In-hospital interventions for reducing readmissions to acute care for adults aged 65 and over: An umbrella review

Nurses' Roles, Responsibilities and Actions in the Hospital Discharge Process of Older Adults with Health and Social Care Needs in Three Nordic Cities: A Vignette Study

The hospital discharge process of older adults in need of both medical and social care post hospitalisation requires the involvement of nurses at multiple levels across the different phases. This study aims to examine and compare what roles, responsibilities and actions nurses take in the hospital discharge process of older adults with complex care needs in three Nordic cities: Copenhagen (Denmark), Stockholm (Sweden) and Tampere (Finland). A vignette-based interview study consisting of three cases was conducted face-to-face with nurses in Copenhagen (n = 11), Stockholm (n = 16) and Tampere (n = 8). The vignettes represented older patients with medical conditions, cognitive loss and various home situations. The interviews were conducted in the local language, recorded, transcribed and analysed thematically. The findings show that nurses exchanged information with both healthcare (all cities) and social care services (Copenhagen, Tampere). Nurses in all cities, particularly Stockholm, reported to inform, and also convince patients to make use of home care. Nurses in Stockholm and Tampere reported that some patients refuse care due to co-payment. Nurses in these two cities were more likely to involve close relatives, possibly due to such costs. Not accepting care, due to costs, poses inequity in later life. Additionally, organisational changes towards a shift in location of care, i.e., from hospital to home, and from professional to informal caregivers, might be reflected in the work of the nurses through their initiatives to convince older patients to accept home care and to involve close relatives.

Interventions to Reduce Hospital Readmissions in Older African Americans: A Systematic Review of Studies Including African American Patients

OBJECTIVES

This systematic review aims to summarize interventions that effectively reduced hospital readmission rates for African Americans (AAs) aged 65 and older.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed for this review. Studies were identified by searching PubMed for clinical trials on reducing hospital readmission among older patients published between 1 January 1990 and 31 January 2020. Eligibility criteria for the included studies were mean or median age ≥ 65 years, AAs included in the study, randomized clinical trial or quasi-experimental design, presence of an intervention, and hospital readmission as an outcome.

RESULTS

There were 5270 articles identified and 11 were included in the final review based on eligibility criteria. The majority of studies were conducted in academic centers, were multi-center trials, and included over 200 patients, and 6-90% of participants were older AAs. The length of intervention ranged from 1 week to over a year, with readmission assessed between 30 days and 1 year. Four studies which reported interventions that significantly reduced readmissions included both inpatient (e.g., discharge planning prior to discharge) and outpatient care components (e.g., follow-ups after discharge), and the majority used a multifaceted approach.

CONCLUSION

Findings from the review suggest successful interventions to reduce readmissions among AAs aged 65 and older should include inpatient and outpatient care components at a minimum. This systematic review showed limited evidence of interventions successfully decreasing readmission in older AAs, suggesting a need for research in the area to reduce readmission disparities and improve overall health.

Assessment of drug-related problems at the emergency department in older patients living with frailty: pharmacist-led medication reviews within a geriatric care team

BACKGROUND

Older patients are vulnerable to experiencing drug related problems (DRPs), which may result in emergency department (ED) visits. However, it is not standard practice to conduct medications reviews during ED visit. The aim of this study was to assess the number of DRPs in older patients living with frailty at the ED, identified through pharmacist-led medication reviews within a geriatric care team, and to determine the acceptance rate of pharmacists' recommendations among hospital physicians and general practitioners or elderly care specialists.

METHODS

A retrospective observational study was performed in patients ≥ 70 years living with frailty at the ED at Tergooi Medical Center. Pharmacist-led medication reviews were conducted to identify and classify DRPs as part of a larger geriatric assessment. The acceptance rate of given recommendations was determined during follow-up.

RESULTS

A total of 356 ED visits were included. The mean (standard deviation, SD) age of patients was 83 (6.8) years. About 76% of patients had at least one DRP. In total, 548 DRPs were identified with a mean of 1.5 DRP (SD 1.3) per patient. The acceptance rate of medication recommendations in admitted patients was 55%, and 32% among general practitioners/elderly care specialists in discharged patients.

CONCLUSIONS

Pharmacist-led medication reviews as part of a geriatric care team identified DRPs in 76% of older patients living with frailty at the ED. The acceptance rate was substantially higher in admitted patients compared to discharged patients.

Why reducing avoidable hospital readmissions is a 'wicked' problem for leaders: A qualitative exploration of nursing and allied health perceptions

AIMS

To investigate nursing and allied health professional perceptions of the interrelationship between avoidable hospital readmissions and fundamental care delivery.

DESIGN

A qualitative, exploratory study using a critical realist approach.

