Predictive validity of the Pra instrument among older recipients of managed care

Individualized prediction of critical illness in older adults: Validation of an elders risk assessment model

BACKGROUND

The electronic health record (EHR) presents new opportunities for the timely identification of patients at high risk of critical illness and the implementation of preventive strategies. This study aims to externally validate an EHR-based Elders Risk Assessment (ERA) score to identify older patients at high risk of future critical illness during a primary care visit.

METHODS

This historical cohort study included patients aged ≥65 years who had primary care visits at Mayo Clinic Rochester, MN, between July 2019 and December 2021. The ERA score at the time of the primary care visit was used to predict critical illness, defined as death or ICU admission within 1 year of the visit.

RESULTS

A total of 12,885 patients were included in the analysis. The median age at the time of the primary care visit was 75 years, with 44.6% being male. 93.7% of participants were White, and 64.2% were married. The median (25th, 75th percentile) ERA score was 4 (0, 9). 11.3% of study participants were admitted to the ICU or died within 1 year of the visit. The ERA score predicted critical illness within 1 year of a primary care visit with an area under the receiver operating characteristic curve of 0.84 (95% CI 0.83-0.85), which indicates good discrimination. An ERA score of 9 was identified as optimal for implementing and testing potential preventive strategies, with the odds ratio of having the primary outcome in patients with ERA score ≥9 being 11.33 (95%CI 9.98-12.87).

CONCLUSIONS

This simple EHR-based risk assessment model can predict critical illness within 1 year of primary care visits in older patients. The findings of this study can serve as a basis for testing and implementation of preventive strategies to promote the well-being of older adults at risk of critical illness and its consequences.

Telehealth Use and Hospital Readmission Rates in Long-term Care Facilities in Southeastern Minnesota During the COVID-19 Pandemic

Objective

To determine whether the length of a telehealth visit predicted the risk of hospital readmission at 30 days in skilled nursing facilities (SNFs) in southeastern Minnesota during the coronavirus disease 2019 pandemic.

Patients and Methods

This was a retrospective cohort study conducted in SNFs located in southeastern Minnesota from March 1, 2020 through July 15, 2020. The primary outcomes included hospitalization within 30 days of a video visit, and the secondary outcome was the number of provider video visits during the stay at an SNF. The primary predictor was the duration of video visits, and we collected the data regarding other known predictors of hospitalization. We used the χ² test for categorical variables and multivariate conditional logistic regression.

Results

We included 722 patients (mean age, 82.8 years [SD, 10.8 years]). Of those, 76 SNF residents (10.5%) were rehospitalized within 30 days. The average length of a video visit was 34.0 minutes (SD, 22.7 minutes) in admitted residents compared with 30.0 minutes (SD, 15.9 minutes) in nonadmitted residents. After full adjustment, there was no difference in the video visit duration between admitted and nonadmitted residents (odds ratio, 1.01; 95% CI, 0.99-1.03). The number of subsequent provider video visits was 2.26 (SD, 1.9) in admitted residents vs 1.58 (SD, 1.6), which was significant after adjustment (odds ratio, 1.17; 95% CI, 1.02-1.34).

Conclusion

There was no difference in the length of video visits for hospitalized SNF residents vs those who were not hospitalized within 30 days of a video visit. There were more visits in residents with hospital readmission. This may reflect the acuity of care for patients requiring a hospital stay. More research is needed to determine the ideal use of telehealth during the coronavirus disease 2019 pandemic in the postacute and long-term care environment.

Risk of hospitalization of elderly rural workers in the state of Rio Grande do Sul

Abstract Objective : To analyze the risk of hospitalization of elderly rural workers in the state of Rio Grande do Sul, Brazil. Method : A cross-sectional, population-based study was carried out of retired rural workers (N=604), over 60 years of age, of both genders, selected by clusters. In order to evaluate the risk of hospitalization, the Probability of Repeated Hospitalization (or PIR) instrument validated and evaluated for Brazil was used. Risk of hospitalization was calculated through logistic regression analysis, and was classified into the following strata: low (<0.300); medium (0.300-0.399); medium-high (0.400-0.499) and high (≥0.500). Results : The rural elderly persons surveyed had a low risk of hospitalization (n=553; 91.6%). There was a predominance of men among the medium to high risk categories (n=42; 82.3%), distributed mainly in the Santa Maria, Sul and Camaquã regions. Conclusion: The results of the present study suggest a low risk of hospitalization among this population, however, there is a need for improved, more profound and robust research into the identification of factors associated with the health specificities of this population.

Effect of health risk assessment and counselling on health behaviour and survival in older people: a pragmatic randomised trial

BACKGROUND

Potentially avoidable risk factors continue to cause unnecessary disability and premature death in older people. Health risk assessment (HRA), a method successfully used in working-age populations, is a promising method for cost-effective health promotion and preventive care in older individuals, but the long-term effects of this approach are unknown. The objective of this study was to evaluate the effects of an innovative approach to HRA and counselling in older individuals for health behaviours, preventive care, and long-term survival.

METHODS AND FINDINGS

This study was a pragmatic, single-centre randomised controlled clinical trial in community-dwelling individuals aged 65 y or older registered with one of 19 primary care physician (PCP) practices in a mixed rural and urban area in Switzerland. From November 2000 to January 2002, 874 participants were randomly allocated to the intervention and 1,410 to usual care. The intervention consisted of HRA based on self-administered questionnaires and individualised computer-generated feedback reports, combined with nurse and PCP counselling over a 2-y period. Primary outcomes were health behaviours and preventive care use at 2 y and all-cause mortality at 8 y. At baseline, participants in the intervention group had a mean ± standard deviation of 6.9 ± 3.7 risk factors (including unfavourable health behaviours, health and functional impairments, and social risk factors) and 4.3 ± 1.8 deficits in recommended preventive care. At 2 y, favourable health behaviours and use of preventive care were more frequent in the intervention than in the control group (based on z-statistics from generalised estimating equation models). For example, 70% compared to 62% were physically active (odds ratio 1.43, 95% CI 1.16-1.77, p = 0.001), and 66% compared to 59% had influenza vaccinations in the past year (odds ratio 1.35, 95% CI 1.09-1.66, p = 0.005). At 8 y, based on an intention-to-treat analysis, the estimated proportion alive was 77.9% in the intervention and 72.8% in the control group, for an absolute mortality difference of 4.9% (95% CI 1.3%-8.5%, p = 0.009; based on z-test for risk difference). The hazard ratio of death comparing intervention with control was 0.79 (95% CI 0.66-0.94, p = 0.009; based on Wald test from Cox regression model), and the number needed to receive the intervention to prevent one death was 21 (95% CI 12-79). The main limitations of the study include the single-site study design, the use of a brief self-administered questionnaire for 2-y outcome data collection, the unavailability of other long-term outcome data (e.g., functional status, nursing home admissions), and the availability of long-term follow-up data on mortality for analysis only in 2014.

CONCLUSIONS

This is the first trial to our knowledge demonstrating that a collaborative care model of HRA in community-dwelling older people not only results in better health behaviours and increased use of recommended preventive care interventions, but also improves survival. The intervention tested in our study may serve as a model of how to implement a relatively low-cost but effective programme of disease prevention and health promotion in older individuals.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number: ISRCTN 28458424.

Patient-reported geriatric symptoms as risk factors for hospitalization and emergency department visits

There is an urgent need to identify predictors of adverse outcomes and increased health care utilization in the elderly. The Mayo Ambulatory Geriatric Evaluation (MAGE) is a symptom questionnaire that was completed by patients aged 65 years and older during office visits to Primary Care Internal Medicine at Mayo Clinic in Rochester, MN. It was introduced to improve screening for geriatric conditions. We conducted this study to explore the relationship between self-reported geriatric symptoms and hospitalization and emergency department (ED) visits within 1 year of completing the survey. This was a retrospective cohort study of patients who completed the MAGE from April 2008 to December 2010. The primary outcome was an ED visit or hospitalization within 1 year. Predictors included responses to individual questions in the MAGE. Data were obtained from the electronic medical record and administrative records. Logistic regression analyses were performed from significant univariate factors to determine predictors in a multivariable setting. A weighted scoring system was created based upon the odds ratios derived from a bootstrap process. The sensitivity, specificity, and AUC were calculated using this scoring system. The MAGE survey was completed by 7738 patients. The average age was 76.2 ± 7.68 years and 57% were women. Advanced age, a self-report of worse health, history of 2 or more falls, weight loss, and depressed mood were significantly associated with hospitalization or ED visits within 1 year. A score equal to or greater than 2 had a sensitivity of 0.74 and specificity of 0.45. The calculated AUC was 0.60. The MAGE questionnaire, which was completed by patients at an outpatient visit to screen for common geriatric issues, could also be used to assess risk for ED visits and hospitalization within 1 year.

