Clinical Corner: Acute Care for Older Adults

Clinical Corner

Today’s Department of Medicine Grand Rounds featured an informative and entertaining presentation by Dr. Samir Sinha, from Toronto’s Mount Sinai and University Health Network Hospitals. Dr. Sinha, whose presentation was titled “Rethinking Traditional Models of Acute Care for Older Adults,” discussed how current healthcare delivery in Canada and the United States can negatively impact older adults. He presented the Acute Care for Elders (ACE) Strategy, employed at his hospital, as an alternative.

The following articles and resources, many of which were discussed by Dr. Sinha, are related to the topic of patient and system outcomes for older adults:


J Am Geriatr Soc. 2015 Apr;63(4):763-9. doi: 10.1111/jgs.13336.

Derivation and validation of the detection of indicators and vulnerabilities for emergency room trips scale for classifying the risk of emergency department use in frail community-dwelling older adults.

Costa AP, Hirdes JP, Bell CM, Bronskill SE, Heckman GA, Mitchell L, Poss JW, Sinha SK, Stolee P.

Abstract

OBJECTIVES:

To develop and validate a prognostic case finding tool that classifies the risk of emergency department (ED) use in an older home care population.

DESIGN:

Population-based retrospective cohort study using routinely collected data from home care clinical assessments linked prospectively to ED records.

SETTING:

Ontario and the Winnipeg Regional Health Authority, Canada.

PARTICIPANTS:

Older adults living at home and expected to receive in-home services for at least 60 days (N = 361,942).

MEASUREMENTS:

One or more ED visits within 6 months after an in-home clinical assessment was used as the main dependent measure. Ninety-five person-level risk measures from a clinical assessment instrument were selected as potential independent variables. The Detection of Indicators and Vulnerabilities for Emergency Room Trips (DIVERT) Scale was derived using recursive partitioning analyses informed by a multinational clinical panel.

RESULTS:

Overall, 41.2% had one or more ED visits within 6 months of their in-home assessment. Previous ED use and cardiorespiratory symptoms, cardiac conditions, and specific geriatric syndromes were predictors within the six-level DIVERT Scale. The scale provided adequate risk differentiation for case finding, with an area under the receiver operating characteristic curve of 0.62 (95% confidence interval = 0.61-0.62) and distinct risk gradients between risk scores. The multilevel validation demonstrated consistent performance across geographic and participant clusters.

CONCLUSION:

The DIVERT Scale is a valid case-finding tool for ED use in older home care clients. It may be suitable for preemptively and systematically risk-stratifying individuals or groups for additional assessment, case management, and preventative interventions. It may also be suitable for the stratification and adjustment of performance metrics.

PMID: 25900490

Full text (free to UCD-AMC affiliates)


J Am Geriatr Soc. 2014 Dec;62(12):2243-51. doi: 10.1111/jgs.13088. Epub 2014 Nov 4.

Systematic review of outcomes from home-based primary care programs for homebound older adults.

Stall N, Nowaczynski M, Sinha SK.

Abstract

OBJECTIVES:

To describe the effect of home-based primary care for homebound older adults on individual, caregiver, and systems outcomes.

DESIGN:

A systematic review of home-based primary care interventions for community-dwelling older adults (aged ≥65) using the Cochrane, PubMed, and MEDLINE databases from the earliest available date through March 15, 2014. Studies were included if the house calls visitor was the ongoing primary care provider and if the intervention measured emergency department visits, hospitalizations, hospital beds days of care, long-term care admissions, or long-term care bed days of care.

SETTING:

Home-based primary care programs.

PARTICIPANTS:

Homebound community-dwelling older adults (N = 46,154).

MEASUREMENTS:

Emergency department visits, hospitalizations, hospital bed days of care, long-term care admissions, long-term care bed days of care, costs, program design, and individual and caregiver quality of life and satisfaction with care.

RESULTS:

Of 357 abstracts identified, nine met criteria for review. The nine interventions were all based in North America, with five emerging from the Veterans Affairs system. Eight of nine programs demonstrated substantial effects on at least one inclusion outcome, with seven programs affecting two outcomes. Six interventions shared three core program components: interprofessional care teams, regular interprofessional care meetings, and after-hours support.

CONCLUSION:

Specifically designed home-based primary care programs may substantially affect individual, caregiver and systems outcomes. Adherence to the core program components identified in this review could guide the development and spread of these programs.

PMID: 25371236

Full text (free to UCD-AMC affiliates)


Ann Emerg Med. 2011 Jun;57(6):672-82. doi: 10.1016/j.annemergmed.2011.01.021.

A systematic review and qualitative analysis to inform the development of a new emergency department-based geriatric case management model.

Sinha SK, Bessman ES, Flomenbaum N, Leff B.

Abstract

STUDY OBJECTIVE:

We inform the future development of a new geriatric emergency management practice model. We perform a systematic review of the existing evidence for emergency department (ED)-based case management models designed to improve the health, social, and health service utilization outcomes for noninstitutionalized older patients within the context of an index ED visit.

