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Albanesi B, Conti A, Politano G, Dimonte V, Gianino MM, Campagna S. Emergency department visits by nursing home residents. A retrospective Italian study of administrative databases from 2015 to 2019. BMC Geriatr 2024; 24:295. [PMID: 38549053 PMCID: PMC10976813 DOI: 10.1186/s12877-024-04912-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 03/21/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Visits to Emergency Departments (ED) can be traumatic for Nursing Home (NH) residents. In Italy, the rate of ED visits by NH residents was recently calculated as 3.3%. The reduction of inappropriate ED visits represents a priority for National Healthcare Systems worldwide. Nevertheless, research on factors associated with ED visits is still under-studied in the Italian setting. This study has two main aims: (i) to describe the baseline characteristics of NH residents visiting ED at regional level; (ii) to assess the characteristics, trends, and factors associated with these visits. METHODS A retrospective study of administrative data for five years was performed in the Piedmont Region. Data from 24,208 NH residents were analysed. Data were obtained by merging two ministerial databases of residential care and ED use. Sociodemographic and clinical characteristics of the residents, trends, and rates of ED visits were collected. A Generalized Linear Model (GLM) regression was used to evaluate the factors associated with ED visits. RESULTS In 5 years, 12,672 residents made 24,609 ED visits. Aspecific symptoms (45%), dyspnea (17%) and trauma (16%) were the most frequent problems reported at ED. 51% of these visits were coded as non-critical, and 58% were discharged to the NH. The regression analysis showed an increased risk of ED visits for men (OR = 1.61, 95% CI 1.51-1.70) and for residents with a stay in NH longer than 400 days (OR = 2.19, 95% CI 2.08-2.31). CONCLUSIONS Our study indicates that more than half of NH residents' ED visits could potentially be prevented by treating residents in NH. Investments in the creation of a structured and effective network within primary care services, promoting the use of health technology and palliative care approaches, could reduce ED visits and help clinicians manage residents on-site and remotely.
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Affiliation(s)
- Beatrice Albanesi
- Department of Sciences of Public Health and Pediatrics, University of Turin, Via Santena 5 bis, Turin, 10126, Italy
| | - Alessio Conti
- Department of Sciences of Public Health and Pediatrics, University of Turin, Via Santena 5 bis, Turin, 10126, Italy.
| | - Gianfranco Politano
- Department of Control and Computer Engineering, Politecnico di Torino, Turin, Italy
| | - Valerio Dimonte
- Department of Sciences of Public Health and Pediatrics, University of Turin, Via Santena 5 bis, Turin, 10126, Italy
| | - Maria Michela Gianino
- Department of Sciences of Public Health and Pediatrics, University of Turin, Via Santena 5 bis, Turin, 10126, Italy
| | - Sara Campagna
- Department of Sciences of Public Health and Pediatrics, University of Turin, Via Santena 5 bis, Turin, 10126, Italy
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Brotherhood K, Searle B, Spiers GF, Caiado C, Hanratty B. Variations in older people's emergency care use by social care setting: a systematic review of international evidence. Br Med Bull 2024; 149:32-44. [PMID: 38112600 PMCID: PMC10938536 DOI: 10.1093/bmb/ldad033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/16/2023] [Accepted: 11/28/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Older adults' use of social care and their healthcare utilization are closely related. Residents of care homes access emergency care more often than the wider older population; however, less is known about emergency care use across other social care settings. SOURCES OF DATA A systematic review was conducted, searching six electronic databases between January 2012 and February 2022. AREAS OF AGREEMENT Older people access emergency care from a variety of community settings. AREAS OF CONTROVERSY Differences in study design contributed to high variation observed between studies. GROWING POINTS Although data were limited, findings suggest that emergency hospital attendance is lowest from nursing homes and highest from assisted living facilities, whilst emergency admissions varied little by social care setting. AREAS TIMELY FOR DEVELOPING RESEARCH There is a paucity of published research on emergency hospital use from social care settings, particularly home care and assisted living facilities. More attention is needed on this area, with standardized definitions to enable comparisons between studies.
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Affiliation(s)
- Kelly Brotherhood
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Biomedical Research Building (Second Floor), Newcastle upon Tyne NE1 7RU, UK
| | - Ben Searle
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Biomedical Research Building (Second Floor), Newcastle upon Tyne NE1 7RU, UK
| | - Gemma Frances Spiers
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Biomedical Research Building (Second Floor), Newcastle upon Tyne NE1 7RU, UK
| | - Camila Caiado
- Department of Mathematical Sciences, Mathematical Sciences & Computer Science Building, Durham University, Upper Mountjoy Campus, Stockton Road, Durham, DH1 3LE, UK
| | - Barbara Hanratty
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Biomedical Research Building (Second Floor), Newcastle upon Tyne NE1 7RU, UK
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Hekman DJ, Cochran AL, Maru AP, Barton HJ, Shah MN, Wiegmann D, Smith MA, Liao F, Patterson BW. Effectiveness of an Emergency Department-Based Machine Learning Clinical Decision Support Tool to Prevent Outpatient Falls Among Older Adults: Protocol for a Quasi-Experimental Study. JMIR Res Protoc 2023; 12:e48128. [PMID: 37535416 PMCID: PMC10436111 DOI: 10.2196/48128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/04/2023] [Accepted: 05/23/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Emergency department (ED) providers are important collaborators in preventing falls for older adults because they are often the first health care providers to see a patient after a fall and because at-home falls are often preceded by previous ED visits. Previous work has shown that ED referrals to falls interventions can reduce the risk of an at-home fall by 38%. Screening patients at risk for a fall can be time-consuming and difficult to implement in the ED setting. Machine learning (ML) and clinical decision support (CDS) offer the potential of automating the screening process. However, it remains unclear whether automation of screening and referrals can reduce the risk of future falls among older patients. OBJECTIVE The goal of this paper is to describe a research protocol for evaluating the effectiveness of an automated screening and referral intervention. These findings will inform ongoing discussions about the use of ML and artificial intelligence to augment medical decision-making. METHODS To assess the effectiveness of our program for patients receiving the falls risk intervention, our primary analysis will be to obtain referral completion rates at 3 different EDs. We will use a quasi-experimental design known as a sharp regression discontinuity with regard to intent-to-treat, since the intervention is administered to patients whose risk score falls above a threshold. A conditional logistic regression model will be built to describe 6-month fall risk at each site as a function of the intervention, patient demographics, and risk score. The odds ratio of a return visit for a fall and the 95% CI will be estimated by comparing those identified as high risk by the ML-based CDS (ML-CDS) and those who were not but had a similar risk profile. RESULTS The ML-CDS tool under study has been implemented at 2 of the 3 EDs in our study. As of April 2023, a total of 1326 patient encounters have been flagged for providers, and 339 unique patients have been referred to the mobility and falls clinic. To date, 15% (45/339) of patients have scheduled an appointment with the clinic. CONCLUSIONS This study seeks to quantify the impact of an ML-CDS intervention on patient behavior and outcomes. Our end-to-end data set allows for a more meaningful analysis of patient outcomes than other studies focused on interim outcomes, and our multisite implementation plan will demonstrate applicability to a broad population and the possibility to adapt the intervention to other EDs and achieve similar results. Our statistical methodology, regression discontinuity design, allows for causal inference from observational data and a staggered implementation strategy allows for the identification of secular trends that could affect causal associations and allow mitigation as necessary. TRIAL REGISTRATION ClinicalTrials.gov NCT05810064; https://www.clinicaltrials.gov/study/NCT05810064. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/48128.