Impact of discharge planning decision support on time to readmission among older adult medical patients

PURPOSE OF THE STUDY

Hospital clinicians are overwhelmed with the volume of patients churning through the health care systems. The study purpose was to determine whether alerting case managers about high-risk patients by supplying decision support results in better discharge plans as evidenced by time to first hospital readmission.

PRIMARY PRACTICE SETTING

Four medical units at one urban, university medical center.

METHODOLOGY AND SAMPLE

A quasi-experimental study including a usual care and experimental phase with hospitalized English-speaking patients aged 55 years and older. The intervention included using an evidence-based screening tool, the Discharge Decision Support System (D2S2), that supports clinicians' discharge referral decision making by identifying high-risk patients upon admission who need a referral for post-acute care. The usual care phase included collection of the D2S2 information, but not sharing the information with case managers. The experimental phase included data collection and then sharing the results with the case managers. The study compared time to readmission between index discharge date and 30 and 60 days in patients in both groups (usual care vs. experimental).

RESULTS

After sharing the D2S2 results, the percentage of referral or high-risk patients readmitted by 30 and 60 days decreased by 6% and 9%, respectively, representing a 26% relative reduction in readmissions for both periods.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Supplying decision support to identify high-risk patients recommended for postacute referral is associated with better discharge plans as evidenced by an increase in time to first hospital readmission. The tool supplies standardized information upon admission allowing more time to work with high-risk admissions.

The Outcome and Assessment Information Set (OASIS): a review of validity and reliability

The Outcome and Assessment Information Set (OASIS) is the patient-specific, standardized assessment used in Medicare home health care to plan care, determine reimbursement, and measure quality. Since its inception in 1999, there has been debate over the reliability and validity of the OASIS as a research tool and outcome measure. A systematic literature review of English-language articles identified 12 studies published in the last 10 years examining the validity and reliability of the OASIS. Empirical findings indicate the validity and reliability of the OASIS range from low to moderate but vary depending on the item studied. Limitations in the existing research include: nonrepresentative samples; inconsistencies in methods used, items tested, measurement, and statistical procedures; and the changes to the OASIS itself over time. The inconsistencies suggest that these results are tentative at best; additional research is needed to confirm the value of the OASIS for measuring patient outcomes, research, and quality improvement.

Association between underweight and hospitalization, emergency room visits, and mortality among patients in community medical homes

Background

In older adults, underweight (body mass index [BMI] <18.5) has been associated with increased mortality. This increased mortality risk may be associated with increased health care utilization. We evaluated the relationship between underweight and hospitalization, emergency room visits, and mortality.

Methods

An analysis of a retrospective cohort study was conducted at a multisite academic primary care medical practice in Minnesota. The patients were ≥60 years of age, impaneled within primary care on January 1, 2011, and had a BMI measurement recorded between January 1, 2011, and December 31, 2011. Individuals were excluded if they refused review of their medical record. The primary measurement was BMI, which was categorized as underweight (BMI < 18.5) or normal and obese (BMI ≥ 18.5). The outcomes were hospitalization, emergency room visits, and mortality in the 2011 calendar year. Associations between underweight and each outcome were calculated using logistic regression. Interactions between underweight and gender were assessed in the logistic regression models. The final results were adjusted for age, gender, comorbid health conditions, and single living status.

Results

The final cohort included 21,019 patients, of whom 220 (1%) were underweight. Underweight patients had a higher likelihood of hospitalization compared with patients with higher BMI (adjusted odds ratio [OR] 1.64; 95% confidence interval [CI] 1.21–2.22). Underweight patients were also more likely to visit the emergency room (adjusted OR 1.70; 95% CI 1.28–2.25) or to die (adjusted OR 3.64; 95% CI 2.33–5.69). Men with a BMI < 18.5 compared with those having a BMI ≥ 18.5 had the highest odds of hospitalization (OR 3.45; 95% CI 1.59–7.48).

Conclusion

Underweight older adults, especially men, have higher odds of hospitalization, emergency room visits, and mortality. Future work on underweight might involve improving weight status, which may reduce the risk of hospitalization, emergency room visits, and mortality.

The relationship between Elder Risk Assessment Index score and 30-day readmission from the nursing home

OBJECTIVE

Preventable early readmission to the hospital is expensive, and identification of patients at risk is an important task for health care providers. The objective of this study was to determine the relationship between a high score on the Elder Risk Assessment (ERA) Index and 30-day readmission to the hospital in older patients discharged to a nursing home.

PATIENTS

Patients aged > 60 years residing in the community on January 1, 2005 and subsequently admitted to a local nursing home following hospitalization were included. The cohort was selected from all patients in a primary care internal medicine practice in Rochester, MN.

METHODS

This was a retrospective cohort study that used an electronically archived administrative risk index, the ERA Index, which was derived from demographic and clinical factors. The primary outcome was hospital readmission within 30 days following initial admission to a nursing home. The predictor variable was the ERA Index score. Univariate association between the total ERA Index score and individual components of the ERA Index and 30-day rehospitalization were determined. The ERA Index score cutoff with optimal sensitivity and specificity for hospital readmission was also identified.

RESULTS

Of 12 650 patients in the population, 800 were admitted to a facility between 2005 and 2007. Thirty-day readmission was not higher in the group with the highest ERA Index score (top quartile), with a relative risk of 1.72 (95% confidence interval [CI], 0.93-3.56) compared with the lowest-scoring group. The second- and third-highest quartiles were significantly associated with higher 30-day readmission. The individual component of the ERA Index that had the strongest association with early readmission was dementia, with an odds ratio of 2.69 (95% CI, 1.71-4.23). A cutoff score of 5 on the ERA Index resulted in a sensitivity of 0.81 and a specificity of 0.34 with an area under the curve of 0.55.

DISCUSSION

Those with the highest ERA Index score, the top quartile, were not at risk for early hospital readmission. The ERA Index does not predict readmissions from the nursing home to the hospital. There is a need to develop a unique index to predict rehospitalizations in nursing home residents.

Use of the elderly risk assessment (ERA) index to predict 2-year mortality and nursing home placement among community dwelling older adults

The objective was to determine the relationship between a high score on the ERA index and 2-year mortality and nursing home placement. As of January 1, 2005, 12,650 community-dwelling patients over 60 years of age were impaneled with a primary care practice at the Mayo Clinic in Rochester, MN. This was a retrospective cohort study utilizing an administrative risk score, the ERA score. Primary outcomes were 2-year mortality and 2-year nursing home placement. The predictor variable was ERA score. Relative risk estimates were used to describe the association between the ERA index and mortality and nursing home placement. The relative risk of 2-year mortality was 51.4 (95% confidence interval=CI=28.0-94.4) in patients in the highest risk group compared to the lowest group. The relative risk of nursing home placement was 113.2 (95% CI=76.1-168.4). Patients with high ERA scores are at high risk for 2-year mortality and 2-year nursing home placement. These findings suggest that the utilization of an electronic risk score can help identify patients at risk for death or nursing home placement. Clinically, the identification of high risk individuals may be useful for utilization of clinical case management.

Validade preditiva de instrumento para identificação do idoso em risco de hospitalização

OBJETIVO: Avaliar a validade de predição do Instrumento de Predição de Risco de Admissão Hospitalar Repetida da hospitalização de idosos. MÉTODOS: Estudo de coorte de base populacional com seguimento de seis meses com 515 idosos (> 60 anos de idade) não-institucionalizados, atendidos pela Estratégia Saúde da Família na cidade de Progresso, RS, em 2005. Os idosos responderam a oito perguntas objetivas, que foram reunidas em modelo de regressão logística para estimar seu risco de admissão hospitalar futura, por estratos de risco. Análise de sobrevida e a curva Receiver Operating Characteristics foram empregadas para aferir a validade do instrumento. RESULTADOS: Dos entrevistados, 56,1% eram mulheres e 10,1% foram hospitalizados. O grupo de risco alto teve freqüência de internação hospitalar 6,5 vezes superior em relação ao grupo de risco baixo. CONCLUSÕES: O instrumento é efetivo ao predizer o risco de hospitalização dos idosos atendidos pela Estratégia Saúde da Família do Sistema Único de Saúde.

