVES

To determine whether geriatric triage decisions made using a comprehensive geriatric assessment (CGA) performed online are less reliable than face-to-face (FTF) decisions.

DESIGN

Multisite noninferiority prospective cohort study. Two specialist geriatricians assessed individuals sequentially referred for an acute care geriatric consultation. Participants were allocated to one FTF assessment and an additional assessment (FTF or online (OL)), creating two groups-two FTF (FTF-FTF, n = 81) or online and FTF (OL-FTF, n = 85).

SETTING

Three acute care public hospitals in two Australian states.

PARTICIPANTS

Admitted individuals referred for CGA.

INTERVENTION

Nurse-administered CGA, based on the interRAI Acute Care assessment system accessed online and other online clinical data such as pathology results and imaging enabling geriatricians to review participants' information and provide input into their care from a distance.

MEASUREMENTS

The primary decision subjected to this analysis was referral for permanent residential care. Geriatricians also recorded recommendations for referrals and variations for medication management and judgment regarding prognosis at discharge and after 3 months.

RESULTS

Overall percentage agreement was 88% (n = 71) for the FTF-FTF group and 91% (n = 77) for the OL-FTF group. The difference in agreement between the FTF-FTF and OL-FTF groups was -3%, indicating that there was no difference between the methods of assessment. Judgements made regarding diagnoses of geriatric syndromes, medication management, and prognosis (with regard to hospital outcome and location at 3 months) were found to be equally reliable in each mode of consultation.

CONCLUSION

Geriatric assessment performed online using a nurse-administered structured CGA system was no less reliable than conventional assessment in making clinical triage decisions.

Health status assessment of the elderly

The elderly are a heterogeneous population group who range from well and completely independent individuals to a smaller proportion who are frail, require help and are high users of the healthcare system. Since health is a state of well-being which includes the domains of social, spiritual, psychological and physical function, each of these domains must be evaluated when we are measuring the health of older adults. In this article, we discuss some of the more important aspects of these domains. If we focus exclusively on the diseases which occur in older adults we will miss important aspects of their health status. We may miss the interactions of several different disease processes occurring in 1 individual, and the impact of those diseases on the individual's ability to live independently and his or her quality of life. In this article, we not only justify the measurement of function, cognition, affect and quality of life in the elderly but we also describe the necessary measurement qualities of instruments used to measure health-related quality of life in the elderly. We provide some examples of measurement approaches with which we as researchers and health workers are familiar.

Neurovascular changes after four-layer compression bandaging in people with chronic venous leg ulcers

Objectives: Venous leg ulcers represent a major clinical problem, with poor rates of healing. Ideal treatment is compression bandaging. The effect of compression on neurovascular tissues involved in wound repair is unclear. This study aims to assess the effect of four-layer compression therapy (40 mmHg) on neurovascular function and wound healing in people with chronic venous leg ulcers – 15 people (55 years or older) with venous leg ulcers for more than six weeks.

Methods: Basal microvascular perfusion measurement (MPM), oxygen tension (tc pO2) measured at sensor temperatures of 39°C and 44°C and sensory nerve function using electrical cutaneous perception thresholds (ECPT) at 5, 250 and 2000 Hz (corresponding to C, A δ and A β fibres) were assessed adjacent to the ulcer site, and at a mirror location on the non-ulcerated limb. Testing was undertaken before and after therapy for 5–12 weeks of four-layer compression bandaging.

Results: There was significant improvement in tc pO2 at 44°C and ECPT at 2000 Hz ( P<0.05) compared with pre-intervention. Changes in basal MPM, tc pO2 at 39°C and ECPT at 5 and 250 Hz after compression therapy did not reach statistical significance.

Conclusion: Four-layer compression bandaging in people with venous leg ulcers improved some components of neurovascularture in people with chronic venous leg ulcers. Whether this improvement has contributed to wound healing in this study requires further investigation.

Web-based (online) comprehensive geriatric assessment is more time efficient, and as reliable, as reading patient medical records and conducting traditional in person consultations

The aim of this study was to report the time taken by geriatricians to reach triage decisions using an online assessment format compared with face-to-face (FTF) assessment. Patients ( N = 166) were randomly allocated to two groups: online and FTF assessments (OF group); and dual FTF assessments (FF group). Case preparation was conducted by trained nurse assessors using a web-enabled clinical decision support system. Geriatricians allocated to perform an ‘online’ assessment had access to this information only. Geriatricians allocated FTF assessments reviewed this data, as well as the paper-based medical file and then consulted directly with the patient and attending staff. Data were collected in relation to time taken to complete OL assessments, compared with FTF assessments. A complete OL consultation averages 10 minutes, and a FTF consultation almost 26 minutes. In FTF consultations, less time is spent using the OL material when the geriatrician is aware that they will have access to the patient chart and need time to speak with the patient. The less time taken using the OL approach did not significantly alter the triage decisions made by the geriatricians.

Gastrointestinal bleeding risk with rivaroxaban vs aspirin in atrial fibrillation: A multinational study

PURPOSE

Comparative gastrointestinal bleeding (GIB) risk between rivaroxaban and low-dose aspirin is unknown in patients with atrial fibrillation (AF). This study investigated GIB risk with rivaroxaban vs aspirin among two separate AF cohorts in Hong Kong and the United Kingdom, using a common protocol approach.

METHODS

This was a population-based cohort study using separate data from the Clinical Data Analysis and Reporting System (CDARS) of the Hong Kong Hospital Authority (2010-2018) and The Health Improvement Network (THIN) database in the United Kingdom (2011-2017). Patients with AF newly prescribed aspirin or rivaroxaban were included. Cox proportional hazards regression was used to compare GIB risks for rivaroxaban vs aspirin, accounting for confounders using propensity score fine stratification approach.

RESULTS

In CDARS, 29 213 patients were included; n = 1052 (rivaroxaban), n = 28 161 (aspirin). Crude GIB event rates per 100 patient-years in CDARS were 3.0 (aspirin) and 2.6 (rivaroxaban). No difference in GIB risk was observed between rivaroxaban and aspirin overall (HR = 1.04, 95%CI = 0.76-1.42), and in dose-stratified analyses (HR = 1.21, 95%CI = 0.84-1.74 [20 mg/day]; HR = 0.80, 95%CI = 0.44-1.45 [≤15 mg/day]). In THIN, 11 549 patients were included, n = 3496 (rivaroxaban) and n = 8053 (aspirin). Crude GIB event rates were 1.3 (aspirin) and 2.4 (rivaroxaban) per 100 patient-years. No difference in GIB risk was observed between rivaroxaban and aspirin overall (HR = 1.40, 95%CI = 1.00-1.98) and low-dose rivaroxaban (≤15 mg/day) (HR = 1.00, 95%CI = 0.56-1.30), but increased GIB risk was observed for rivaroxaban 20 mg/day vs aspirin (HR = 1.57, 95%CI = 1.08-2.29).

CONCLUSION

In patients with AF, GIB risk was comparable between aspirin and rivaroxaban ≤15 mg/day. GIB risk for rivaroxaban 20 mg/day vs aspirin remains uncertain and warrants further investigation.