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Affiliation(s)
- Daniel J Hekman
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, United States
| | - Amy L Cochran
- Department of Population Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Apoorva P Maru
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, United States
| | - Hanna J Barton
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, United States
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, United States
| | - Douglas Wiegmann
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, United States
| | - Maureen A Smith
- Health Innovation Program, University of Wisconsin-Madison, Madison, WI, United States
| | - Frank Liao
- Department of Applied Data Science, UWHealth Hospitals and Clinics, University of Wisconsin-Madison, Madison, WI, United States
| | - Brian W Patterson
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, United States
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Smyth J, Umapathysivam K, Hendrix I, Grantham H, Arendts G, Visvanathan R. Review article: Roles of activities of daily living and frailty assessments for residents of residential aged care services in emergency department transfers: A scoping review. Emerg Med Australas 2022; 34:675-686. [DOI: 10.1111/1742-6723.14055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/13/2022] [Accepted: 07/25/2022] [Indexed: 11/28/2022]
Affiliation(s)
- James Smyth
- Emergency Department The Queen Elizabeth Hospital Adelaide South Australia Australia
| | | | - Ivanka Hendrix
- Pharmacy Department The Queen Elizabeth Hospital Adelaide South Australia Australia
| | - Hugh Grantham
- School of Nursing, Midwifery and Paramedicine Curtin University Perth Western Australia Australia
| | - Glenn Arendts
- Department of Emergency Medicine, Medical School The University of Western Australia Perth Western Australia Australia
- Centre for Clinical Research in Emergency Medicine Harry Perkins Institute of Medical Research Perth Western Australia Australia
| | - Renuka Visvanathan
- School of Medicine The University of Adelaide Adelaide South Australia Australia
- Aged and Extended Care Services The Queen Elizabeth Hospital Adelaide South Australia Australia
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Huang MH, Tsai CF, Cheng CM, Lin YS, Lee WJ, Kuo YS, Chan YLE, Fuh JL. Predictors of emergency department visit among people with dementia in Taiwan. Arch Gerontol Geriatr 2022; 101:104701. [DOI: 10.1016/j.archger.2022.104701] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/02/2022] [Accepted: 04/03/2022] [Indexed: 01/01/2023]
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Marincowitz C, Preston L, Cantrell A, Tonkins M, Sabir L, Mason S. Factors associated with increased Emergency Department transfer in older long-term care residents: a systematic review. THE LANCET. HEALTHY LONGEVITY 2022; 3:e437-e447. [PMID: 36098321 DOI: 10.1016/s2666-7568(22)00113-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 01/15/2023] Open
Abstract
The proportion of adults older than 65 years is rapidly increasing. Care home residents in this age group have disproportionate rates of transfer to the Emergency Department (ED) and around 40% of attendances might be avoidable. We did a systematic review to identify factors that predict ED transfer from care homes. Six electronic databases were searched. Observational studies that provided estimates of association between ED attendance and variables at a resident or care home level were included. 26 primary studies met the inclusion criteria. Seven common domains of factors assessed for association with ED transfer were identified and within these domains, male sex, age, presence of specific comorbidities, polypharmacy, rural location, and care home quality rating were associated with likelihood of ED transfer. The identification of these factors provides useful information for policy makers and researchers intending to either develop interventions to reduce hospitalisations or use adjusted rates of hospitalisation as a care home quality indicator.
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Affiliation(s)
- Carl Marincowitz
- Centre for Urgent and Emergency Care Research (CURE), Health Services Research, School of Health and Related Research, University of Sheffield, Sheffield, UK.
| | - Louise Preston
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Anna Cantrell
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Michael Tonkins
- Centre for Urgent and Emergency Care Research (CURE), Health Services Research, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Lisa Sabir
- Centre for Urgent and Emergency Care Research (CURE), Health Services Research, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Suzanne Mason
- Centre for Urgent and Emergency Care Research (CURE), Health Services Research, School of Health and Related Research, University of Sheffield, Sheffield, UK
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Giacomini G, Minutiello E, Politano G, Dalmasso M, Albanesi B, Campagna S, Gianino MM. Trajectories and determinants of emergency department use among nursing home residents: a time series analysis (2012-2019). BMC Geriatr 2022; 22:418. [PMID: 35549898 PMCID: PMC9101855 DOI: 10.1186/s12877-022-03078-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 04/04/2022] [Indexed: 11/10/2022] Open
Abstract
Background Emergency department (ED) use among nursing home (NH) residents is an internationally-shared issue that is understudied in Italy. The long term care in Italy is part of the health system. This study aimed to assess trajectories of ED use among NH residents and determinants between demographic, health supply, clinical/functional factors. Methods A pooled, cross-sectional, time series analysis was performed in an Italian region in 2012/2019. The analysis measured the trend of ED user percentages associated with chronic conditions identified at NH admission. A GLM multivariate model was used to evaluate determinants of ED use. The variables collected were sex, age, assistance intensity, destination after discharge from NH, chronic conditions at NH admission, need for daily life assistance, degree of mobility, cognitive impairments, behavioural disturbances and were taken from two databases of the official Italian National Information System (FAR and C2 registries) that were combined to create a unique and anonymous code for each patient. Results A total of 37,311 residents were enrolled; 55.75% (20,800 residents) had at least one ED visit. The majority of the residents had cardiovascular (25.99%) or mental diseases (24.37%). In all pathologies, the percentage of ED users decreased and the decrease accelerated over time. These results were confirmed in the fixed effects regression model (coefficient for linear term (b = − 3.6177, p = 0, 95% CI = [− 5.124, − 2.1114]); coefficient for quadratic term = − 0.7691, p = 0.0046, 95% CI = [− 1.2953, − 0.2429]). Analysis showed an increased odds of ED visits involving males (OR = 1.27, 95% CI 1.24;1.30) and patients affected by urogenital diseases (OR = 1.16, 95% CI [1.031–1.314]). The lowest odds of ED visits were observed among subjects aged > 90 years (OR = 0.64, 95% CI [0.60–0.67]), who required assistance for their daily life activities (OR = 0.86; 95% CI = [0.82, 0.91]), or with serious cognitive disturbances (OR = 0.86; 95% CI = [0.84, 0.89]), immobile (OR = 0.93; 95% CI = [0.89, 0.96]), or without behavioural disturbances (OR = 0.92; 95% CI = [0.90, 0.94]). Conclusions The percentage of ED users has decreased, through support from the Italian disciplinary long-term care system. The demographic, clinical/functional variables associated with ED visits in this study will be helpful to develop targeted and tailored interventions to avoid unnecessary ED use.
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Affiliation(s)
- Gianmarco Giacomini
- Department of Public Health Sciences and Pediatrics, Università di Torino, Via Santena 5 bis, 10126, Torino, Italy
| | - Ettore Minutiello
- Department of Public Health Sciences and Pediatrics, Università di Torino, Via Santena 5 bis, 10126, Torino, Italy
| | - Gianfranco Politano
- Department of Control and Computer Engineering, Politecnico di Torino, Torino, Italy
| | - Marco Dalmasso
- Unit of Epidemiology- Local Health Unit TO3, Via Sabaudia 164, Turin, Grugliasco, Italy
| | - Beatrice Albanesi
- Department of Public Health Sciences and Pediatrics, Università di Torino, Via Santena 5 bis, 10126, Torino, Italy
| | - Sara Campagna
- Department of Public Health Sciences and Pediatrics, Università di Torino, Via Santena 5 bis, 10126, Torino, Italy
| | - Maria Michela Gianino
- Department of Public Health Sciences and Pediatrics, Università di Torino, Via Santena 5 bis, 10126, Torino, Italy.
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Jenkins D, Stickel A, González HM, Tarraf W. Out-of-pocket health expenditures and healthcare services use among older Americans with cognitive impairment: Results from the 2008-2016 Health and Retirement Study. THE GERONTOLOGIST 2021; 62:911-922. [PMID: 34718569 PMCID: PMC9290880 DOI: 10.1093/geront/gnab160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The evidence base on health services use and cost burdens associated with transition to severe cognitive impairment (SCI) and dementia is underdeveloped. We examine how change in cognitive impairment status influences nursing-home use, hospitalizations, and out-of-pocket expenditures (OOP). RESEARCH DESIGN AND METHODS We use prospective data from the Health and Retirement Study (2007/08-2015/16) on adults 70-years and older meeting research criteria for cognitive impairment not dementia (CIND) at baseline (Unweighted N=1,692) to fit two-part models testing how reversion to normal cognition, stability (CIND maintenance), and transition into SCI/dementia influence change in yearly nursing-home use, hospitalizations, and OOP. RESULTS Over 8-years, 5.9% reverted, 15.9% remained CIND, 14.9% transitioned to SCI/dementia, and 63.3% died. We observed substantial increases in the propensity of any nursing home use that were particularly pronounced among those that transitioned or died during follow-up, and similar but less pronounced differences in patterns of inpatient hospitalizations. Average baseline OOP spending was similar among reverters ($1156 [95% confidence interval=832;1,479]), maintainers ($1,145 [993;1,296]), and transitioners ($1,385 [1,041;1,730]). Individuals that died during follow-up spent $2,529 [2,101;2,957]. By the 8th year of follow-up, spending among reverters increased to $1,402 [869;1,934], and $2,188 [1,402;2,974], and $8,988 [5,820;12,157] for maintainers and transitioners, respectively. Average spending at the wave preceding death was $7,719 [4,345;11,094]. Estimates were only partly attenuated through adjustment to covariables. DISCUSSION AND IMPLICATIONS A better understanding of variations in health services use and cost burdens among individuals with mild cognitive impairment can help guide targeted care and financial planning.