Use of an electronic administrative database to identify older community dwelling adults at high-risk for hospitalization or emergency department visits: the elders risk assessment index

BACKGROUND

The prevention of recurrent hospitalizations in the frail elderly requires the implementation of high-intensity interventions such as case management. In order to be practically and financially sustainable, these programs require a method of identifying those patients most at risk for hospitalization, and therefore most likely to benefit from an intervention. The goal of this study is to demonstrate the use of an electronic medical record to create an administrative index which is able to risk-stratify this heterogeneous population.

METHODS

We conducted a retrospective cohort study at a single tertiary care facility in Rochester, Minnesota. Patients included all 12,650 community-dwelling adults age 60 and older assigned to a primary care internal medicine provider on January 1, 2005. Patient risk factors over the previous two years, including demographic characteristics, comorbid diseases, and hospitalizations, were evaluated for significance in a logistic regression model. The primary outcome was the total number of emergency room visits and hospitalizations in the subsequent two years. Risk factors were assigned a score based on their regression coefficient estimate and a total risk score created. This score was evaluated for sensitivity and specificity.

RESULTS

The final model had an AUC of 0.678 for the primary outcome. Patients in the highest 10% of the risk group had a relative risk of 9.5 for either hospitalization or emergency room visits, and a relative risk of 13.3 for hospitalization in the subsequent two year period.

CONCLUSIONS

It is possible to create a screening tool which identifies an elderly population at high risk for hospital and emergency room admission using clinical and administrative data readily available within an electronic medical record.

Use of an electronic administrative database to identify older community dwelling adults at high-risk for hospitalization or emergency department visits: the elders risk assessment index

BACKGROUND

The prevention of recurrent hospitalizations in the frail elderly requires the implementation of high-intensity interventions such as case management. In order to be practically and financially sustainable, these programs require a method of identifying those patients most at risk for hospitalization, and therefore most likely to benefit from an intervention. The goal of this study is to demonstrate the use of an electronic medical record to create an administrative index which is able to risk-stratify this heterogeneous population.

METHODS

We conducted a retrospective cohort study at a single tertiary care facility in Rochester, Minnesota. Patients included all 12,650 community-dwelling adults age 60 and older assigned to a primary care internal medicine provider on January 1, 2005. Patient risk factors over the previous two years, including demographic characteristics, comorbid diseases, and hospitalizations, were evaluated for significance in a logistic regression model. The primary outcome was the total number of emergency room visits and hospitalizations in the subsequent two years. Risk factors were assigned a score based on their regression coefficient estimate and a total risk score created. This score was evaluated for sensitivity and specificity.

RESULTS

The final model had an AUC of 0.678 for the primary outcome. Patients in the highest 10% of the risk group had a relative risk of 9.5 for either hospitalization or emergency room visits, and a relative risk of 13.3 for hospitalization in the subsequent two year period.

CONCLUSIONS

It is possible to create a screening tool which identifies an elderly population at high risk for hospital and emergency room admission using clinical and administrative data readily available within an electronic medical record.

A comparison of in-person home care, home care with telephone contact and home care with telemonitoring for disease management

We compared the effects of evidence-based disease management guidelines delivered to patients with heart failure and diabetes using three different modalities: in-person visits alone (Control), in-person visits and a telephone intervention (Telephone), and in-person visits and telemonitoring (Telemonitoring). Patients were randomized to the three groups. There were 112 patients in the Control group, 93 in the Telephone group and 98 in the Telemonitoring group. During the first 60 days, 10% of the Control group were rehospitalized, 17% of the Telephone group and 16% of the Telemonitoring group. Having heart failure and receiving more in-person visits were significantly related to readmission and time to readmission. However, after adjusting for diagnosis and visits, the differences between the three groups were non-significant. There was a trend for increased risk of readmission for the Telephone group compared to Control alone (P = 0.07, risk ratio 2.2, 95% CI: 0.9 to 5.2) and for readmission sooner (P = 0.02, risk ratio 2.3, 95% CI: 1.2 to 4.6). Patient rehospitalization and emergency department visit rates were lower than the national average, making it difficult to detect a difference between groups. Previous rehospitalization was a consistent predictor of those who were rehospitalized, suggesting that it may be a useful indicator for identifying patients likely to need additional attention.

Do hierarchical condition category model scores predict hospitalization risk in newly enrolled Medicare advantage participants as well as probability of repeated admission scores?

OBJECTIVES

To compare how well hierarchical condition categories (HCC) and probability of repeated admission (P(RA)) scores predict hospitalization.

DESIGN

Longitudinal cohort study with 12-month follow-up.

SETTING

A Medicare Advantage (MA) plan.

PARTICIPANTS

Four thousand five hundred six newly enrolled beneficiaries.

MEASUREMENT

HCC scores were identified from enrollment files. The P(RA) tool was administered by mail and telephone. Inpatient admissions were based on notifications. The Mann-Whitney test was used to compare HCC scores of P(RA) responders and nonresponders. The receiver operating characteristic curve provided the area under the curve (AUC) for each score. Admission risk in the top 5% of scores was evaluated using logistic regression.

RESULTS

Within 60 days of enrollment, 45.1% of the 3,954 beneficiaries with HCC scores completed the P(RA) tool. HCC scores were lower for the 1,783 P(RA) respondents than the 2,171 nonrespondents (0.71 vs 0.81, P<.001). AUCs predicting hospitalization with regard to HCC and P(RA) were similar (0.638, 95% confidence interval (CI)=0.603-0.674; 0.654, 95% CI=0.618-0.690). Individuals identified in the top 5% of scores using both tools, using HCC alone, or using P(RA) alone had higher risk for hospitalization than those below the 95th percentile (odds ratio (OR)=8.5, 95% CI=3.7-19.4, OR=3.8, 95% CI=2.3-6.3, and OR=3.9, 95% CI=2.3-6.4, respectively).

CONCLUSION

HCC scores provided to MA plans for risk adjustment of revenue can also be used to identify hospitalization risk. Additional studies are required to evaluate whether a hybrid approach incorporating administrative and self-reported models would further optimize risk stratification efforts.

Patient readmissions, emergency visits, and adverse events after software-assisted discharge from hospital: cluster randomized trial

BACKGROUND

One of the causes of postdischarge adverse events is poor discharge communication between hospital-based physicians, patients, and outpatient physicians. The value of hospital discharge software to improve communication and clinically relevant outcomes is unknown.

OBJECTIVE

To measure effects of a discharge software application of computerized physician order entry (CPOE).

DESIGN

Cluster randomized controlled trial.

SETTING

Tertiary care, teaching hospital in central Illinois.

PATIENTS

A total of 631 inpatients discharged to home with high risk for readmission.

INTERVENTION

Seventy internal medicine hospital physicians were randomly assigned (allocation concealed) to discharge software versus usual care, handwritten discharge.

MEASUREMENTS

Blinded assessment of patient readmission, emergency department visit, and postdischarge adverse event.

RESULTS

A total of 590 (94%) patients provided 6-month follow-up data. Generalized estimating equations gave intervention variable coefficients with 95% confidence interval (CI). When comparing patients assigned to discharge software versus usual care, there was no difference in hospital readmission within 6 months (37.0% versus 37.8%; coefficient -0.005 [95% CI, -0.074 to 0.065]; P = 0.894), emergency department visit within 6 months (35.4% versus 40.6%; coefficient -0.052 [95% CI, -0.115 to 0.011]; P = 0.108), or adverse event within 1 month (7.3% versus 7.3%; coefficient 0.003 [95% CI; -0.037 to 0.043]; P = 0.884).

CONCLUSIONS

Discharge software with CPOE did not affect readmissions, emergency department visits, or adverse events after discharge. Future studies should assess other endpoints such as patient perceptions or physician perceptions to see if discharge software has value.

