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Fournaise A, Lauridsen JT, Bech M, Wiil UK, Rasmussen JB, Kidholm K, Espersen K, Andersen-Ranberg K. Prevention of AcuTe admIssioN algorithm (PATINA): study protocol of a stepped wedge randomized controlled trial. BMC Geriatr 2021; 21:146. [PMID: 33639833 PMCID: PMC7912968 DOI: 10.1186/s12877-021-02092-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 02/16/2021] [Indexed: 11/18/2022] Open
Abstract
Background The challenges imposed by ageing populations will confront health care systems in the years to come. Hospital owners are concerned about the increasing number of acute admissions of older citizens and preventive measures such as integrated care models have been introduced in primary care. Yet, acute admission can be appropriate and lifesaving, but may also in itself lead to adverse health outcome, such as patient anxiety, functional loss and hospital-acquired infections. Timely identification of older citizens at increased risk of acute admission is therefore needed. We present the protocol for the PATINA study, which aims at assessing the effect of the ‘PATINA algorithm and decision support tool’, designed to alert community nurses of older citizens showing subtle signs of declining health and at increased risk of acute admission. This paper describes the methods, design and intervention of the study. Methods We use a stepped-wedge cluster randomized controlled trial (SW-RCT). The PATINA algorithm and decision support tool will be implemented in 20 individual area home care teams across three Danish municipalities (Kerteminde, Odense and Svendborg). The study population includes all home care receiving community-dwelling citizens aged 65 years and above (around 6500 citizens). An algorithm based on home care use triggers an alert based on relative increase in home care use. Community nurses will use the decision support tool to systematically assess health related changes for citizens with increased risk of acute hospital admission. The primary outcome is acute admission. Secondary outcomes are readmissions, preventable admissions, death, and costs of health care utilization. Barriers and facilitators for community nurse’s acceptance and use of the algorithm will be explored too. Discussion This ‘PATINA algorithm and decision support tool’ is expected to positively influence the care for older community-dwelling citizens, by improving nurses’ awareness of citizens at increased risk, and by supporting their clinical decision-making. This may increase preventive measures in primary care and reduce use of secondary health care. Further, the study will increase our knowledge of barriers and facilitators to implementing algorithms and decision support in a community care setup. Trial registration ClinicalTrials.gov, identifier: NCT04398797. Registered 13 May 2020.
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Affiliation(s)
- Anders Fournaise
- Department of Cross-sectoral Collaboration, Region of Southern Denmark, Damhaven 12, 7100, Vejle, Denmark. .,Epidemiology, Biostatistics and Biodemography, Department of Public Health, University of Southern Denmark, 5000, Odense, Denmark. .,Geriatric Research Unit, Department of Geriatric Medicine, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark.
| | - Jørgen T Lauridsen
- Department of Business and Economics, University of Southern Denmark, Campusvej 55, 5000, Odense, Denmark
| | - Mickael Bech
- The Danish Center for Social Science Research (VIVE), Herluf Trolles Gade 11, 1052, Copenhagen, Denmark
| | - Uffe K Wiil
- The Maersk Mc-Kinney Moller Institute, University of Southern Denmark, Campusvej 55, 5000, Odense, Denmark
| | - Jesper B Rasmussen
- The Maersk Mc-Kinney Moller Institute, University of Southern Denmark, Campusvej 55, 5000, Odense, Denmark
| | - Kristian Kidholm
- Centre for Innovative Medical Technology, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark
| | - Kurt Espersen
- Department of Cross-sectoral Collaboration, Region of Southern Denmark, Damhaven 12, 7100, Vejle, Denmark
| | - Karen Andersen-Ranberg
- Epidemiology, Biostatistics and Biodemography, Department of Public Health, University of Southern Denmark, 5000, Odense, Denmark.,Geriatric Research Unit, Department of Geriatric Medicine, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark.,Danish Ageing Research Center, University of Southern Denmark, J. B. Winsløws Vej 9B, 5000, Odense, Denmark
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Joshi FR, Lønborg J, Sadjadieh G, Helqvist S, Holmvang L, Sørensen R, Jørgensen E, Pedersen F, Tilsted HH, Høfsten D, Køber L, Kelbaek H, Engstrøm T. The benefit of complete revascularization after primary PCI for STEMI is attenuated by increasing age: Results from the DANAMI-3-PRIMULTI randomized study. Catheter Cardiovasc Interv 2020; 97:E467-E474. [PMID: 32681717 DOI: 10.1002/ccd.29131] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/19/2020] [Accepted: 06/19/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To ascertain the effect of age on outcomes after culprit-only and complete revascularization after Primary PCI (PPCI) for ST-elevation myocardial infarction (STEMI). BACKGROUND The numbers of older patients being treated with PPCI are increasing. The optimal management of nonculprit stenoses in such patients is unclear. METHODS We conducted an analysis of