METHOD

One-to-one semi-structured interviews with 14 nursing and allied health professionals conducted between May and September 2019.

RESULTS

Several tensions and contradictions were identified in the data, which demonstrated clinicians' perceptions about the priority of both fundamental care and two avoidable readmission conditions (aspiration pneumonia and constipation). These tensions are illustrated in two major themes: Avoidable versus inevitable; and everyone versus no one. The first theme demonstrates clinicians' perceptions that readmissions for aspiration pneumonia and constipation are not common, despite acknowledging that they generally lacked knowledge on readmission rates; and that these conditions may not be preventable in acute settings. The second theme demonstrates clinicians' perception that preventing readmissions is everyone's responsibility, however, this was coupled with a lack of articulation around how this multidisciplinary approach could be achieved, leading to a distinct lack of agency for care delivery.

CONCLUSION

Articulating the tensions described in the results provides vital knowledge for understanding how clinicians may respond to initiatives designed to reduce avoidable readmissions. Avoidable hospital readmissions may be usefully understood as a wicked problem: one that is complex and requires adaptive, not linear, solutions. Wicked problems pose a challenge for leaders and managers in healthcare because top-down, hierarchical strategies are unlikely to be successful. Effective prevention of avoidable readmissions requires leaders to enable facilitator-led change through relational leadership strategies.

IMPACT

Avoidable hospital readmissions are a global problem increasingly addressed via funding changes and the introduction of penalties to hospitals. This study provides insights on clinicians' perspectives of avoidable hospital readmissions and their prevention, demonstrating the complexity of this challenge and the need for healthcare leaders to enable individual and organizational readiness for change.

Readmission Reduction as a Hospital Quality Measure: Time to Move on to More Pressing Concerns?

The authors of this Viewpoint argue that the focus on hospital readmission rates as a measure of quality during the past decade, although undoubtedly leading to some improvements in care, has had minimal demonstrable benefit and has even distracted clinicians and health system leaders from other crucial quality concerns.

The effectiveness of interventions to reduce adverse outcomes among older adults following Emergency Department discharge: umbrella review

BACKGROUND

Population ageing is increasing rapidly worldwide. Older adults are frequent users of health care services including the Emergency Department (ED) and experience a number of adverse outcomes following an ED visit. Adverse outcomes include functional decline, unplanned hospital admission and an ED revisit. Given these adverse outcomes a number of interventions have been examined to improve the outcomes of older adults following presentation to the ED. The aim of this umbrella review was to evaluate the effectiveness of ED interventions in reducing adverse outcomes in older adults discharged from the ED.

METHODS

Systematic reviews of randomised controlled trials investigating ED interventions for older adults presenting to the ED exploring clinical, patient experience and healthcare utilisation outcomes were included. A comprehensive search strategy was employed in eleven databases and the PROSPERO register up until June 2020. Grey literature was also searched. Quality was assessed using the A MeaSurement Tool to Assess Systematic Reviews 2 tool. Overlap between systematic reviews was assessed using a matrix of evidence table. An algorithm to assign the Grading of Recommendations Assessment, Development and Evaluation to assess the strength of evidence was applied for all outcomes.

RESULTS

Nine systematic reviews including 29 randomised controlled trials were included. Interventions comprised of solely ED-based or transitional interventions. The specific interventions delivered were highly variable. There was high overlap and low methodological quality of the trials informing the systematic reviews. There is low quality evidence to support ED interventions in reducing functional decline, improving patient experience and improving quality of life. The quality of evidence of the effectiveness of ED interventions to reduce mortality and ED revisits varied from very low to moderate. Results were presented narratively and summary of evidence tables created.

CONCLUSION

Older adults are the most important emerging group in healthcare for several economic, social and political reasons. The existing evidence for the effectiveness of ED interventions for older adults is limited. This umbrella review highlights the challenge of synthesising evidence due to significant heterogeneity in methods, intervention content and reporting of outcomes. Higher quality intervention studies in line with current geriatric medicine research guidelines are recommended, rather than the publication of further systematic reviews.

TRIAL REGISTRATION

UMBRELLA REVIEW REGISTRATION: PROSPERO ( CRD42020145315 ).

Geriatric co-management and interdisciplinary transitional care reduced hospital readmissions in frail older patients in Argentina: results from a randomized controlled trial

BACKGROUND

Hospitalization is a moment of extreme vulnerability for frail older adults. There is scarce evidence on the effectiveness of geriatric co-management or transitional care interventions in Latin America.

AIMS

To assess whether geriatric co-management combined with an interdisciplinary transitional care intervention could reduce 30-day hospital readmission rate compared to usual care in hospitalized frail older patients in a tertiary hospital in Argentina.