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Affiliation(s)
- Derek Jenkins
- Department of Healthcare Sciences and Institute of Gerontology, Wayne State University, Detroit, Michigan, USA
| | - Ariana Stickel
- Department of Neurosciences and Shiley-Marcos Alzheimer's Disease Research Center, University of California San Diego School of Medicine, San Diego, California, USA
| | - Hector M González
- Department of Neurosciences and Shiley-Marcos Alzheimer's Disease Research Center, University of California San Diego School of Medicine, San Diego, California, USA
| | - Wassim Tarraf
- Department of Healthcare Sciences and Institute of Gerontology, Wayne State University, Detroit, Michigan, USA.,Institute of Gerontology, Wayne State University, Detroit, Michigan, USA
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Williamson LE, Evans CJ, Cripps RL, Leniz J, Yorganci E, Sleeman KE. Factors Associated With Emergency Department Visits by People With Dementia Near the End of Life: A Systematic Review. J Am Med Dir Assoc 2021; 22:2046-2055.e35. [PMID: 34273269 DOI: 10.1016/j.jamda.2021.06.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 05/10/2021] [Accepted: 06/04/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Emergency department (ED) attendance is common among people with dementia and increases toward the end of life. The aim was to systematically review factors associated with ED attendance among people with dementia approaching the end of life. DESIGN Systematic search of 6 databases (MEDLINE, EMBASE, ASSIA, CINAHL, PsycINFO, and Web of Science) and gray literature. Quantitative studies of any design were eligible. Newcastle-Ottawa Scales and Cochrane risk-of-bias tools assessed study quality. Extracted data were reported narratively, using a theoretical model. Factors were synthesized based on strength of evidence using vote counting (PROSPERO registration: CRD42020193271). SETTING AND PARTICIPANTS Adults with dementia of any subtype and severity, in the last year of life, or in receipt of services indicative of nearness to end of life. MEASUREMENTS The primary outcome was ED attendance, defined as attending a medical facility that provides 24-hour access to emergency care, with full resuscitation resources. RESULTS After de-duplication, 18,204 titles and abstracts were screened, 367 were selected for full-text review and 23 studies were included. There was high-strength evidence that ethnic minority groups, increasing number of comorbidities, neuropsychiatric symptoms, previous hospital transfers, and rural living were positively associated with ED attendance, whereas higher socioeconomic position, being unmarried, and living in a care home were negatively associated with ED attendance. There was moderate-strength evidence that being a woman and receiving palliative care were negatively associated with ED attendance. There was only low-strength evidence for factors associated with repeat ED attendance. CONCLUSIONS AND IMPLICATIONS The review highlights characteristics that could help identify patients at risk of ED attendance near the end of life and potential service-related factors to reduce risks. Better understanding of the mechanisms by which residential facilities and palliative care are associated with reduced ED attendance is needed.
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Affiliation(s)
- Lesley E Williamson
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom.
| | - Catherine J Evans
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom; Sussex Community NHS Foundation Trust, Brighton General Hospital, Brighton, United Kingdom
| | - Rachel L Cripps
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom
| | - Javiera Leniz
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom
| | - Emel Yorganci
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom
| | - Katherine E Sleeman
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom
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Stephens CE, Halifax E, David D, Bui N, Lee SJ, Shim J, Ritchie CS. "They Don't Trust Us": The Influence of Perceptions of Inadequate Nursing Home Care on Emergency Department Transfers and the Potential Role for Telehealth. Clin Nurs Res 2020; 29:157-168. [PMID: 31007055 PMCID: PMC10242499 DOI: 10.1177/1054773819835015] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
In this descriptive, qualitative study, we conducted eight focus groups with diverse informal and formal caregivers to explore their experiences/challenges with nursing home (NH) to emergency department (ED) transfers and whether telehealth might be able to mitigate some of those concerns. Interviews were transcribed and analyzed using a grounded theory approach. Transfers were commonly viewed as being influenced by a perceived lack of trust in NH care/capabilities and driven by four main factors: questioning the quality of NH nurses' assessments, perceptions that physicians were absent from the NH, misunderstandings of the capabilities of NHs and EDs, and perceptions that responses to medical needs were inadequate. Participants believed technology could provide "the power of the visual" permitting virtual assessment for the off-site physician, validation of nursing assessment, "real time" assurance to residents and families, better goals of care discussions with multiple parties in different locations, and family ability to say goodbye.
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Affiliation(s)
- Caroline E. Stephens
- Department of Community Health Systems, University of California, San Francisco, CA, USA
| | - Elizabeth Halifax
- Department of Physiological Nursing, University of California, San Francisco, CA, USA
| | - Daniel David
- Department of Community Health Systems, University of California, San Francisco, CA, USA
| | - Nhat Bui
- Asian Health Services, Oakland, CA, USA
| | - Sei J. Lee
- Division of Geriatrics, University of California, San Francisco, CA, USA
- San Francisco VA Healthcare System, San Francisco, CA, USA
| | - Janet Shim
- Department of Social and Behavioral Sciences, University of California, San Francisco, CA, USA
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11
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Patterson BW, Engstrom CJ, Sah V, Smith MA, Mendonça EA, Pulia MS, Repplinger MD, Hamedani AG, Page D, Shah MN. Training and Interpreting Machine Learning Algorithms to Evaluate Fall Risk After Emergency Department Visits. Med Care 2019; 57:560-566. [PMID: 31157707 PMCID: PMC6590914 DOI: 10.1097/mlr.0000000000001140] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Machine learning is increasingly used for risk stratification in health care. Achieving accurate predictive models do not improve outcomes if they cannot be translated into efficacious intervention. Here we examine the potential utility of automated risk stratification and referral intervention to screen older adults for fall risk after emergency department (ED) visits. OBJECTIVE This study evaluated several machine learning methodologies for the creation of a risk stratification algorithm using electronic health record data and estimated the effects of a resultant intervention based on algorithm performance in test data. METHODS Data available at the time of ED discharge were retrospectively collected and separated into training and test datasets. Algorithms were developed to predict the outcome of a return visit for fall within 6 months of an ED index visit. Models included random forests, AdaBoost, and regression-based methods. We evaluated models both by the area under the receiver operating characteristic (ROC) curve, also referred to as area under the curve (AUC), and by projected clinical impact, estimating number needed to treat (NNT) and referrals per week for a fall risk intervention. RESULTS The random forest model achieved an AUC of 0.78, with slightly lower performance in regression-based models. Algorithms with similar performance, when evaluated by AUC, differed when placed into a clinical context with the defined task of estimated NNT in a real-world scenario. CONCLUSION The ability to translate the results of our analysis to the potential tradeoff between referral numbers and NNT offers decisionmakers the ability to envision the effects of a proposed intervention before implementation.
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Affiliation(s)
- Brian W Patterson
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health
- Health Innovation Program
| | | | - Varun Sah
- Department of Computer Sciences, University of Wisconsin-Madison
| | - Maureen A Smith
- Health Innovation Program
- Departments of Population Health Sciences
- Family Medicine
| | - Eneida A Mendonça
- Biostatistics and Medical Informatics
- Pediatrics, University of Wisconsin School of Medicine and Public Health
| | - Michael S Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health
| | - Michael D Repplinger
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health
| | - Azita G Hamedani
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health
| | - David Page
- Department of Computer Sciences, University of Wisconsin-Madison
- Biostatistics and Medical Informatics
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health
- Departments of Population Health Sciences
- Department of Medicine, Division of Geriatrics and Gerontology, University of Wisconsin School of Medicine and Public Health, Madison, WI
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12
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Resident-Level Factors Associated with Hospitalization Rates for Newly Admitted Long-Term Care Residents in Canada: A Retrospective Cohort Study. Can J Aging 2019; 38:441-448. [DOI: 10.1017/s0714980818000715] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
RÉSUMÉChez les résidents en soins de longue durée (SLD), l’hospitalisation peut amener des complications telles que le déclin fonctionnel. L’objectif de notre étude était d’examiner l’association entre les données démographiques et de santé et le taux d’hospitalisation des résidents nouvellement admis en SLD. Nous avons mené une étude de cohorte rétrospective incluant tous les centres de SLD de six provinces et d’un territoire du Canada, à l’aide des données de la RAI-MDS 2.0 et de la Discharge Abstract Database. Nous avons inclus les résidents nouvellement admis ayant eu une évaluation entre le 1er janvier et le 31 décembre 2013 (n = 37 998). Les résidents de sexe masculin avec une santé plus instable et une déficience fonctionnelle de modérée à grave présentaient des taux d’hospitalisation plus élevés, tandis que les résidents avec une déficience cognitive de modérée à grave avaient des taux moindres. Les résultats de notre étude pourraient contribuer à l’identification des résidents nouvellement admis qui seraient plus à risque d’hospitalisation et à l’élaboration de stratégies préventives plus ciblées, incluant la réadaptation, la planification préalable de soins, les soins palliatifs et les services gériatriques spécialisés.