METHODS:

This was a systematic review of English-language articles indexed in MEDLINE and CINAHL (1966 to 2010), describing ED-based case management models for older adults. Bibliographies of the retrieved articles were reviewed to identify additional references. A systematic qualitative case study analytic approach was used to identify the core operational components and outcome measures of the described clinical interventions. The authors of the included studies were also invited to verify our interpretations of their work. The determined patterns of component adherence were then used to postulate the relative importance and effect of the presence or absence of a particular component in influencing the overall effectiveness of their respective interventions.

RESULTS:

Eighteen of 352 studies (reported in 20 articles) met study criteria. Qualitative analyses identified 28 outcome measures and 8 distinct model characteristic components that included having an evidence-based practice model, nursing clinical involvement or leadership, high-risk screening processes, focused geriatric assessments, the initiation of care and disposition planning in the ED, interprofessional and capacity-building work practices, post-ED discharge follow-up with patients, and evaluation and monitoring processes. Of the 15 positive study results, 6 had all 8 characteristic components and 9 were found to be lacking at least 1 component. Two studies with positive results lacked 2 characteristic components and none lacked more than 2 components. Of the 3 studies with negative results demonstrating no positive effects based on any outcome tested, one lacked 2, one lacked 3, and one lacked 4 of the 8 model components.

CONCLUSION:

Successful models of ED-based case management models for older adults share certain key characteristics. This study builds on the emerging literature in this area and leverages the differences in these models and their associated outcomes to support the development of an evidence-based normative and effective geriatric emergency management practice model designed to address the special care needs and thereby improve the health and health service utilization outcomes of older patients.

PMID: 21621093

Full text (free to UCD-AMC affiliates)


J Am Geriatr Soc. 2009 Feb;57(2):273-8. doi: 10.1111/j.1532-5415.2008.02103.x. Epub 2008 Dec 11.

Comparison of functional outcomes associated with hospital at home care and traditional acute hospital care.

Leff B, Burton L, Mader SL, Naughton B, Burl J, Greenough WB 3rd, Guido S, Steinwachs D.

Abstract

OBJECTIVES:

To compare differences in the functional outcomes experienced by patients cared for in Hospital at Home (HaH) and traditional acute hospital care.

DESIGN:

Survey questionnaire of participants in a prospective nonrandomized clinical trial.

SETTING:

Three Medicare managed care health systems and a Veterans Affairs Medical Center.

PARTICIPANTS:

Two hundred fourteen community-dwelling elderly patients who required acute hospital admission for community-acquired pneumonia, exacerbations of chronic heart failure or chronic obstructive pulmonary disease, or cellulitis, 84 of whom were treated in HaH and 130 in an acute care hospital.

INTERVENTION:

Treatment in a HaH care model that substitutes for care provided in the traditional acute care hospital.

MEASUREMENTS:

Change in activity of daily living (ADL) and instrumental activity of daily living (IADL) scores from 1 month before admission to 2 weeks post admission to HaH or acute hospital and the proportion of groups that experienced improvement, no change, or decline in ADL and IADL scores.

RESULTS:

Patients treated in HaH experienced modest improvements in performance scores, whereas those treated in the acute care hospital declined (ADL, 0.39 vs -0.60, P=.10, range -12.0 to 7.0; IADL 0.74 vs -0.70, P=.007, range -5.0 to 10.0); a greater proportion of HaH patients improved in function and smaller proportions declined or had no change in ADLs (44% vs 25%, P=.10) or IADLs (46% vs 17%, P=.04).

CONCLUSION:

HaH care is associated with modestly better improvements in IADL status and trends toward more improvement in ADL status than traditional acute hospital care.

PMID: 19170781

Full text (free to UCD-AMC affiliates)


Cochrane Database Syst Rev. 2009 Jan 21;(1):CD000356. doi: 10.1002/14651858.CD000356.pub3.

Early discharge hospital at home.

Shepperd S, Doll H, Broad J, Gladman J, Iliffe S, Langhorne P, Richards S, Martin F, Harris R.

Abstract

BACKGROUND:

‘Early discharge hospital at home’ is a service that provides active treatment by health care professionals in the patient’s home for a condition that otherwise would require acute hospital in-patient care. If hospital at home were not available then the patient would remain in an acute hospital ward.

OBJECTIVES:

To determine, in the context of a systematic review and meta-analysis, the effectiveness and cost of managing patients with early discharge hospital at home compared with in-patient hospital care.

SEARCH STRATEGY:

We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Register , MEDLINE (1950 to 2008), EMBASE (1980 to 2008), CINAHL (1982 to 2008) and EconLit through to January 2008. We checked the reference lists of articles identified for potentially relevant articles.