METHODS

Single-blinded randomized controlled trial. Usual care treatment arm: all procedures performed during hospitalization were overseen by a senior internal medicine specialist and complied with pre-defined protocols. Patients had access to specialist care if needed, as well as hospital-at-home or home-based primary care services after discharge. Intervention treatment arm: in addition to usual care, a geriatric co-management team performed a comprehensive geriatric assessment during hospitalization, provided tailored recommendations to minimize geriatric syndromes and planned transition of care. A health and social care counselor oversaw continuity of care in patients' homes after discharge.

RESULTS

We included 120 participants in each of the intervention and usual care (control) arms. Thirty-day hospital readmissions were 47.7% lower in the intervention arm (18.3% vs 35.0%; P = 0.040); and emergency room visits within the first 6 months after discharge were 27.8% lower (43.3% vs 60.0%; P = 0.010). There was a non-statistically significant decrease in 6-month mortality in the intervention arm (25.0% vs 35.0%; P = 0.124).

CONCLUSION

Geriatric co-management of frail older patients during hospitalization combined with an interdisciplinary transitional care intervention reduced 30-day hospital readmissions and emergency visits 6 months after discharge.

TRIAL REGISTRATION NUMBER

Trial registration number: RENIS IS003081.

Effects of a new early municipality-based versus a geriatric team-based transitional care intervention on readmission and mortality among frail older patients - a randomised controlled trial

Purpose Previous studies reported reduced risk of readmission, mortality and shorter length of hospital stay (LOS) among geriatric patients receiving an early (<24h), hospital-based geriatric team intervention after discharge. The objective of this study was to compare a novel, early municipality-based, nurse-led and general practitioner (GP)-supported transitional care intervention (TCI) to an established hospital-based TCI among frail, older, geriatric patients. Material and methods A randomised controlled trial was conducted within a single geriatric department and the adjacent municipality. Inclusion criteria: acutely admitted, frail patients 75+ years old. Eligible patients were randomly allocated (1:1) to the two TCIs. Primary outcome was 30-day unplanned readmission. Secondary outcomes were 90-day all-cause mortality and LOS. Stratified analysis according to type of dwelling was made. Odds ratios (OR) with 95% confidence intervals (CI), and number needed to treat (NNT) were reported. Results 3,103 patients (median age (IQR): 85 (80-90); 57% female) were included. Readmission rates were 22% in the municipality-based intervention (n=332/1,545), and 18% in the hospital-based intervention (n=276/1,558); OR was 1.27, 95% CI (1.06-1.52), p=0.008 and NNT=27. OR for cohabiting patients was 1.47, 95% CI (1.02-2.08); p=0.035. No significant difference was observed in mortality (22% vs. 21%; OR=1.05, 95% CI (0.89-1.25), p=0.577) or LOS (median (IQR): 6 (2-8) vs. 6 (2-8) days, p=0.1787). Conclusions The new municipality-based, nurse-led and GP-supported intervention was inferior to the hospital-based geriatric team intervention in preventing 30-day readmission among frail, geriatric patients. There was no significant difference between the two interventions in regard to 90-day mortality or LOS.

LACE Score-Based Risk Management Tool for Long-Term Home Care Patients: A Proof-of-Concept Study in Taiwan

Background: Effectively predicting and reducing readmission in long-term home care (LTHC) is challenging. We proposed, validated, and evaluated a risk management tool that stratifies LTHC patients by LACE predictive score for readmission risk, which can further help home care providers intervene with individualized preventive plans. Method: A before-and-after study was conducted by a LTHC unit in Taiwan. Patients with acute hospitalization within 30 days after discharge in the unit were enrolled as two cohorts (Pre-Implement cohort in 2017 and Post-Implement cohort in 2019). LACE score performance was evaluated by calibration and discrimination (AUC, area under receiver operator characteristic (ROC) curve). The clinical utility was evaluated by negative predictive value (NPV). Results: There were 48 patients with 87 acute hospitalizations in Pre-Implement cohort, and 132 patients with 179 hospitalizations in Post-Implement cohort. These LTHC patients were of older age, mostly intubated, and had more comorbidities. There was a significant reduction in readmission rate by 44.7% (readmission rate 25.3% vs. 14.0% in both cohorts). Although LACE score predictive model still has room for improvement (AUC = 0.598), it showed the potential as a useful screening tool (NPV, 87.9%; 95% C.I., 74.2–94.8). The reduction effect is more pronounced in infection-related readmission. Conclusion: As real-world evidence, LACE score-based risk management tool significantly reduced readmission by 44.7% in this LTHC unit. Larger scale studies involving multiple homecare units are needed to assess the generalizability of this study.