Detecção do risco para internação hospitalar em população idosa: um estudo a partir da porta de entrada no sistema de saúde suplementar

O envelhecimento populacional impõe a necessidade de criar estratégias de avaliação e acompanhamento para os diferentes grupos da população idosa. O objetivo do artigo é apresentar uma proposta de hierarquização da demanda de idosos em sistema de saúde complementar, com base no uso de instrumento de detecção do risco de internação hospitalar. Esse instrumento foi aplicado por meio telefônico em 2.637 usuários do plano de saúde. A seguir, realizou-se o cálculo do coeficiente de risco de cada idoso, segundo aplicação de regressão logística. A partir dessas respostas calculou-se o índice de probabilidade de admissão hospitalar: 3,23% encontravam-se nos grupos de alto risco; 7,23% de médio-alto, e 13,4% apresentaram médio risco. O modelo permitiu a hierarquização da demanda da população de idosos, de acordo com o risco de internação hospitalar, o que proporcionou melhorar o planejamento e gestão do serviço, pois passou a ser possível dimensionar o quantitativo de indivíduos para intervenção e planejar a assistência. Portanto, estudos que apontem critérios para a distribuição de recursos são cada vez mais imprescindíveis para sustentar políticas de gestão realistas e consistentes.

Prediction of early readmission in medical inpatients using the Probability of Repeated Admission instrument

BACKGROUND

In the absence of an instrument to predict risk of early readmission, examination of the well-validated probability of repeated admission (Pra) for this new purpose is indicated.

OBJECTIVE

The objective of this study was to examine the use of the Pra in accurately identifying and predicting adult medical inpatients at risk of early readmission.

METHODS

Over 20 months, 1,077 consecutively admitted medical patients were enrolled in this prospective cohort study at a Midwestern tertiary care medical center. Pra score values were calculated within 2 days of discharge. Databases at the index medical center and other institutions were queried to identify readmission within 41 days.

RESULTS

Prevalence of readmission was 14% (confidence interval = 12.4%-15.6%). Pra score values ranged from .16 to .75. Indices to identify and predict readmission for a range of cut points were reported to minimize loss of information. The likelihood ratio for patients with a Pra score value > or = .53 was 1.67. Using a Pra cut point of > or = .45, readmission of patients with a high Pra was 2.3 times more likely than that of patients with a low Pra (p < .001, confidence interval = 1.63-3.27). Comparisons between cohorts indicated that differences existed with four of the eight variables used to calculate the Pra score: diabetes (p = .01), self-rated health status (p = .007), and number of doctor visits (p < .001) and hospitalizations (p < .001) in the past year.

DISCUSSION

Within this heterogeneous sample, prediction of readmission using the Pra was better than chance. These findings may facilitate development of a better predictive model by combining select Pra variables with other variables associated with early readmission.

Brief scale measuring patient preparedness for hospital discharge to home: Psychometric properties

BACKGROUND

Adverse events occur when patients transition from the hospital to outpatient care. For quality improvement and research purposes, clinicians need appropriate, reliable, and valid survey instruments to measure and improve the discharge processes.

OBJECTIVE

The object was to describe psychometric properties of the Brief PREPARED (B-PREPARED) instrument to measure preparedness for hospital discharge from the patient's perspective.

METHODS

The study was a prospective cohort of 460 patient or proxy telephone interviews following hospital discharge home. We administered the Satisfaction with Information about Medicines Scale and the PREPARED instrument 1 week after discharge. PREPARED measured patients' perceptions of quality and outcome of the discharge-planning processes. Four weeks after discharge, interviewers elicited emergency department visits. The main outcome was the B-PREPARED scale value: the sum of scores from 11 items. Internal consistency, construct, and predictive validity were assessed.

RESULTS

: The mean B-PREPARED scale value was 17.3 +/- 4.2 (SD) with a range of 3 to 22. High scores reflected high preparedness. Principal component analysis identified 3 domains: self-care information, equipment/services, and confidence. The B-PREPARED had acceptable internal consistency (Cronbach's alpha 0.76) and construct validity. The B-PREPARED correlated with medication information satisfaction (P < 0.001). Higher median B-PREPARED scores appropriately discriminated patients with no worry about managing at home from worriers (P < 0.001) and predicted patients without emergency department visits after discharge from those who had visits (P = 0.011).

CONCLUSIONS

The B-PREPARED scale measured patients' perceptions of their preparedness for hospital discharge home with acceptable internal consistency and construct and predictive validity. Brevity may potentiate use by patients and proxies. Clinicians and researchers may use B-PREPARED to evaluate discharge interventions.

Discharge planning scale: community physicians' perspective

BACKGROUND

Adverse events occur when patients transition from hospital to outpatient care. For quality improvement and research purposes, clinicians need appropriate, reliable, and valid survey instruments to measure and improve discharge processes.

OBJECTIVE

The objective of this study was to validate the Modified Physician-PREPARED scale to measure qualities of hospital discharge from the outpatient physician perspective. Descriptions include item development and psychometric properties.

METHODS

The design was a postal survey of outpatient physicians/practitioners who followed 403 patients who were discharged from hospital to home. We mailed questionnaires 10 days after discharge. Questionnaire items assessed perceptions of quality and outcome of discharge planning and communication. Analysis yielded the Modified Physician-PREPARED scale value: the sum of scores from 8 items. Internal consistency and construct validity were assessed.

RESULTS

Survey response rate was 76%. Mean Modified Physician-PREPARED scale value was 16.6 +/- 4.0 with range 8 to 24. High scores reflected high perceptions of discharge quality. Analysis identified 2 principal components: timeliness of communication, and adequacy of discharge plan/transmission. The scale had acceptable internal consistency (Cronbach's alpha 0.86) and construct validity. When considering the discharge planning and communication for a specific patient, outpatient primary care physicians reported higher scores when they were involved in the discharge planning (P < 0.001) and when they were aware of community support services (P = 0.002).

CONCLUSIONS

The Modified Physician-PREPARED scale measured outpatient physician perceptions of quality of hospital discharge to home. Clinicians and researchers may find the scale useful to evaluate discharge processes.

[Risk of repeated hospitalizations in elderly users of an academic health center]

The aim of this study was to stratify 305 elderly (> 65 years) treated at an academic health center (Botucatu, São Paulo, Brazil) according to risk of repeated hospitalization. Data collection used an instrument to evaluate risk of repeated hospital admissions, including eight health indicators: self-rated health, hospitalizations, doctor visits, diabetes, cardiovascular disease, gender, social support, and age. 56.4% of interviewees presented low probability of repeated hospitalization, as compared to 26.9% medium, 10.5% medium-high, and 6.2% high probability. Combining health indicators with the probability of repeated hospitalization, for elderly classified as medium, medium-high, and high risk compared to low, the relative risk was significant: medium or bad health (2.31); hospitalization (2.38); > 3 doctor visits (1.75); diabetes (2.10); cardiovascular disease (2.76); male gender (1.68); and > 75 years of age (1.62). The instrument was able to stratify elderly at risk of repeated hospitalization and is thus useful for reorganizing public health services.

Advanced illness index: Predictive modeling to stratify elders using self-report data

OBJECTIVES

Develop a prediction model to identify persons who have an increased risk of dying within the next 36 months, in order to focus additional resources and assessment in areas related to advanced care planning.

DESIGN

Retrospective study with a 3-year observation period.

SETTING

Integrated, not-for-profit managed care organization.

PARTICIPANTS

Beneficiaries aged 65-105 responding to an annual survey (n = 4888).

MEASUREMENTS

Survey instrument includes physical function, geriatric syndromes, health care utilization, special equipment use, self-care deficits, caregiving responsibilities, and general health problems.

RESULTS

An 11-variable model changed the baseline chi2 from 315.71 (df = 1) to 742.511 (df = 11). The percent of subjects correctly classified was 74.3% and the negative predictive value was 92.2%.

CONCLUSION

Advanced Illness Index (AII) model is stable. Characteristic variables used are not easily reversed: the 1997 cohort classified as at-risk consistently remained at risk or died in the subsequent years (1998, 92%; and 1999, 96%) and 92% of those not at-risk survived the next 36 months. Persons at high risk should at a minimum be made aware of the types of integrated home and community-based services available to them should it be needed. They also should be targeted for elicitation of treatment preferences, values, designation of health care proxy, planning, and advanced care directives.

Predicting the risk of hospital admission in older persons--validation of a brief self-administered questionnaire in three European countries

OBJECTIVES

To validate the Probability of Repeated Admission (Pra) questionnaire, a widely used self-administered tool for predicting future healthcare use in older persons, in three European healthcare systems.