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Brucksch A, Hoffmann F, Allers K. Age and sex differences in emergency department visits of nursing home residents: a systematic review. BMC Geriatr 2018; 18:151. [PMID: 29970027 PMCID: PMC6029412 DOI: 10.1186/s12877-018-0848-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 06/26/2018] [Indexed: 12/22/2022] Open
Abstract
Background Nursing home residents (NHRs) are often transferred to emergency departments (EDs). A great proportion of ED visits is considered inappropriate. There is evidence that male NHRs are more often hospitalised, but this is less clear for ED visits. It is unclear, which influence age has on ED visits. We aimed to study the epidemiology of ED visits in NHRs focusing on age- and sex-specific differences. Methods A systematic review was carried out based on articles found in MEDLINE (via PubMed), CINAHL and Scopus. Articles published on or before Aug 31, 2017 were eligible. Two reviewers independently identified articles for inclusion. The quality of studies was assessed by the Joanna Briggs Institute critical appraisal tool for prevalence studies. Results Out of 1192 references, we found seven studies meeting our inclusion criteria. Six studies were conducted in the USA or Canada. Overall, 29–62% of NHRs had at least one ED visit over the course of 1 year. Most studies assessing the influence of sex found that male residents visited EDs more frequently. All but one of the five studies with multivariable analyses reported a statistically significant positive association (with odds or rate ratios of 1.05–1.38). All studies assessed the influence of age. There was no clear pattern with some studies showing no association between ED visits and age and other studies reporting decreasing ED visits with increasing age or increasing proportions followed by a decrease in the highest age group. Studies used 85+ or 86+ years as the highest age category. Hospital admission rate ranged from 36.4 to 48.7%. There was no study reporting stratified analyses by age and sex. Only one study reported main diagnoses leading to ED visits stratified by sex. Conclusion Male NHRs visit EDs more often than females, but there is no evidence on reasons. The association with age is unclear. Any future study on acute care of NHRs should assess the influence of age and sex. These studies should include large sample sizes to provide a more differentiated age categorisation. Trial registration PROSPERO CRD42017074845. Electronic supplementary material The online version of this article (10.1186/s12877-018-0848-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Annika Brucksch
- Department 11 Human and Health Sciences, University Bremen, Bremen, Germany
| | - Falk Hoffmann
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Katharina Allers
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany.
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Abstract
Despite hospital palliative care consultations during which goals of care are discussed in the context of poor prognoses, older adults are admitted to nursing homes for post-acute care where the focus is on rehabilitation. The purpose of this qualitative descriptive study was to describe factors that influence discontinuity between a palliative care consult and nursing home care and explore the potential consequences of this discontinuity. Twelve adults (mean age of 80 years) were enrolled from one community hospital and nursing home in the mid-Atlantic United States. Semi-structured interviews and medical record reviews were used to elicit information about clinical course, care processes, and patient/family preferences at hospital discharge and up to four times after nursing home admission. Data were analyzed using inductive content analysis techniques. Analysis revealed two themes: Inadequate Communication characterized by the lack of information about the palliative care consult after hospital discharge and Prognosis Incongruence evidenced by data demonstrating a discrepancy between hospital prognosis and nursing home care. Ongoing communication between settings to re-address goals of care, prognosis, and symptoms-the central tenets of palliative care-is lacking. Efforts to improve access to comprehensive palliative care delivery after hospitalization and during nursing home transitions are greatly needed.
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St-Hilaire A, Hudon C, Préville M, Potvin O. Utilization of healthcare services among elderly with cognitive impairment no dementia and influence of depression and anxiety: a longitudinal study. Aging Ment Health 2017; 21:810-822. [PMID: 26998576 DOI: 10.1080/13607863.2016.1161006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Little objective and nationally representative data are available concerning the influence of cognitive impairment no dementia (CIND) on utilization of healthcare services. The main objective was to compare the use of healthcare services over three years, between elders with current or incident CIND and those without CIND. A second objective was to evaluate the effect of depression and anxiety. METHODS Cross-sectional and longitudinal data from a population-based survey of 2265 older adults living in Quebec (Canada) were used. CIND was identified using normative data for the Mini-Mental State Examination and was linked with medical records from public health insurance plan. Multinomial logistic regressions adjusted for relevant socio-demographic, social network and health-related confounders were conducted for each service. Interaction between CIND and depression/anxiety was also examined. MAIN RESULTS Current CIND was a predictor of longer anxiolytic/sedative/hypnotic medication use. Incident CIND led to longer hospital stay. Depression raised the likelihood of frequenting geriatricians, psychiatrists or neurologists and emergency department, but lessened the likelihood of visiting general practitioners. The addition of the psychiatric conditions to the incident CIND did not increase the likelihood of consuming antidepressants, while the incident CIND cases without psychiatric conditions increased this likelihood. DISCUSSION Compared to older adults without CIND, older adults with CIND have a distinct utilization of healthcare services. Multiple evaluations over many years may help to better understand the utilization of healthcare services in individuals with CIND. In the meantime, evaluations of these conditions at key moments could allow a more efficient use of health resources.
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Affiliation(s)
| | - Carol Hudon
- a École de psychologie , Université Laval , Québec , QC , Canada.,b Centre de recherche de l'Institut universitaire en santé mentale de Québec , Québec , QC , Canada
| | - Michel Préville
- c Département des sciences de la santé communautaire , Université de Sherbrooke , Sherbrooke , QC , Canada.,d Centre de recherche Hôpital Charles LeMoyne , Longueuil , QC , Canada
| | - Olivier Potvin
- b Centre de recherche de l'Institut universitaire en santé mentale de Québec , Québec , QC , Canada
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Perrin A, Tavassoli N, Mathieu C, Hermabessière S, Houles M, McCambridge C, Magre E, Fernandez S, Caquelard A, Charpentier S, Lauque D, Azema O, Bismuth S, Chicoulaa B, Oustric S, Costa N, Molinier L, Vellas B, Bérard E, Rolland Y. Factors predisposing nursing home resident to inappropriate transfer to emergency department. The FINE study protocol. Contemp Clin Trials Commun 2017; 7:217-223. [PMID: 29696189 PMCID: PMC5898573 DOI: 10.1016/j.conctc.2017.07.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 07/18/2017] [Accepted: 07/20/2017] [Indexed: 11/19/2022] Open
Abstract
Background Each year, around one out of two nursing home (NH) residents are hospitalized in France, and about half to the emergency department (ED). These transfers are frequently inappropriate. This paper describes the protocol of the FINE study. The first aim of this study is to identify the factors associated with inappropriate transfers to ED. Methods/design FINE is a case-control observational study. Sixteen hospitals participate. Inclusion period lasts 7 days per season in each center for a total period of inclusion of one year. All the NH residents admitted in ED during these periods are included. Data are collected in 4 times: before transfer in the NH, at the ED, in hospital wards in case of patient's hospitalization and at the patient's return to NH. The appropriateness of ED transfers (i.e. case versus control NH residents) is determined by a multidisciplinary team of experts. Results Our primary objective is to determine the factors predisposing NH residents to inappropriate transfer to ED. Our secondary objectives are to assess the cost of the transfers to ED; study the evolution of NH residents' functional status and the psychotropic and inappropriate drugs prescription between before and after the transfer; calculate the prevalence of potentially avoidable transfers to ED; and identify the factors predisposing NH residents to potentially avoidable transfer to ED. Discussion A better understanding of the determinant factors of inappropriate transfers to ED of NH residents may lead to proposals of recommendations of better practice in NH and would allow implementing quality improvement programs in the health organization.