patients aged ≥75 years randomized in the DANAMI-3-PRIMULTI study to either culprit-only or complete FFR-guided revascularization. The primary endpoint was a composite of all-cause mortality, nonfatal reinfarction, and ischaemia-driven revascularization of lesions in noninfarct-related arteries after a median of 27 months of follow-up. RESULTS One hundred and ten of six hundred and twenty seven patients in the DANAMI-3-PRIMULTI trial were aged ≥75 years. These patients were more likely female (p < .001), hypertensive (p < .001), had lower hemoglobin levels (p < .001), and higher serum creatinine levels (p < .001) than the younger patients in the trial. Other than less use of drug-eluting stents (96.6 versus 88.0%: p = .02), there were no significant differences in procedural technique and success between patients aged <75 years and those ≥75 years of age. There was no significant difference in the incidence of the primary endpoint in patients ≥75 years randomized to culprit-only or FFR-guided complete revascularization (HR 1.49 [95% CI 0.57-4.65]; log-rank p = .19; p for interaction versus patients <75 years <.001). There was a significant interaction between age as a continuous variable, treatment assignment, and the primary outcome (p < .001); beyond the age of about 75 years, there may be no prognostic advantage to complete revascularization. CONCLUSIONS In patients ≥75 years, after treatment of the culprit lesion in STEMI, there is no significant prognostic benefit to prophylactic complete revascularization of nonculprit stenoses. Pending further study, data would support a symptom-guided approach to further invasive treatment.
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Affiliation(s)
- Francis R Joshi
- Department of Cardiology, The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jacob Lønborg
- Department of Cardiology, The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Golnaz Sadjadieh
- Department of Cardiology, The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Steffen Helqvist
- Department of Cardiology, The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lene Holmvang
- Department of Cardiology, The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Rikke Sørensen
- Department of Cardiology, The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Erik Jørgensen
- Department of Cardiology, The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Frants Pedersen
- Department of Cardiology, The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Hans Henrik Tilsted
- Department of Cardiology, The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Dan Høfsten
- Department of Cardiology, The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Henning Kelbaek
- Department of Cardiology, Sjaellands University Hospital, Roskilde, Denmark
| | - Thomas Engstrøm
- Department of Cardiology, The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Prediction of unplanned hospital admissions in older community dwellers using the 6-item Brief Geriatric Assessment: Results from REPERAGE, an observational prospective population-based cohort study. Maturitas 2019; 122:1-7. [PMID: 30797525 DOI: 10.1016/j.maturitas.2019.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 12/07/2018] [Accepted: 01/03/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND The 6-item Brief Geriatric Assessment (BGA) provides a priori risk stratification of incident hospital health adverse events, but it has not been used yet to assess the risk of unplanned hospital admission for older patients in primary care. This study aims to examine the association between the a priori risk stratification levels of the 6-item BGA performed by general practitioners (GPs) and incident unplanned hospital admissions in older community patients. METHODS Based on an observational prospective cohort design, 668 participants (mean age 84.7 ± 3.9 years; 64.7% female) were recruited by their GPs during an index primary care visit. The 6-item BGA was completed at baseline and provided an a priori risk stratification in three levels (low, moderate, high). Incident unplanned hospital admissions were recorded during a 6-month follow-up. RESULTS The incidence of unplanned hospital admissions increased with the risk level of the 6-item BGA stratification, the highest prevalence (35.3%) being reported with the high-risk level (P = 0.001). The risk of unplanned hospital admission at the high-risk level was significant (crude odds ratio (OR) = 5.48, P = 0.001 and fully adjusted OR = 3.71, P = 0.032, crude hazard ratio (HR) = 4.20; P = 0.002 and fully adjusted HR = 2.81; P = 0.035). The Kaplan-Meier's distributions of incident unplanned hospital admissions differed significantly between the three risk levels (P-value = 0.002). Participants with a high-risk level were more frequently admitted to hospital than those at a low-risk level (P = 0.001). Criteria performances of all risk levels were poor, except the specificity of the high-risk level, which was 98.2%. CONCLUSIONS The a priori 6-item BGA risk stratification was significantly associated with incident unplanned hospital admissions in primary care older patients. However, except for the specificity of the high-risk level, its criteria performances were poor, suggesting that this tool is unsuitable for screening older patients in primary care settings at risk of unplanned hospital admission.