DESIGN

Prospective study with 1-year follow-up.

SETTING

Hamburg, Germany; London, United Kingdom; Canton of Solothurn, Switzerland.

PARTICIPANTS

Nine thousand seven hundred thirteen independently living community-dwelling people aged 65 and older.

MEASUREMENTS

Self-administered eight-item Pra questionnaire at baseline. Self-reported number of hospital admissions and physician visits during 1 year of follow-up.

RESULTS

In the combined sample, areas under the receiver operating characteristic curves (AUCs) were 0.64 (95% confidence interval (CI)=0.62-0.66) for the prediction of one or more hospital admissions and 0.68 (95% CI=0.66-0.69) for the prediction of more than six physician visits during the following year. AUCs were similar between sites. In comparison, prediction models based on a person's age and sex alone exhibited poor predictive validity (AUC <or= 0.57). High-risk individuals (Pra score >or= 0.5) were 2.3 times as likely (95% CI=2.1-2.6) as low-risk individuals to have a hospital admission, and 2.1 times as likely (95% CI=2.0-2.2) to have more than six physician visits.

CONCLUSION

The Pra instrument exhibits good validity for predicting future health service use on a population level in different healthcare settings. Administrative data have shown similar predictive validity, but in practice, such data are often not available. The Pra is likely of high interest to governments and health insurance companies worldwide as a basis for programs aimed at health risk management in older persons.

Clinical Features of High-Risk Older Persons Identified by Predictive Modeling

The objective of this study was to describe the clinical features of older persons identified as high risk by a predictive modeling algorithm and to determine their suitability for clinical interventions like case management or disease management. A cross-sectional survey was undertaken at a community-based general internal medicine practice with 826 older patients enrolled in a Medicare-like health plan for military retirees and their dependents. Administrative claims data provided information about all 826 enrollees' chronic conditions, their use of health services, and the cost of those services during the past year. A survey mailed to 150 identified high-risk enrollees provided information about sociodemographic characteristics, general health, bed disability days, restricted activity days, activities of daily living (ADL) limitations, and instrumental activities of daily living (IADL) limitations. Compared to the 676 low-risk enrollees, the 150 high-risk enrollees had higher prevalence of eight individual chronic conditions, higher total chronic conditions (2.93 vs. 1.48, p < 0.001), higher annual rates of hospital admission (1.1 vs. 0.1, p < 0.001), more annual hospital days (7.3 vs. 0.5, p < 0.001), and higher total health insurance expenditures ($22,815 vs. $3,726, p < 0.001). The high-risk respondents to the survey (response rate = 80.0%) had suboptimal health (42.8% "fair or poor"), impaired functional ability (36.3% with 1+ ADL limitations, 58.1% with 1+ IADL limitations), and frequent health-related disruptions in their activities during the previous six months (38.7% with 1+ bed disability day, 52.3% with 1+ restricted activity day). A claims-based predictive modeling algorithm identifies older persons whose health, functional ability, and use of health services suggest they are good candidates for clinical interventions such as case management and disease management.

Usefulness of a single item in a mail survey to identify persons with possible dementia: a new strategy for finding high-risk elders

The objective of this study was to examine the characteristics of elderly persons who responded positively to a question about "severe memory problems" on a mailed health questionnaire yet were missed by the existing health risk algorithm to identify vulnerable elderly persons. A total of 324,471 respondents aged 65 and older completed a primary care health status questionnaire that gathered clinical information to quickly identify members with functional impairment, multiple chronic diseases, and higher medical care needs. The respondents were part of a large, integrated, not-for-profit managed care organization that implemented a model of care for elders using a uniform risk identification method across eight regions. Respondents with severe memory problems were compared to general respondents by morbidity, geriatric syndromes, functional impairments, service utilization, sensory impairments, sociodemographic characteristics, and activities of daily living. Of the respondents, 13,902 persons (4.3%) reported severe memory problems; the existing health risk algorithm missed 47.1% of these. When severe memory problems were included in the risk algorithm, identification increased from 11% to 13%, and risk prevalence by age groups ranged from 4.4% to 40.5%; one third had severe memory problems, a finding that was fairly consistent within age groups (28.4% to 36.5%). A question about severe memory problems should be incorporated into population risk-identification techniques. While false-negative rates are unknown, the false-positive rate of a self-report mail survey appears to be minimal. Persons reporting severe memory problems clearly have multiple comorbidities, higher prevalence of geriatric syndromes, and greater functional and sensory impairments.

Assistência ambulatorial geriátrica: hierarquização da demanda

No Brasil, o rápido crescimento da população de idosos vem produzindo grande impacto no sistema de saúde, com elevação dos custos e da utilização dos serviços. A ineficiência dos modelos tradicionais de assistência ao idoso torna imprescindível a mudança no paradigma de atenção à saúde dessa população, por meio do desenvolvimento de novos modelos de atenção que incorporem a identificação, a avaliação e o tratamento de idosos com perfis mórbidos e funcionais variados, passíveis de serem aplicados nas diversas modalidades assistenciais. Propõe-se um modelo ambulatorial, em duas etapas, que se diferencia pela profundidade e abrangência das ações, organizadas em níveis crescentes de complexidade e capazes de selecionar subgrupos de indivíduos que, por suas características de risco, devem progredir, diferenciadamente, na estrutura de atenção. Descreve-se a primeira etapa, que pressupõe a captação e identificação de risco de grandes grupos de idosos, por meio de um fluxo hierarquizado de ações e o uso de instrumentos de avaliação com sensibilidades e especificidades adequadas. O indivíduo com 65 anos ou mais, captado por demanda espontânea ambulatorial, captação domiciliar ou busca telefônica, é classificado segundo avaliação de risco, denominada Triagem Rápida, composta de oito itens. Dependendo do risco encontrado, o indivíduo será encaminhado para acompanhamento clínico usual e atividades em centros de convivência de idosos (risco baixo e médio) ou para outra etapa da avaliação funcional (riscos médio-alto e alto). A segunda etapa será tema de artigo posterior.

Framework for assessing causality in disease management programs: principles

To credibly state that a disease management (DM) program "caused" a specific outcome it is required that metrics observed in the DM population be compared with metrics that would have been expected in the absence of a DM intervention. That requirement can be very difficult to achieve, and epidemiologists and others have developed guiding principles of causality by which credible estimates of DM impact can be made. This paper introduces those key principles. First, DM program metrics must be compared with metrics from a "reference population." This population should be "equivalent" to the DM intervention population on all factors that could independently impact the outcome. In addition, the metrics used in both groups should use the same defining criteria (ie, they must be "comparable" to each other). The degree to which these populations fulfill the "equivalent" assumption and metrics fulfill the "comparability" assumption should be stated. Second, when "equivalence" or "comparability" is not achieved, the DM managers should acknowledge this fact and, where possible, "control" for those factors that may impact the outcome(s). Finally, it is highly unlikely that one study will provide definitive proof of any specific DM program value for all time; thus, we strongly recommend that studies be ongoing, at multiple points in time, and at multiple sites, and, when observational study designs are employed, that more than one type of study design be utilized. Methodologically sophisticated studies that follow these "principles of causality" will greatly enhance the reputation of the important and growing efforts in DM.

Frequency and determinants of urgent requests to home care agencies for community-dwelling elderly

We analyzed a one-year case series and performed a longitudinal (4 month) cohort analysis of urgent requests made to home care agencies by and for their > or = 65 years old clients in order to estimate the frequency of unscheduled services delivered by home care agencies and to identify risk factors. All 40 home care agencies located in a Swiss region were included in the study and we registered 3,816 urgent requests (75/1,000 > or = 65 years residents per year). Among home care users, the presence of a urinary catheter, incontinence and the need for assistance in bathing were predictors of unscheduled services. Resources should be planned in order to help home care teams to handle unexpected, disruptive clusters of urgent requests that may compromise their scheduled activities.

Partnering managed care and community-based services for frail elders: the care advocate program

OBJECTIVES

To describe a demonstration program that uses master's-level care managers (care advocates) to link Medicare managed care enrollees to home- and community-based services, testing whether referrals to noninsured services can reduce service usage and increase member satisfaction and retention.