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Affiliation(s)
- Amélie Perrin
- Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Neda Tavassoli
- Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- Équipe Régionale Vieillissement et Prévention de La Dépendance (ERVPD), Toulouse, France
- Corresponding author. La Cité de la Santé - Équipe Régionale Vieillissement et Prévention de la Dépendance, 20 rue du Pont Saint Pierre – TSA 60033, 31059, Toulouse Cedex 9, France.
| | - Céline Mathieu
- Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- Observatoire Régional de La Santé de Midi-Pyrénées (ORSMIP), Toulouse, France
| | | | - Mathieu Houles
- Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Cécile McCambridge
- Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- Équipe Régionale Vieillissement et Prévention de La Dépendance (ERVPD), Toulouse, France
- Pôle Pharmacie, Centre Hospitalo-Universitaire de Toulouse, Toulouse, France
| | - Elodie Magre
- Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- Pôle Pharmacie, Centre Hospitalo-Universitaire de Toulouse, Toulouse, France
| | - Sophie Fernandez
- Pôle Médecine D’Urgence, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Anne Caquelard
- Pôle Médecine D’Urgence, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Sandrine Charpentier
- Pôle Médecine D’Urgence, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- UMR 1027, INSERM - Université de Toulouse III, Toulouse, France
| | - Dominique Lauque
- Pôle Médecine D’Urgence, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- UFR Sciences Médicales, Université de Toulouse III, Toulouse, France
| | - Olivier Azema
- Observatoire Régional des Urgences de Midi-Pyrénées (ORU-MiP), Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Serge Bismuth
- Département Universitaire de Médecine Générale (DUMG), Université de Toulouse III, Toulouse, France
| | - Bruno Chicoulaa
- Département Universitaire de Médecine Générale (DUMG), Université de Toulouse III, Toulouse, France
| | - Stéphane Oustric
- UMR 1027, INSERM - Université de Toulouse III, Toulouse, France
- Département Universitaire de Médecine Générale (DUMG), Université de Toulouse III, Toulouse, France
| | - Nadège Costa
- UMR 1027, INSERM - Université de Toulouse III, Toulouse, France
- Département D’Information Médicale (DIM), Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Laurent Molinier
- UMR 1027, INSERM - Université de Toulouse III, Toulouse, France
- Département D’Information Médicale (DIM), Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- Département D’Epidémiologie, D’Economie de La Santé et de Santé Publique, Université Toulouse III, Toulouse, France
| | - Bruno Vellas
- Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- Équipe Régionale Vieillissement et Prévention de La Dépendance (ERVPD), Toulouse, France
- UMR 1027, INSERM - Université de Toulouse III, Toulouse, France
| | - Emilie Bérard
- UMR 1027, INSERM - Université de Toulouse III, Toulouse, France
- Service D'Epidémiologie, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Yves Rolland
- Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- Équipe Régionale Vieillissement et Prévention de La Dépendance (ERVPD), Toulouse, France
- UMR 1027, INSERM - Université de Toulouse III, Toulouse, France
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LaMantia MA, Messina FC, Jhanji S, Nazir A, Maina M, McGuire S, Hobgood CD, Miller DK. Emergency medical service, nursing, and physician providers' perspectives on delirium identification and management. DEMENTIA 2016; 16:329-343. [PMID: 26112165 DOI: 10.1177/1471301215591896] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose of the study The study objective was to understand providers' perceptions regarding identifying and treating older adults with delirium, a common complication of acute illness in persons with dementia, in the pre-hospital and emergency department environments. Design and methods The authors conducted structured focus group interviews with separate groups of emergency medical services staff, emergency nurses, and emergency physicians. Recordings of each session were transcribed, coded, and analyzed for themes with representative supporting quotations identified. Results Providers shared that the busy emergency department environment was the largest challenge to delirium recognition and treatment. When describing delirium, participants frequently detailed hyperactive features of delirium, rather than hypoactive features. Participants shared that they employed no clear diagnostic strategy for identifying the condition and that they used heterogeneous approaches to treat the condition. To improve care for older adults with delirium, emergency nurses identified the need for more training around the management of the condition. Emergency medical services providers identified the need for more support in managing agitated patients when in transport to the hospital and more guidance from emergency physicians on what information to collect from the patient's home environment. Emergency physicians felt that delirium care would be improved if they could have baseline mental status data on their patients and if they had access to a simple, accurate diagnostic tool for the condition. Implications Emergency medical services providers, emergency nurses, and emergency physicians frequently encounter delirious patients, but do not employ clear diagnostic strategies for identifying the condition and have varying levels of comfort in managing the condition. Clear steps should be taken to improve delirium care in the emergency department including the development of mechanisms to communicate patients' baseline mental status, the adoption of a systematized approach to recognizing delirium, and the institution of a standardized method to treat the condition when identified.
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Affiliation(s)
- Michael A LaMantia
- Indiana University Center for Aging Research and Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Frank C Messina
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Shola Jhanji
- Indiana University-Purdue University, Indianapolis, IN, USA
| | - Arif Nazir
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mungai Maina
- Indiana University Center for Aging Research and Regenstrief Institute, Inc., Indianapolis, IN
| | - Siobhan McGuire
- Indiana University Center for Aging Research and Regenstrief Institute, Inc., Indianapolis, IN
| | | | - Douglas K Miller
- Indiana University Center for Aging Research and Regenstrief Institute, Inc., Indianapolis, IN
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LaMantia MA, Lane KA, Tu W, Carnahan JL, Messina F, Unroe KT. Patterns of Emergency Department Use Among Long-Stay Nursing Home Residents With Differing Levels of Dementia Severity. J Am Med Dir Assoc 2016; 17:541-6. [PMID: 27052563 DOI: 10.1016/j.jamda.2016.02.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 02/10/2016] [Accepted: 02/12/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To describe emergency department (ED) utilization among long-stay nursing home residents with different levels of dementia severity. DESIGN Retrospective cohort study. SETTING Public Health System. PARTICIPANTS A total of 4491 older adults (age 65 years and older) who were long-stay nursing home residents. MEASUREMENTS Patient demographics, dementia severity, comorbidities, ED visits, ED disposition decisions, and discharge diagnoses. RESULTS Forty-seven percent of all long-stay nursing home residents experienced at least 1 transfer to the ED over the course of a year. At their first ED transfer, 36.4% of the participants were admitted to the hospital, whereas 63.1% of those who visited the ED were not. The median time to first ED visit for the participants with advanced stage dementia was 258 days, whereas it was 250 days for the participants with early to moderate stage dementia and 202 days for the participants with no dementia (P = .0034). Multivariate proportional hazard modeling showed that age, race, number of comorbidities, number of hospitalizations in the year prior, and do not resuscitate status all significantly influenced participants' time to first ED visit (P < .05 for all). After accounting for these effects, dementia severity (P = .66), years in nursing home before qualification (P = .46), and gender (P = .36) lost their significance. CONCLUSIONS This study confirms high rates of transfer of long-stay nursing home residents, with nearly one-half of the participants experiencing at least 1 ED visit over the course of a year. Although dementia severity is not a predictor of time to ED use in our analyses, other factors that influence ED use are readily identifiable. Nursing home providers should be aware of these factors when developing strategies that meet patient care goals and avoid transfer from the nursing home to the ED.
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Affiliation(s)
- Michael A LaMantia
- Indiana University School of Medicine, Indianapolis, IN; Indiana University Center for Aging Research, Indianapolis, IN; Regenstrief Institute, Inc, Indianapolis, IN.
| | - Kathleen A Lane
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN
| | - Wanzhu Tu
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN
| | - Jennifer L Carnahan
- Indiana University School of Medicine, Indianapolis, IN; Indiana University Center for Aging Research, Indianapolis, IN; Regenstrief Institute, Inc, Indianapolis, IN
| | - Frank Messina
- Indiana University School of Medicine, Indianapolis, IN
| | - Kathleen T Unroe
- Indiana University School of Medicine, Indianapolis, IN; Indiana University Center for Aging Research, Indianapolis, IN; Regenstrief Institute, Inc, Indianapolis, IN
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Stephens C, Halifax E, Bui N, Lee SJ, Harrington C, Shim J, Ritchie C. Provider Perspectives on the Influence of Family on Nursing Home Resident Transfers to the Emergency Department: Crises at the End of Life. Curr Gerontol Geriatr Res 2015; 2015:893062. [PMID: 26379704 PMCID: PMC4561315 DOI: 10.1155/2015/893062] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 08/16/2015] [Indexed: 11/29/2022] Open
Abstract
Background. Nursing home (NH) residents often experience burdensome and unnecessary care transitions, especially towards the end of life. This paper explores provider perspectives on the role that families play in the decision to transfer NH residents to the emergency department (ED). Methods. Multiple stakeholder focus groups (n = 35 participants) were conducted with NH nurses, NH physicians, nurse practitioners, physician assistants, NH administrators, ED nurses, ED physicians, and a hospitalist. Stakeholders described experiences and challenges with NH resident transfers to the ED. Focus group interviews were recorded and transcribed verbatim. Transcripts and field notes were analyzed using a Grounded Theory approach. Findings. Providers perceive that families often play a significant role in ED transfer decisions as they frequently react to a resident change of condition as a crisis. This sense of crisis is driven by 4 main influences: insecurities with NH care; families being unprepared for end of life; absent/inadequate advance care planning; and lack of communication and agreement within families regarding goals of care. Conclusions. Suboptimal communication and lack of access to appropriate and timely palliative care support and expertise in the NH setting may contribute to frequent ED transfers.