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Andreasen J, Aadahl M, Sørensen EE, Eriksen HH, Lund H, Overvad K. Associations and predictions of readmission or death in acutely admitted older medical patients using self-reported frailty and functional measures. A Danish cohort study. Arch Gerontol Geriatr 2018; 76:65-72. [PMID: 29462759 DOI: 10.1016/j.archger.2018.01.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Revised: 01/25/2018] [Accepted: 01/29/2018] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To assess whether frailty in acutely admitted older medical patients, assessed by a self-report questionnaire and evaluation of functional level at discharge, was associated with readmission or death within 6 months after discharge. A second objective was to assess the predictive performance of models including frailty, functional level, and known risk factors. METHODS A cohort study including acutely admitted older patients 65+ from seven medical and two acute medical units. The Tilburg Frailty Indicator (TFI), Timed-Up-and-Go (TUG), and grip strength (GS) exposure variables were measured. Associations were assessed using Cox regression with first unplanned readmission or death (all-causes) as the outcome. Prediction models including the three exposure variables and known risk factors were modelled using logistic regression and C-statistics. RESULTS Of 1328 included patients, 50% were readmitted or died within 6 months. When adjusted for gender and age, there was an 88% higher risk of readmission or death if the TFI scores were 8-13 points compared to 0-1 points (HR 1.88, CI 1.38;2.58). Likewise, higher TUG and lower GS scores were associated with higher risk of readmission or death. The area under the curve for the prediction models ranged from 0.64 (0.60;0.68) to 0.72 (0.68;0.76). CONCLUSION In acutely admitted older medical patients, higher frailty assessed by TFI, TUG, and GS was associated with a higher risk of readmission or death within 6 months after discharge. The performance of the prediction models was mediocre, and the models cannot stand alone as risk stratification tools in clinical practice.
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Affiliation(s)
- Jane Andreasen
- Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Hobrovej 18-22, 9000, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 15, 9000, Aalborg, Denmark.
| | - Mette Aadahl
- Research Centre for Prevention and Health, The Capital Region of Denmark, Rigshospitalet- Glostrup Hospital, Ndr. Ringvej 57, Afsnit 84/85, 2600, Glostrup, Denmark; Department of Public Health, Faculty of Health Sciences, University of Copenhagen, Denmark.
| | - Erik Elgaard Sørensen
- Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 15, 9000, Aalborg, Denmark; Clinical Nursing Research Unit, Aalborg University Hospital, Sdr. Skovvej 15, 9000, Aalborg, Denmark.
| | - Helle Højmark Eriksen
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Sdr. Skovvej 15, 9000, Aalborg, Denmark.
| | - Hans Lund
- Centre for Evidence-Based Practice, Western Norway University of Applied Sciences, Inndalsveien 28, Postbox 7030, N-5020, Bergen, Norway.
| | - Kim Overvad
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9000, Aalborg, Denmark; Section for Epidemiology, Department of Public Health, Aarhus University, Bartholins Alle 2, 8000, Aarhus C, Denmark.
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Lloyd HM, Pearson M, Sheaff R, Asthana S, Wheat H, Sugavanam TP, Britten N, Valderas J, Bainbridge M, Witts L, Westlake D, Horrell J, Byng R. Collaborative action for person-centred coordinated care (P3C): an approach to support the development of a comprehensive system-wide solution to fragmented care. Health Res Policy Syst 2017; 15:98. [PMID: 29166917 PMCID: PMC5700670 DOI: 10.1186/s12961-017-0263-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 10/26/2017] [Indexed: 11/21/2022] Open
Abstract
Background Fragmented care results in poor outcomes for individuals with complexity of need. Person-centred coordinated care (P3C) is perceived to be a potential solution, but an absence of accessible evidence and the lack of a scalable ‘blue print’ mean that services are ‘experimenting’ with new models of care with little guidance and support. This paper presents an approach to the implementation of P3C using collaborative action, providing examples of early developments across this programme of work, the core aim of which is to accelerate the spread and adoption of P3C in United Kingdom primary care settings. Methods Two centrally funded United Kingdom organisations (South West Collaboration for Leadership in Applied Health Research and Care and South West Academic Health Science Network) are leading this initiative to narrow the gap between research and practice in this urgent area of improvement through a programme of service change, evaluation and research. Multi-stakeholder engagement and co-design are core to the approach. A whole system measurement framework combines outcomes of importance to patients, practitioners and health organisations. Iterative and multi-level feedback helps to shape service change while collecting practice-based data to generate implementation knowledge for the delivery of P3C. The role of the research team is proving vital to support informed change and challenge organisational practice. The bidirectional flow of knowledge and evidence relies on the transitional positioning of researchers and research organisations. Results Extensive engagement and embedded researchers have led to strong collaborations across the region. Practice is beginning to show signs of change and data flow and exchange is taking place. However, working in this way is not without its challenges; progress has been slow in the development of a linked data set to allow us to assess impact innovations from a cost perspective. Trust is vital, takes time to establish and is dependent on the exchange of services and interactions. If collaborative action can foster P3C it will require sustained commitment from both research and practice. This approach is a radical departure from how policy, research and practice traditionally work, but one that we argue is now necessary to deal with the most complex health and social problems.