DESIGN

Using an algorithm designed to target frail, high-cost users of Medicare insured healthcare services, the program partners PacifiCare's Secure Horizons and four of its medical groups with two social service organizations.

SETTING

Three care advocates located in two community-based social services agencies using telephone interviews to interact with targeted elders living in the community.

PARTICIPANTS

Three hundred ninety PacifiCare members aged 69 to 96 receiving care from four PacifiCare-contracted medical groups.

INTERVENTION

The 12-month intervention provides telephone assessment, links to eight types of home- and community-based services, and monthly follow-up contacts.

MEASUREMENTS

Sociodemographic characteristics of intervention participants, types of service referrals, and acceptance rates.

RESULTS

Lessons learned included the importance of building a shared vision among partners, building on existing relationships between members and providers, and building trust without face-to-face interactions.

CONCLUSION

The program builds on current insured case management services and offers a practical bridge to community-based services.

Using self-reported data to predict expenditures for the health care of older people

OBJECTIVES

To create and test a method for using self-reported data to predict future expenditures for the health care of older people.

DESIGN

A two-stage regression model of the relationship between self-reported data and Medicare expenditures during the following year was constructed from a randomly selected (derivation) half of a cohort of fee-for-service Medicare beneficiaries. For the other (validation) half of the cohort, two sets of predictions of 12-month Medicare expenditures were generated, one using the new two-stage model and the other using the principal inpatient diagnostic cost group (PIP-DCG) method now used to risk-adjust capitation payments to Medicare + Choice health plans. Both sets of predictions were compared with Medicare's actual 12-month expenditures for the validation cohort.

SETTING

Ramsey County, Minnesota.

PARTICIPANTS

Community-dwelling Medicare beneficiaries aged 70 and older (N = 13,682) who responded to a mailed survey.

MEASUREMENTS

Predicted-to-observed ratio (PTOR) of Medicare expenditures.

RESULTS

For the validation cohort, Medicare's actual 12-month expenditures totaled $26.5 million. The two-stage model predicted Medicare expenditures of $26.4 million (PTOR = 1.00); the PIP-DCG method predicted $31.2 million (PTOR = 1.18). Within subpopulations of healthy and ill beneficiaries, the two-stage model's predictions remained considerably more accurate than the PIP-DCG predictions.

CONCLUSION

Self-reported data may predict future Medicare expenditures more accurately than administrative data about beneficiaries' demographic characteristics, and previous hospitalizations.

Prospective evaluation of a screen for complex discharge planning in hospitalized adults

OBJECTIVES

To test the predictive ability of the Probability of Repeated Admission (PRA) screen for nonroutine discharge planning (requiring new referrals for formal services).

DESIGN

Prospective cohort.

SETTING

Two hospitals within a large Midwestern, tertiary care, referral-based system.

PARTICIPANTS

Nine hundred ninety-one hospitalized adults identified using a systematic sampling strategy.

MEASUREMENTS

The PRA screen was administered, and use of nonroutine discharge planning resources and nonroutine discharge disposition were determined using observation and open record review. Prolonged length of stay was determined by comparing the actual length of stay with the combined average length of stay for diagnosis-related groupings.

RESULTS

Significant differences in PRA scores existed in two of three endpoints, but the differences were small, and the ranges of scores overlapped almost completely. Using, logistic regression, items predicting use of nonroutine discharge-planning resources were self-rated health, caregiver availability, age, and sex (chi-square (chi2) = 105.7, df = 9, P <.001), accounting for 17.9% of the variability and area under receiver operating characteristic curve (AUC) of 0.74. Self-rated health and sex predicted prolonged length of stay (chi2 = 15.3, df = 5, P =.009), but only explained 2.2% of the variability, with an AUC of 0.58. The predictors of nonroutine discharge disposition were self-rated health, caregiver availability, age, sex, and diabetes mellitus (chi2 = 125.8, df = 11, P <.001), accounting for 23.0% of the variability, with an AUC of 0.79.

CONCLUSION

The clinical utility of using the PRA as a screen for early identification of persons who use nonroutine discharge planning is limited, although certain individual items may be useful.

Biomedical factors associated with hospitalization of older adults: The Bambuí Health and Aging Study (BHAS)

The objective of this study was to identify biomedical factors (body mass index, blood pressure, blood glucose, total cholesterol and fractions, triglycerides, and albumin) associated with hospitalization of older adults. All residents of the town of Bambuí, Minas Gerais State, ages > or = 60 years (n = 1,742) were selected for the study, of whom 1,494 (85.2%) participated. None of the biomedical factors studied was independently associated with occurrence of 1 hospitalization during the previous 12 months. Body mass index < 20 Kg/m and total cholesterol = 200-263 mg/dl and > or 264 mg/dl were independently associated with > or = 2 hospitalizations. The introduction of biomedical factors did not modify the previously identified associations between hospitalization and indicators constructed from information obtained in a questionnaire survey. The results show that data easily obtained through interviews can be useful both for identifying older adults at risk of hospitalization and thus for assisting in prevention.

Screening for risk of rehospitalization from home care: use of the outcomes assessment information set and the probability of readmission instrument

The purpose of this study was to evaluate the Outcomes Assessment Information Set (OASIS) compared with the Probability of Readmission (P(ra)) instrument for use in predicting rehospitalization during home care. Using logistic regression and receiver operating characteristic (ROC) curve analysis, the P(ra) instrument was found to be significantly better at predicting rehospitalization than the OASIS case mix weight, clinical, or service scores. The area under the curve (AUC) for the P(ra) was .686 compared with .549 for the OASIS case mix weight (p =.010). Similar results were found for the OASIS clinical and service scores. The AUC for the function score of >/=2 (.599) provided the closest approximation to the P(ra) (.686), and the difference between the two was not statistically significant (p =.120). The OASIS function score could be used to identify at-risk home care patients without having to also use the P(ra) instrument.

Physical performance measures in the clinical setting

OBJECTIVES

To assess the ability of gait speed alone and a three-item lower extremity performance battery to predict 12-month rates of hospitalization, decline in health, and decline in function in primary care settings serving older adults.

DESIGN

Prospective cohort study.

SETTING

Primary care programs of a Medicare health maintenance organization (HMO) and Veterans Affairs (VA) system.

PARTICIPANTS

Four hundred eighty-seven persons aged 65 and older.

MEASUREMENTS

Lower extremity performance Established Population for Epidemiologic Studies of the Elderly (EPESE) battery including gait speed, chair stands, and tandem balance tests; demographics; health care use; health status; functional status; probability of repeated admission scale (Pra); and primary physician's hospitalization risk estimate.

RESULTS

Veterans had poorer health and higher use than HMO members. Gait speed alone and the EPESE battery predicted hospitalization; 41% (21/51) of slow walkers (gait speed <0.6 m/s) were hospitalized at least once, compared with 26% (70/266) of intermediate walkers (0.6-1.0 m/s) and 11% (15/136) of fast walkers (>1.0 m/s) (P <.0001). The relationship was stronger in the HMO than in the VA. Both performance measures remained independent predictors after accounting for Pra. The EPESE battery was superior to gait speed when both Pra and primary physician's risk estimate were included. Both performance measures predicted decline in function and health status in both health systems. Performance measures, alone or in combination with self-report measures, were more able to predict outcomes than self-report alone.

CONCLUSION

Gait speed and a physical performance battery are brief, quantitative estimates of future risk for hospitalization and decline in health and function in clinical populations of older adults. Physical performance measures might serve as easily accessible "vital signs" to screen older adults in clinical settings.

The yield, reliability, and validity of a postal survey for screening community-dwelling older people

OBJECTIVES

To assess the yield, reliability, and validity of a postal survey developed to identify older persons in need of outpatient geriatric assessment and follow-up services.

DESIGN

A longitudinal cohort study.

SETTING

Outpatient primary care clinic at a Department of Veterans Affairs teaching ambulatory care center.

PARTICIPANTS

Patients (N = 2,382) aged 65 and older who returned a Geriatric Postal Screening Survey (GPSS) that screened for common geriatric conditions (depression, cognitive impairment, urinary incontinence, falls, and functional status impairment). Validity and reliability testing was performed with subsamples of patients classified as high or lower risk based on responses to the GPSS.