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Affiliation(s)
- Caroline Stephens
- Department of Community Health Systems, School of Nursing, University of California, San Francisco, 2 Koret Way, N531E, UCSF Box 0608, San Francisco, CA 94143-0608, USA
| | - Elizabeth Halifax
- Department of Community Health Systems, School of Nursing, University of California, San Francisco, 2 Koret Way, N531E, UCSF Box 0608, San Francisco, CA 94143-0608, USA
| | - Nhat Bui
- Department of Community Health Systems, School of Nursing, University of California, San Francisco, 2 Koret Way, N531E, UCSF Box 0608, San Francisco, CA 94143-0608, USA
| | - Sei J. Lee
- Department of Geriatrics, Palliative & Extended Care, San Francisco VA Medical Center, Division of Geriatrics, School of Medicine, University of California, San Francisco, 4150 Clement Street, Building 1, Room 220F, San Francisco, CA 94121, USA
| | - Charlene Harrington
- Department of Social & Behavioral Sciences, School of Nursing, University of California, San Francisco, 3333 California Street, Suite 455, UCSF Box 0612, San Francisco, CA 94118, USA
| | - Janet Shim
- Department of Social & Behavioral Sciences, School of Nursing, University of California, San Francisco, 3333 California Street, Suite 455, UCSF Box 0612, San Francisco, CA 94118, USA
| | - Christine Ritchie
- Division of Geriatrics, School of Medicine, University of California, San Francisco, 3333 California Street, Suite 380, San Francisco, CA 94143-1265, USA
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Suffoletto B, Miller T, Shah R, Callaway C, Yealy DM. Predicting older adults who return to the hospital or die within 30 days of emergency department care using the ISAR tool: subjective versus objective risk factors. Emerg Med J 2015; 33:4-9. [DOI: 10.1136/emermed-2014-203936] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 04/27/2015] [Indexed: 11/03/2022]
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Burke RE, Rooks SP, Levy C, Schwartz R, Ginde AA. Identifying Potentially Preventable Emergency Department Visits by Nursing Home Residents in the United States. J Am Med Dir Assoc 2015; 16:395-9. [PMID: 25703449 DOI: 10.1016/j.jamda.2015.01.076] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 12/26/2014] [Accepted: 01/06/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To identify and describe potentially preventable emergency department (ED) visits by nursing home (NH) residents in the United States. These visits are important because they are common, frequently lead to hospitalization, and can be associated with significant cost to the patient and the health care system. DESIGN Retrospective analysis of the 2005-2010 National Hospital Ambulatory Care Survey (NHAMCS), comparing ED visits by nursing home residents that did not lead to hospital admission (potentially preventable) with those that led to admission (less likely preventable). SETTING Nationally representative sample of US EDs; federal hospitals and hospitals with fewer than 6 beds were excluded. PARTICIPANTS Older (age ≥65 years) NH residents with an ED visit during this time period. MEASUREMENTS Patient demographics, ED visit information including testing performed, interventions (both procedures and medications) provided, and diagnoses treated. RESULTS Older NH residents accounted for 3857 of 208,956 ED visits during the time period of interest (1.8%). When weighted to be nationally representative, these represent 13.97 million ED visits, equivalent to 1.8 ED visits annually per NH resident in the United States. More than half of visits (53.5%) did not lead to hospital admission; of those discharged from the ED, 62.8% had normal vital signs on presentation and 18.9% did not have any diagnostic testing before ED discharge. Injuries were 1.78 times more likely to be discharged than admitted (44.8% versus 25.3%, respectively, P < .001), whereas infections were 2.06 times as likely to be admitted as discharged (22.9% versus 11.1%, respectively). Computed tomography (CT) scans were performed in 25.4% and 30.1% of older NH residents who were discharged from the ED and admitted to the hospital, respectively, and more than 70% of these were CTs of the head. NH residents received centrally acting, sedating medications before ED discharge in 9.4% of visits. CONCLUSION This nationally representative sample of older NH residents suggests ED visits for injury, those that are associated with normal triage vital signs, and those that are not associated with any diagnostic testing are potentially preventable. Those discharged from the ED often undergo important testing and receive medications that may alter their physical examination on return to the nursing facility, highlighting the need for seamless communication of the ED course to NHs.
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Affiliation(s)
- Robert E Burke
- Department of Veterans Affairs Medical Center, Eastern Colorado Health Care System, Denver, CO; Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Denver, CO.
| | - Sean P Rooks
- University of Texas Health Science Center, San Antonio School of Medicine, San Antonio, TX
| | - Cari Levy
- Division of Health Care Policy and Research, University of Colorado School of Medicine, Denver, CO
| | - Robert Schwartz
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Denver, CO
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Denver, CO
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Kotagal V, Langa KM, Plassman BL, Fisher GG, Giordani BJ, Wallace RB, Burke JR, Steffens DC, Kabeto M, Albin RL, Foster NL. Factors associated with cognitive evaluations in the United States. Neurology 2014; 84:64-71. [PMID: 25428689 DOI: 10.1212/wnl.0000000000001096] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We aimed to explore factors associated with clinical evaluations for cognitive impairment among older residents of the United States. METHODS Two hundred ninety-seven of 845 subjects in the Aging, Demographics, and Memory Study (ADAMS), a nationally representative community-based cohort study, met criteria for dementia after a detailed in-person study examination. Informants for these subjects reported whether or not they had ever received a clinical cognitive evaluation outside of the context of ADAMS. Among subjects with dementia, we evaluated demographic, socioeconomic, and clinical factors associated with an informant-reported clinical cognitive evaluation using bivariate analyses and multivariable logistic regression. RESULTS Of the 297 participants with dementia in ADAMS, 55.2% (representing about 1.8 million elderly Americans in 2002) reported no history of a clinical cognitive evaluation by a physician. In a multivariable logistic regression model (n = 297) controlling for demographics, physical function measures, and dementia severity, marital status (odds ratio for currently married: 2.63 [95% confidence interval: 1.10-6.35]) was the only significant independent predictor of receiving a clinical cognitive evaluation among subjects with study-confirmed dementia. CONCLUSIONS Many elderly individuals with dementia do not receive clinical cognitive evaluations. The likelihood of receiving a clinical cognitive evaluation in elderly individuals with dementia associates with certain patient-specific factors, particularly severity of cognitive impairment and current marital status.
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Affiliation(s)
- Vikas Kotagal
- From the Departments of Neurology (V.K., B.J.G., R.L.A.), Internal Medicine (K.M.L., M.K.), Psychiatry (B.J.G.), and Psychology (B.J.G.), University of Michigan, Ann Arbor; Departments of Psychiatry (B.L.P.) and Neurology (J.R.B.), Duke University Medical Center, Durham, NC; Department of Psychology (G.G.F.), Colorado State University, Fort Collins; Department of Epidemiology (R.B.W.), University of Iowa, Iowa City; Department of Psychiatry (D.C.S.), University of Connecticut Health Center, Farmington; and Department of Neurology (N.L.F.), University of Utah, Salt Lake City.