SELECTION CRITERIA:

Randomised controlled trials recruiting patients aged 18 years and over. Studies comparing early discharge hospital at home with acute hospital in-patient care. Evaluations of obstetric, paediatric and mental health hospital at home schemes are excluded from this review.

DATA COLLECTION AND ANALYSIS:

Two authors independently extracted data and assessed study quality. Our statistical analyses were done on an intention-to-treat basis. We requested individual patient data (IPD) from trialists, and relied on published data when we did not receive trial data sets or the IPD did not include the relevant outcomes. For the IPD meta-analysis, where at least one event was reported in both study groups in a trial, Cox regression models were used to calculate the log hazard ratio and its standard error for mortality and readmission separately for each data set. The calculated log hazard ratios were combined using fixed-effect inverse variance meta-analysis.

MAIN RESULTS:

Twenty-six trials were included in this review [n = 3967]; 21 were eligible for the IPD meta-analysis and 13 of the 21 trials contributed data [1899/2872; 66%]. For patients recovering from a stroke and elderly patients with a mix of conditions there was insufficient evidence of a difference in mortality between groups (adjusted HR 0.79, 95% CI 0.32 to 1.91; N = 494; and adjusted HR 1.06, 95% CI 0.69 to 1.61; N = 978). Readmission rates were significantly increased for elderly patients with a mix of conditions allocated to hospital at home (adjusted HR 1.57; 95% CI 1.10 to 2.24; N = 705). For patients recovering from a stroke and elderly patients with a mix of conditions respectively, significantly fewer people allocated to hospital at home were in residential care at follow up (RR 0.63; 95% CI 0.40 to 0.98; N = 4 trials; RR 0.69, 95% CI 0.48 to 0.99; N =3 trials). Patients reported increased satisfaction with early discharge hospital at home. There was insufficient evidence of a difference for readmission between groups in trials recruiting patients recovering from surgery. Evidence on cost savings was mixed.

AUTHORS’ CONCLUSIONS:

Despite increasing interest in the potential of early discharge hospital at home services as a cheaper alternative to in-patient care, this review provides insufficient objective evidence of economic benefit or improved health outcomes.

PMID: 19160179

Full text (free to UCD-AMC affiliates)


J Am Geriatr Soc. 2003 Apr;51(4):451-8.

Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age.

Covinsky KE, Palmer RM, Fortinsky RH, Counsell SR, Stewart AL, Kresevic D, Burant CJ, Landefeld CS.

Abstract

OBJECTIVES:

To describe the changes in activities of daily living (ADL) function occurring before and after hospital admission in older people hospitalized with medical illness and to assess the effect of age on loss of ADL function.

DESIGN:

Prospective observational study.

SETTING:

The general medical service of two hospitals.

PARTICIPANTS:

Two thousand two hundred ninety-three patients aged 70 and older (mean age 80, 64% women, 24% nonwhite).

MEASUREMENTS:

At the time of hospital admission, patients or their surrogates were interviewed about their independence in five ADLs (bathing, dressing, eating, transferring, and toileting) 2 weeks before admission (baseline) and at admission. Subjects were interviewed about ADL function at discharge. Outcome measures included functional decline between baseline and discharge and functional changes between baseline and admission and between admission and discharge.

RESULTS:

Thirty-five percent of patients declined in ADL function between baseline and discharge. This included the 23% of patients who declined between baseline and admission and failed to recover to baseline function between admission and discharge and the 12% of patients who did not decline between baseline and admission but declined between hospital admission and discharge. Twenty percent of patients declined between baseline and admission but recovered to baseline function between admission and discharge. The frequency of ADL decline between baseline and discharge varied markedly with age (23%, 28%, 38%, 50%, and 63% in patients aged 70-74, 75-79, 80-84, 85-89, and > or =90, respectively, P <.001). After adjustment for potential confounders, age was not associated with ADL decline before hospitalization (odds ratio (OR) for patients aged > or =90 compared with patients aged 70-74 = 1.26, 95% confidence interval (CI) = 0.88-1.82). In contrast, age was associated with the failure to recover ADL function during hospitalization in patients who declined before admission (OR for patients aged > or =90 compared with patients aged 70-74 = 2.09, 95% CI = 1.20-3.65) and with new losses of ADL function during hospitalization in patients who did not decline before admission (OR for patients aged > or =90 compared with patients aged 70-74 = 3.43, 95% CI = 1.92-6.12).

CONCLUSION:

Many hospitalized older people are discharged with ADL function that is worse than their baseline function. The oldest patients are at particularly high risk of poor functional outcomes because they are less likely to recover ADL function lost before admission and more likely to develop new functional deficits during hospitalization

PMID: 12657063

Full text (free to UCD-AMC affiliates)


Geri-EM (http://geri-em.com/) – Personalized e-learning in geriatric medicine. This website contains learning modules for healthcare providers caring for older adults in emergency departments.


 

Kristen DeSanto, MSLS, MS, RD, AHIP

Clinical Librarian

kristen.desanto@ucdenver.edu • 303-724-2121

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