MEASUREMENTS

Test-retest reliability was measured by percentage agreement and kappa statistic. The diagnostic validity of the 10-item GPSS was tested by comparing single GPSS items to standardized geriatric assessment instruments for depression, mental status and functional status, as well as direct questions regarding falls, urinary incontinence, and use of medications. Validity was also tested against clinician evaluation of the specific geriatric conditions. Predictive validity was tested by comparing GPSS score with 1-year follow-up data on functional status, survival, and healthcare use.

RESULTS

Respondents identified as high risk by the GPSS had scores that indicated significantly greater impairment on structured assessment instruments than those identified as lower risk by GPSS. The overall mean percentage agreement between the test and retest surveys was 88.3%, with a mean weighted kappa of 0.70. In comparison with a structured telephone interview and with a clinical assessment, individual items of the GPSS showed good accuracy (range 0.71-0.78) for identifying symptoms of depression, falls, and urinary incontinence. Over a 1-year follow-up period, the GPSS-identified high-risk group had significantly (P <.05) more hospital admissions, hospital days and nursing home admissions than the lower-risk group.

CONCLUSION

A brief postal screening survey can successfully target patients for geriatric assessment services. In screening for symptoms of common geriatric conditions, the GPSS identified a subgroup of older outpatients with multiple geriatric syndromes who were at increased risk for hospital use and nursing home admission and who could potentially benefit from geriatric intervention.

Development of a method to identify seniors at high risk for high hospital utilization

BACKGROUND

A small percentage of older persons account for most Medicare costs. If persons at high risk for high health care utilization can be identified, resources can be directed to improve their health care and reduce utilization.

OBJECTIVE

To develop an efficient and economical approach to identifying older persons at risk for high future health care utilization.

DESIGN

Validation cohort.

SETTING

Three communities.

SUBJECTS

Five thousand one hundred thirty-eight community-dwelling persons aged 71 years or older.

MAIN OUTCOME MEASURES

High utilization (defined as >or=11 hospital days during 3 years) and overall Part A Medicare hospital costs during 3 years.

RESULTS

Predictive multivariable models were created that relied on prior hospitalization only, self-report only, and combined self-report and physical examination/lab data. Ten self-report items (hospitalizations in prior year and year before that, male gender, fair/poor health, not working, infrequent religious participation, needing help bathing, unable to walk 1/2 mile, diabetes, and taking loop diuretics) and two lab tests (low serum albumin and iron) remained as independent predictors of high utilization. Based upon these variables, approximately 1/4 of the population was identified as being at high risk (>or=0.28 probability) for high health care utilization and those identified accounted for approximately half of all Medicare Part A costs for the entire population. Finally, a two-phase strategy was developed in which tests are only administered to individuals whose risk cannot be adequately determined by self-report variables (approximately 1/4 of subjects).

CONCLUSIONS

Simple questions and laboratory tests can accurately and efficiently identify seniors at high risk for high health care utilization.

Using administrative data to study persons with disabilities

Administrative data result from administering health plans--tracking service utilization, paying claims, monitoring costs and quality--and have been used extensively for health services research. This article examines the strengths and limitations of administrative data for health services research studies of people with disabilities. Administrative data offer important advantages: encompassing large populations over time, ready availability, low cost, and computer readability. Questions arise about how to identify people with disabilities, capture disability-related services, and determine meaningful health care outcomes. Potentially useful administrative data elements include eligibility for Medicare or Medicaid through Social Security disability determinations, diagnosis and procedure codes, pharmacy claims, and durable medical equipment claims. Linking administrative data to survey or other data sources enhances the utility of administrative data for disability studies.

A comparison of two methods for identifying frail Medicare-aged persons

This article compares the efficacy of two screening methods to identify frail Medicare-aged persons using self-report questionnaire data: a clinical judgment method developed by nurse and social worker professionals in a community-based long-term care department and an empirical research method previously developed by the Center for Health Research using computer formulas and stepwise logistic regression coefficients. A sub-aim was to see whether the empirical method proved robust over time by measuring aggregate utilization and mortality in frail and nonfrail cohorts, which would increase the interest of physicians, managed care organizations, and other agencies providing service to Medicare beneficiaries.

Patient characteristics at hospital discharge and a comparison of home care referral decisions

OBJECTIVES

Describe the characteristics of hospitalized older adults who were not referred for home care, compare the referral decisions of hospital clinicians with those of nurses with expertise in discharge planning and transitional care, and compare the characteristics of hospitalized older adults who did not receive a home care referral with patients who did receive a home care referral.

DESIGN

Secondary analysis, descriptive, case series.

SETTING

Subjects were discharged to home from one of two urban hospitals in Philadelphia, Pennsylvania.

PARTICIPANTS

Ninety-nine patients for this study were drawn from the control group (n = 186) of a prior randomized clinical trial of advanced practice nurse hospital discharge planning and home follow-up. These 99 patients, or 56 of the control group, did not receive a home care referral even though they were screened into the original study as meeting at least one of the risk criteria associated with poor postdischarge outcomes.

MEASUREMENTS

Case studies were generated from research records of the control group patients who did not receive a home care referral. They included patient sociodemographic and health characteristics. Nurses with expertise in discharge planning and transitional care, blinded to the actual decision, reviewed each case study and made a referral decision.

RESULTS

Case studies revealed that control group patients, discharged without home follow-up, had many characteristics associated with the need for a home care referral, with the likelihood of receiving a referral, or with developing poor postdischarge outcomes. Overall, compared with control group patients who did not receive home care, those who did were older, had a longer hospital stay, more often rated their health as fair or poor, and had worse functional status. However, transitional care nurses judged that 96 of 99 of the control group patients discharged without home care had unmet discharge needs that may have benefited from a postdischarge referral. In addition, the transitional care nurses identified 49 of these 99 patients as having a high-priority need for home care. These patients had at least three of the characteristics associated with the need for a home care referral, the likelihood of receiving a referral, or of developing poor postdischarge outcomes. High-priority patients were significantly different in many sociodemographic and health characteristics and were rehospitalized significantly more often than other control group patients who were discharged without home care (P = .032).

CONCLUSION

Study findings have demonstrated that the majority of older adults in this sample were discharged without postdischarge referrals despite the presence of several characteristics associated with the need for home care and risk of poor discharge outcomes. Findings suggest the need for improved methods to identify and synthesize patient characteristics associated with the need for postdischarge referral and to support clinical decision-making. Insurance or homebound status should also be explored as barriers to patients receiving the postdischarge care that they need.

A Randomized Clinical Trial of Outpatient Geriatric Evaluation and Management

OBJECTIVES

To measure the effects of outpatient geriatric evaluation and management (GEM) on high-risk older persons' functional ability and use of health services.

DESIGN

Randomized clinical trial.

SETTING

Ambulatory clinic in a community hospital.

PARTICIPANTS

A population-based sample of community-dwelling Medicare beneficiaries age 70 and older who were at high risk for hospital admission in the future (N = 568).

INTERVENTION

Comprehensive assessment followed by interdisciplinary primary care.

MEASUREMENTS

Functional ability, restricted activity days, bed disability days, depressive symptoms, mortality, Medicare payments, and use of health services. Interviewers were blinded to participants' group status.

RESULTS

Intention-to-treat analysis showed that the experimental participants were significantly less likely than the controls to lose functional ability (adjusted odds ratio (aOR) = 0.67, 95% confidence interval (CI) = 0.47-0.99), to experience increased health-related restrictions in their daily activities (aOR = 0.60, 95% CI = 0.37-0.96), to have possible depression (aOR = 0.44, 95% CI = 0.20-0.94), or to use home healthcare services (aOR = 0.60, 95% CI = 0.37-0.92) during the 12 to 18 months after randomization. Mortality, use of most health services, and total Medicare payments did not differ significantly between the two groups. The intervention cost $1,350 per person.

CONCLUSION

Targeted outpatient GEM slows functional decline.

The Vulnerable Elders Survey: a tool for identifying vulnerable older people in the community

OBJECTIVES

To develop a simple method for identifying community-dwelling vulnerable older people, defined as persons age 65 and older at increased risk of death or functional decline. To assess whether self-reported diagnoses and conditions add predictive ability to a function-based survey.

DESIGN

Analysis of longitudinal survey data.

SETTING

A nationally representative community-based survey.

PARTICIPANTS

Six thousand two hundred five Medicare beneficiaries age 65 and older.

MEASUREMENTS

Bivariate and multivariate analyses of the Medicare Current Beneficiary Survey; development and comparison of scoring systems that use age, function, and self-reported diagnoses to predict future death and functional decline.