| | - Kenneth M Langa
- From the Departments of Neurology (V.K., B.J.G., R.L.A.), Internal Medicine (K.M.L., M.K.), Psychiatry (B.J.G.), and Psychology (B.J.G.), University of Michigan, Ann Arbor; Departments of Psychiatry (B.L.P.) and Neurology (J.R.B.), Duke University Medical Center, Durham, NC; Department of Psychology (G.G.F.), Colorado State University, Fort Collins; Department of Epidemiology (R.B.W.), University of Iowa, Iowa City; Department of Psychiatry (D.C.S.), University of Connecticut Health Center, Farmington; and Department of Neurology (N.L.F.), University of Utah, Salt Lake City
| | - Brenda L Plassman
- From the Departments of Neurology (V.K., B.J.G., R.L.A.), Internal Medicine (K.M.L., M.K.), Psychiatry (B.J.G.), and Psychology (B.J.G.), University of Michigan, Ann Arbor; Departments of Psychiatry (B.L.P.) and Neurology (J.R.B.), Duke University Medical Center, Durham, NC; Department of Psychology (G.G.F.), Colorado State University, Fort Collins; Department of Epidemiology (R.B.W.), University of Iowa, Iowa City; Department of Psychiatry (D.C.S.), University of Connecticut Health Center, Farmington; and Department of Neurology (N.L.F.), University of Utah, Salt Lake City
| | - Gwenith G Fisher
- From the Departments of Neurology (V.K., B.J.G., R.L.A.), Internal Medicine (K.M.L., M.K.), Psychiatry (B.J.G.), and Psychology (B.J.G.), University of Michigan, Ann Arbor; Departments of Psychiatry (B.L.P.) and Neurology (J.R.B.), Duke University Medical Center, Durham, NC; Department of Psychology (G.G.F.), Colorado State University, Fort Collins; Department of Epidemiology (R.B.W.), University of Iowa, Iowa City; Department of Psychiatry (D.C.S.), University of Connecticut Health Center, Farmington; and Department of Neurology (N.L.F.), University of Utah, Salt Lake City
| | - Bruno J Giordani
- From the Departments of Neurology (V.K., B.J.G., R.L.A.), Internal Medicine (K.M.L., M.K.), Psychiatry (B.J.G.), and Psychology (B.J.G.), University of Michigan, Ann Arbor; Departments of Psychiatry (B.L.P.) and Neurology (J.R.B.), Duke University Medical Center, Durham, NC; Department of Psychology (G.G.F.), Colorado State University, Fort Collins; Department of Epidemiology (R.B.W.), University of Iowa, Iowa City; Department of Psychiatry (D.C.S.), University of Connecticut Health Center, Farmington; and Department of Neurology (N.L.F.), University of Utah, Salt Lake City
| | - Robert B Wallace
- From the Departments of Neurology (V.K., B.J.G., R.L.A.), Internal Medicine (K.M.L., M.K.), Psychiatry (B.J.G.), and Psychology (B.J.G.), University of Michigan, Ann Arbor; Departments of Psychiatry (B.L.P.) and Neurology (J.R.B.), Duke University Medical Center, Durham, NC; Department of Psychology (G.G.F.), Colorado State University, Fort Collins; Department of Epidemiology (R.B.W.), University of Iowa, Iowa City; Department of Psychiatry (D.C.S.), University of Connecticut Health Center, Farmington; and Department of Neurology (N.L.F.), University of Utah, Salt Lake City
| | - James R Burke
- From the Departments of Neurology (V.K., B.J.G., R.L.A.), Internal Medicine (K.M.L., M.K.), Psychiatry (B.J.G.), and Psychology (B.J.G.), University of Michigan, Ann Arbor; Departments of Psychiatry (B.L.P.) and Neurology (J.R.B.), Duke University Medical Center, Durham, NC; Department of Psychology (G.G.F.), Colorado State University, Fort Collins; Department of Epidemiology (R.B.W.), University of Iowa, Iowa City; Department of Psychiatry (D.C.S.), University of Connecticut Health Center, Farmington; and Department of Neurology (N.L.F.), University of Utah, Salt Lake City
| | - David C Steffens
- From the Departments of Neurology (V.K., B.J.G., R.L.A.), Internal Medicine (K.M.L., M.K.), Psychiatry (B.J.G.), and Psychology (B.J.G.), University of Michigan, Ann Arbor; Departments of Psychiatry (B.L.P.) and Neurology (J.R.B.), Duke University Medical Center, Durham, NC; Department of Psychology (G.G.F.), Colorado State University, Fort Collins; Department of Epidemiology (R.B.W.), University of Iowa, Iowa City; Department of Psychiatry (D.C.S.), University of Connecticut Health Center, Farmington; and Department of Neurology (N.L.F.), University of Utah, Salt Lake City
| | - Mohammed Kabeto
- From the Departments of Neurology (V.K., B.J.G., R.L.A.), Internal Medicine (K.M.L., M.K.), Psychiatry (B.J.G.), and Psychology (B.J.G.), University of Michigan, Ann Arbor; Departments of Psychiatry (B.L.P.) and Neurology (J.R.B.), Duke University Medical Center, Durham, NC; Department of Psychology (G.G.F.), Colorado State University, Fort Collins; Department of Epidemiology (R.B.W.), University of Iowa, Iowa City; Department of Psychiatry (D.C.S.), University of Connecticut Health Center, Farmington; and Department of Neurology (N.L.F.), University of Utah, Salt Lake City
| | - Roger L Albin
- From the Departments of Neurology (V.K., B.J.G., R.L.A.), Internal Medicine (K.M.L., M.K.), Psychiatry (B.J.G.), and Psychology (B.J.G.), University of Michigan, Ann Arbor; Departments of Psychiatry (B.L.P.) and Neurology (J.R.B.), Duke University Medical Center, Durham, NC; Department of Psychology (G.G.F.), Colorado State University, Fort Collins; Department of Epidemiology (R.B.W.), University of Iowa, Iowa City; Department of Psychiatry (D.C.S.), University of Connecticut Health Center, Farmington; and Department of Neurology (N.L.F.), University of Utah, Salt Lake City
| | - Norman L Foster
- From the Departments of Neurology (V.K., B.J.G., R.L.A.), Internal Medicine (K.M.L., M.K.), Psychiatry (B.J.G.), and Psychology (B.J.G.), University of Michigan, Ann Arbor; Departments of Psychiatry (B.L.P.) and Neurology (J.R.B.), Duke University Medical Center, Durham, NC; Department of Psychology (G.G.F.), Colorado State University, Fort Collins; Department of Epidemiology (R.B.W.), University of Iowa, Iowa City; Department of Psychiatry (D.C.S.), University of Connecticut Health Center, Farmington; and Department of Neurology (N.L.F.), University of Utah, Salt Lake City
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Brinkman-Stoppelenburg A, Rietjens JAC, van der Heide A. The effects of advance care planning on end-of-life care: a systematic review. Palliat Med 2014; 28:1000-25. [PMID: 24651708 DOI: 10.1177/0269216314526272] [Citation(s) in RCA: 880] [Impact Index Per Article: 88.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Advance care planning is the process of discussing and recording patient preferences concerning goals of care for patients who may lose capacity or communication ability in the future. Advance care planning could potentially improve end-of-life care, but the methods/tools used are varied and of uncertain benefit. Outcome measures used in existing studies are highly variable. AIM To present an overview of studies on the effects of advance care planning and gain insight in the effectiveness of different types of advance care planning. DESIGN Systematic review. DATA SOURCES We systematically searched PubMed, EMBASE and PsycINFO databases for experimental and observational studies on the effects of advance care planning published in 2000-2012. RESULTS The search yielded 3571 papers, of which 113 were relevant for this review. For each study, the level of evidence was graded. Most studies were observational (95%), originated from the United States (81%) and were performed in hospitals (49%) or nursing homes (32%). Do-not-resuscitate orders (39%) and written advance directives (34%) were most often studied. Advance care planning was often found to decrease life-sustaining treatment, increase use of hospice and palliative care and prevent hospitalisation. Complex advance care planning interventions seem to increase compliance with patients' end-of-life wishes. CONCLUSION The effects of different types of advance care planning have been studied in various settings and populations using different outcome measures. There is evidence that advance care planning positively impacts the quality of end-of-life care. Complex advance care planning interventions may be more effective in meeting patients' preferences than written documents alone. More studies are needed with an experimental design, in different settings, including the community.
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Affiliation(s)
| | - Judith A C Rietjens
- Department of Public Health, Erasmus University Medical Center (Erasmus MC), Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus University Medical Center (Erasmus MC), Rotterdam, The Netherlands
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Amador S, Goodman C, King D, Machen I, Elmore N, Mathie E, Iliffe S. Emergency ambulance service involvement with residential care homes in the support of older people with dementia: an observational study. BMC Geriatr 2014; 14:95. [PMID: 25164581 PMCID: PMC4154936 DOI: 10.1186/1471-2318-14-95] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 08/19/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Older people resident in care homes have a limited life expectancy and approximately two-thirds have limited mental capacity. Despite initiatives to reduce unplanned hospital admissions for this population, little is known about the involvement of emergency services in supporting residents in these settings. METHODS This paper reports on a longitudinal study that tracked the involvement of emergency ambulance personnel in the support of older people with dementia, resident in care homes with no on-site nursing providing personal care only. 133 residents with dementia across 6 care homes in the East of England were tracked for a year. The paper examines the frequency and reasons for emergency ambulance call-outs, outcomes and factors associated with emergency ambulance service use. RESULTS 56% of residents used ambulance services. Less than half (43%) of all call-outs resulted in an unscheduled admission to hospital. In addition to trauma following a following a fall in the home, results suggest that at least a reasonable proportion of ambulance contacts are for ambulatory care sensitive conditions. An emergency ambulance is not likely to be called for older rather than younger residents or for women more than men. Length of residence does not influence use of emergency ambulance services among older people with dementia. Contact with primary care services and admission route into the care home were both significantly associated with emergency ambulance service use. The odds of using emergency ambulance services for residents admitted from a relative's home were 90% lower than the odds of using emergency ambulance services for residents admitted from their own home. CONCLUSIONS Emergency service involvement with this vulnerable population merits further examination. Future research on emergency ambulance service use by older people with dementia in care homes, should account for important contextual factors, namely, presence or absence of on-site nursing, GP involvement, and access to residents' family, alongside resident health characteristics.