RESULTS

A multivariate model using function, self-rated health, and age to predict death or functional decline was only slightly improved when self-reported diagnoses and conditions were included as predictors and was significantly better than a model using age plus self-reported diagnoses alone. These analyses provide the basis for a 13-item function-based scoring system that considers age, self-rated health, limitation in physical function, and functional disabilities. A score of >or=3 targeted 32% of this nationally representative sample as vulnerable. This targeted group had 4.2 times the risk of death or functional decline over a 2-year period compared with those with scores <3. The receiver operating characteristics curve had an area of.78. An alternative scoring system that included self-reported diagnoses did not substantially improve predictive ability when compared with a function-based scoring system.

CONCLUSIONS

A function-based targeting system effectively and efficiently identifies older people at risk of functional decline and death. Self-reported diagnoses and conditions, when added to the system, do not enhance predictive ability. The function-based targeting system relies on self-report and is easily transported across care settings.

The Bambuí Health and Aging Study (BHAS): factors associated with hospitalization of the elderly

This study aimed to identify factors associated with hospital admissions of the elderly. All residents of Bambuí, Minas Gerais State >/= 60 years (n = 1,742) were selected. Some 1,606 of these (92.2%) participated in the study. The dependent variable was the number of hospital admissions (none, one, and two or more) during the previous 12 months. Independent variables were grouped as enabling, predisposing, and need-related factors. The strongest associations with multiple hospital admissions were: living alone; financial constraints to purchase of medication; and various indicators of need (worse self-perceived health, more visits to physician, greater use of prescription medications, and history of coronary heart disease). Such variables could help identify older adults at greatest risk and thus prevent hospitalization.

Screening for hospitalization and nutritional risks among community-dwelling older persons

BACKGROUND

The potential for the use of nutritional screening to identify older persons at risk of hospitalization has not been contrasted with the use of tools developed for predicting hospital admissions.

OBJECTIVE

Our goal was to compare the associations of items from the Level II Nutrition Screen (LII) and the Probability of Repeated Admissions (P(ra)) questionnaire with the outcome of hospitalization.

DESIGN

This was a cohort study of participants in a Medicare managed-risk health plan who completed both the LII and P(ra) (n = 386). All hospitalizations within 1 y of screening were recorded. Hierarchical multivariate logistic regression was used to model associations with hospitalization.

RESULTS

P(ra) items that retained significant associations with hospitalization were self-reported health, hospitalization in the past year, and >6 doctor visits in the past year (positive predictive value: 20%; sensitivity: 53.1; specificity: 69.7). LII items that retained significant associations with hospitalization were eating problems and polypharmacy (positive predictive value: 17.9%; sensitivity: 58.0; specificity: 56.3). Those persons designated by the P(ra) score as being at high risk of hospitalization (P(ra) > or = 0.30, 75th percentile) were also more likely to report weight loss, polypharmacy, consumption of a special diet, and functional limitation on the LII.

CONCLUSIONS

Retained items from the P(ra) and the LII were comparable in identifying participants at risk of hospitalization. These observations suggest that nutritional risk factors such as eating problems, weight loss, and consumption of special diets should be considered in the management of older persons at risk of hospitalization, irrespective of the screening approach selected.

Risk screening in a medicare/medicaid population administrative data versus self report

OBJECTIVE

To compare the abilities of two validated indices, one survey-based and the other database-derived, to prospectively identify high-cost, dual-eligible Medicare/Medicaid members.

DESIGN

A longitudinal cohort study.

SETTING

A Medicaid health maintenance organization in Philadelphia, Pa.

PARTICIPANTS

HMO enrollees (N = 558) 65 years and older eligible for both Medicare and Medicaid.

MEASUREMENTS AND MAIN RESULTS

Two hundred ninety six patients responded to a survey containing the Probability of Repeat Admission Questionnaire (Pra) between October and November 1998. Using readily available administrative data, we created an administrative proxy for the Pra. Choosing a cut point of 0.40 for both indices maximized sensitivity at 55% for the administrative proxy and 50% for the survey Pra. This classification yielded 103 high-risk patients by administrative proxy and 73 by survey Pra. High-cost patients averaged at least 2.3 times the resource utilization during the 6-month follow-up. Correlation between the two scores was 0.53, and the scales disagreed on high-cost risk in 78 patients (54 high-cost by administrative proxy only, and 24 high-cost by survey Pra only). These two discordant groups utilized intermediate levels of resources, $2,171 and $2,794, that were not statistically significantly different between the two groups (probability > chi2 =.66). Receiver operating characteristic curve areas (0.68 for survey Pra and administrative proxy for respondents, and 0.67 by administrative proxy for nonrespondents) revealed similar overall discriminative abilities for the two instruments for costs.

CONCLUSIONS

The Medicaid/Medicare dual-eligible population responded to the survey Pra at a rate of 53%, limiting its practical utility as a screening instrument. Using a cut point of 0.40, the administrative proxy performed as well as the survey Pra in this population and was equally applicable to nonrespondents. The time lag inherent in database screening limits its applicability for new patients, but combining database-driven and survey-based approaches holds promise for targeting patients who might benefit from case management intervention.

Hospitalization in the Program of All-Inclusive Care for the Elderly (PACE): rates, concomitants, and predictors

BACKGROUND

The Program of All-Inclusive Care for the Elderly (PACE) replicates the model of comprehensive, community-based geriatric care pioneered by On Lok, that enrolls frail older adults who meet states' criteria for nursing home care, and that uses interdisciplinary teams to assess the participants and to deliver care in appropriate settings. As managed care, PACE receives capitated payment from Medicare and Medicaid. Thus, PACE's fiscal incentives are thought to be aligned with the goals of optimizing health, function, and quality of life through the delivery of effective primary, preventive, restorative, supportive, and palliative care and through the avoidance of inappropriate and expensive hospital and nursing home utilization.

OBJECTIVES

To describe short-term hospital utilization, hospital discharge diagnoses, time from enrollment to first hospitalization and its clinical predictors, and hospitalization in relation to mortality among PACE participants.

METHODS

Data on short-term hospitalization and participants were recovered from PACE's minimum data set. Bed use was evaluated in annual cross-sections of current participants. Primary hospital discharge diagnoses were available for discharges from September 1, 1993 through March 31, 1997. The time from enrollment to hospitalization was calculated for the participants (n = 5478) who were admitted between January 1, 1990 and March 31, 1997. The characteristics of this inception cohort were used to develop a Cox regression model of hospitalization. All PACE deaths were identified and the place of death was recovered, together with the medical records used in the hospital during PACE enrollment or 6 months before death.

RESULTS

Bed-days per 1,000 PACE participants per year were comparable with the general Medicare (fee-for-service) population, at 2,046 (in 1998) versus 2014 (in 1997) despite the greater morbidity and disability for PACE participants, as reflected in their enrollment characteristics and primary hospital discharge diagnoses. The time to hospitalization was 773 days (median); 95% confidence interval, 725, 814, and was predicted by disease, treatment, social and demographic factors. Whereas 8% of PACE deaths occurred in acute hospitals, less than one-third of the decedents spent any time in the hospital in the 6-month interval before death.

CONCLUSIONS

Overall, short-term hospital utilization among PACE participants is low in contrast with that for other older and disabled populations. Participant predictors of hospitalization in PACE are generally consistent with other studies in older clinical and community populations. Both utilization and risk vary considerably across PACE sites, independent of participant-level risk factors, hence suggesting that further investigation is required to study PACE's management of acute illness and hospitalization decisions. Critical to maintaining PACE's success is an understanding of the independent impact of the organization and the environment of health care on this management.

The effects of outpatient geriatric evaluation and management on caregiver burden

This study investigated the effects of outpatient geriatric evaluation and management (GEM) on informal caregivers' sense of burden. We randomized 568 high-risk, community-dwelling older adults to receive either GEM or usual care for 6 months. At baseline and one year later, we assessed the burden experienced by their informal caregivers (N = 88). Compared with caregivers of participants in the usual care group, caregivers of participants in the GEM group were less than half as likely to report increased burden during the one-year follow-up period (16.7% vs 38.5%, p = .034). The findings suggest that GEM helps protect the informal caregivers of high-risk older people from the increases in burden that often accompany advancing age.