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Affiliation(s)
| | - Claire Goodman
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield AL109AB, UK.
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Stephens CE, Newcomer R, Blegen M, Miller B, Harrington C. The effects of cognitive impairment on nursing home residents' emergency department visits and hospitalizations. Alzheimers Dement 2014; 10:835-43. [PMID: 25028060 DOI: 10.1016/j.jalz.2014.03.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Revised: 03/13/2014] [Accepted: 03/31/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Little is known about the relationship of cognitive impairment (CI) in nursing home (NH) residents and their use of emergency department (ED) and subsequent hospital services. METHODS We analyzed 2006 Medicare claims and resident assessment data for 112,412 Medicare beneficiaries aged >65 years residing in US nursing facilities. We estimated the effect of resident characteristics and severity of CI on rates of total ED visits per year, then estimated the odds of hospitalization after ED evaluation. RESULTS Mild CI predicted higher rates of ED visits relative to no CI, and ED visit rates decreased as severity of CI increased. In unadjusted models, mild CI and very severe CI predicted higher odds of hospitalization after ED evaluation; however, after adjusting for other factors, severity of CI was not significant. CONCLUSIONS Higher rates of ED visits among those with mild CI may represent a unique marker in the presentation of acute illness and warrant further investigation.
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Affiliation(s)
- Caroline E Stephens
- Department of Community Health Systems, UCSF School of Nursing, San Francisco, CA, USA; Department of Social & Behavioral Sciences, UCSF School of Nursing, San Francisco, CA, USA.
| | - Robert Newcomer
- Department of Social & Behavioral Sciences, UCSF School of Nursing, San Francisco, CA, USA
| | - Mary Blegen
- Department of Community Health Systems, UCSF School of Nursing, San Francisco, CA, USA
| | - Bruce Miller
- Department of Neurology, UCSF School of Medicine, San Francisco, CA, USA
| | - Charlene Harrington
- Department of Social & Behavioral Sciences, UCSF School of Nursing, San Francisco, CA, USA
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26
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Stephens CE, Sackett N, Govindarajan P, Lee SJ. Emergency department visits and hospitalizations by tube-fed nursing home residents with varying degrees of cognitive impairment: a national study. BMC Geriatr 2014; 14:35. [PMID: 24650076 PMCID: PMC3994482 DOI: 10.1186/1471-2318-14-35] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 03/07/2014] [Indexed: 11/24/2022] Open
Abstract
Background Numerous studies indicate that the use of feeding tubes (FT) in persons with advanced cognitive impairment (CI) does not improve clinical outcomes or survival, and results in higher rates of hospitalization and emergency department (ED) visits. It is not clear, however, whether such risk varies by resident level of CI and whether these ED visits and hospitalizations are potentially preventable. The objective of this study was to determine the rates of ED visits, hospitalizations and potentially preventable ambulatory care sensitive (ACS) ED visits and ACS hospitalizations for long-stay NH residents with FTs at differing levels of CI. Methods We linked Centers for Medicare and Medicaid Services inpatient & outpatient administrative claims and beneficiary eligibility data with Minimum Data Set (MDS) resident assessment data for nursing home residents with feeding tubes in a 5% random sample of Medicare beneficiaries residing in US nursing facilities in 2006 (n = 3479). Severity of CI was measured using the Cognitive Performance Scale (CPS) and categorized into 4 groups: None/Mild (CPS = 0-1, MMSE = 22-25), Moderate (CPS = 2-3, MMSE = 15-19), Severe (CPS = 4-5, MMSE = 5-7) and Very Severe (CPS = 6, MMSE = 0-4). ED visits, hospitalizations, ACS ED visits and ACS hospitalizations were ascertained from inpatient and outpatient administrative claims. We estimated the risk ratio of each outcome by CI level using over-dispersed Poisson models accounting for potential confounding factors. Results Twenty-nine percent of our cohort was considered “comatose” and “without any discernible consciousness”, suggesting that over 20,000 NH residents in the US with feeding tubes are non-interactive. Approximately 25% of NH residents with FTs required an ED visit or hospitalization, with 44% of hospitalizations and 24% of ED visits being potentially preventable or for an ACS condition. Severity of CI had a significant effect on rates of ACS ED visits, but little effect on ACS hospitalizations. Conclusions ED visits and hospitalizations are common in cognitively impaired tube-fed nursing home residents and a substantial proportion of ED visits and hospitalizations are potentially preventable due to ACS conditions.
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Affiliation(s)
- Caroline E Stephens
- Department of Community Health Systems, University of California San Francisco, 2 Koret Way, #N531E, San Francisco, CA 94143-0608, USA.
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de Souto Barreto P, Lapeyre-Mestre M, Mathieu C, Piau C, Bouget C, Cayla F, Vellas B, Rolland Y. The Nursing Home Effect: A Case Study of Residents With Potential Dementia and Emergency Department Visits. J Am Med Dir Assoc 2013; 14:901-5. [DOI: 10.1016/j.jamda.2013.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Revised: 08/09/2013] [Accepted: 08/12/2013] [Indexed: 02/02/2023]
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Nelson D, Washton D, Jeanmonod R. Communication gaps in nursing home transfers to the ED: impact on turnaround time, disposition, and diagnostic testing. Am J Emerg Med 2013; 31:712-6. [DOI: 10.1016/j.ajem.2012.11.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 11/26/2012] [Accepted: 11/27/2012] [Indexed: 11/17/2022] Open
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Hsiao CJ, Hing E. Emergency Department Visits and Resulting Hospitalizations by Elderly Nursing Home Residents, 2001–2008. Res Aging 2013; 36:207-27. [DOI: 10.1177/0164027512473488] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
This study examines emergency department (ED) visits by nursing home (NH) residents aged 65 and over, and factors associated with hospital admission from the ED visit using data from the 2001–2008 National Hospital Ambulatory Medical Care Survey. Cross-sectional analyses were conducted on patient characteristics, diagnosis, procedures received, and triage status. On average, elderly NH residents visited EDs at a rate of 123 visits per 100 institutionalized persons. Nearly 15% of all ED visits had ambulatory care sensitive condition diagnoses. Nearly half of these visits resulted in hospital admission; chronic obstructive pulmonary disease, congestive heart failure, kidney/urinary tract infection, and dehydration were associated with higher odds of admission. Previous studies suggested that adequate medical staffing and appropriate care in the NH could reduce ED visits and hospital admissions. Recent initiatives seek to reduce ED visits and hospitalizations by providing financial incentives to spur better coordination between NH and hospital.
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Affiliation(s)
- Chun-Ju Hsiao
- National Center for Health Statistics, Hyattsville, MD, USA
| | - Esther Hing
- National Center for Health Statistics, Hyattsville, MD, USA
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Ouslander JG, Maslow K. Geriatrics and the triple aim: defining preventable hospitalizations in the long-term care population. J Am Geriatr Soc 2012. [PMID: 23194066 DOI: 10.1111/jgs.12002] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Reducing preventable hospitalizations is fundamental to the "triple aim" of improving care, improving health, and reducing costs. New federal government initiatives that create strong pressure to reduce such hospitalizations are being or will soon be implemented. These initiatives use quality measures to define which hospitalizations are preventable. Reducing hospitalizations could greatly benefit frail and chronically ill adults and older people who receive long-term care (LTC) because they often experience negative effects of hospitalization, including hospital-acquired conditions, morbidity, and loss of functional abilities. Conversely, reducing hospitalizations could mean that some people will not receive hospital care they need, especially if the selected measures do not adequately define hospitalizations that can be prevented without jeopardizing the person's health and safety. An extensive literature search identified 250 measures of preventable hospitalizations, but the measures have not been validated in the LTC population and generally do not account for comorbidity or the capacity of various LTC settings to provide the required care without hospitalization. Additional efforts are needed to develop measures that accurately differentiate preventable from necessary hospitalizations for the LTC population, are transparent and fair to providers, and minimize the potential for gaming and unintended consequences. As the new initiatives take effect, it is critical to monitor their effect and to develop and disseminate training and resources to support the many community- and institution-based healthcare professionals and emergency department staff involved in decisions about hospitalization for this population.
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Affiliation(s)
- Joseph G Ouslander
- Charles E Schmidt College of Medicine and Christine E Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida 33431, USA.
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