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Affiliation(s)
- Helen M Lloyd
- Community and Primary Care Research Group, Clinical Trails and Population Studies, Peninsula School of Medicine and Dentistry, Room N14, ITTC Building, Plymouth Science Park, Derriford, Plymouth, Devon, PL6 8BX, United Kingdom.
| | - Mark Pearson
- NIHR CLAHRC South West Peninsula (PenCLAHRC), Institute of Health Research, University of Exeter Medical School, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, United Kingdom.,Health Services & Policy Research, University of Exeter Collaboration for Academic Primary Care, APEx, University of Exeter Medical School, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, United Kingdom
| | - Rod Sheaff
- School of Law, Criminology and Government, University of Plymouth, Portland Villas, Plymouth, Devon, PL4 8AA, United Kingdom
| | - Sheena Asthana
- School of Law, Criminology and Government, University of Plymouth, Portland Villas, Plymouth, Devon, PL4 8AA, United Kingdom
| | - Hannah Wheat
- Community and Primary Care Research Group, Clinical Trails and Population Studies, Peninsula School of Medicine and Dentistry, Room N14, ITTC Building, Plymouth Science Park, Derriford, Plymouth, Devon, PL6 8BX, United Kingdom
| | - Thava Priya Sugavanam
- Community and Primary Care Research Group, Clinical Trails and Population Studies, Peninsula School of Medicine and Dentistry, Room N14, ITTC Building, Plymouth Science Park, Derriford, Plymouth, Devon, PL6 8BX, United Kingdom
| | - Nicky Britten
- NIHR CLAHRC South West Peninsula (PenCLAHRC), Institute of Health Research, University of Exeter Medical School, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, United Kingdom.,Health Services & Policy Research, University of Exeter Collaboration for Academic Primary Care, APEx, University of Exeter Medical School, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, United Kingdom
| | - Jose Valderas
- NIHR CLAHRC South West Peninsula (PenCLAHRC), Institute of Health Research, University of Exeter Medical School, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, United Kingdom.,Health Services & Policy Research, University of Exeter Collaboration for Academic Primary Care, APEx, University of Exeter Medical School, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, United Kingdom
| | - Michael Bainbridge
- Primary Care Development Somerset Clinical Commissioning Group, Working Together to Improve Health and Wellbeing, Wynford House, Lufton Way, Yeovil, Somerset, BA22 8HR, United Kingdom
| | - Louise Witts
- South West Academic Health Science Network, Pynes Hill Court, Pynes Hill, Exeter, EX2 5AZ, United Kingdom
| | - Debra Westlake
- Community and Primary Care Research Group, Clinical Trails and Population Studies, Peninsula School of Medicine and Dentistry, Room N14, ITTC Building, Plymouth Science Park, Derriford, Plymouth, Devon, PL6 8BX, United Kingdom
| | - Jane Horrell
- Community and Primary Care Research Group, Clinical Trails and Population Studies, Peninsula School of Medicine and Dentistry, Room N14, ITTC Building, Plymouth Science Park, Derriford, Plymouth, Devon, PL6 8BX, United Kingdom
| | - Richard Byng
- Community and Primary Care Research Group, Clinical Trails and Population Studies, Peninsula School of Medicine and Dentistry, Room N14, ITTC Building, Plymouth Science Park, Derriford, Plymouth, Devon, PL6 8BX, United Kingdom
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Gómez-Batiste X, Murray SA, Thomas K, Blay C, Boyd K, Moine S, Gignon M, Van den Eynden B, Leysen B, Wens J, Engels Y, Dees M, Costantini M. Comprehensive and Integrated Palliative Care for People With Advanced Chronic Conditions: An Update From Several European Initiatives and Recommendations for Policy. J Pain Symptom Manage 2017; 53:509-517. [PMID: 28042069 DOI: 10.1016/j.jpainsymman.2016.10.361] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 09/21/2016] [Accepted: 10/07/2016] [Indexed: 11/21/2022]
Abstract
The number of people in their last years of life with advanced chronic conditions, palliative care needs, and limited life prognosis due to different causes including multi-morbidity, organ failure, frailty, dementia, and cancer is rising. Such people represent more than 1% of the population. They are present in all care settings, cause around 75% of mortality, and may account for up to one-third of total national health system spend. The response to their needs is usually late and largely based around institutional palliative care focused on cancer. There is a great need to identify these patients and integrate an early palliative approach according to their individual needs in all settings, as suggested by the World Health Organization. Several tools have recently been developed in different European regions to identify patients with chronic conditions who might benefit from palliative care. Similarly, several models of integrated palliative care have been developed, some with a public health approach to promote access to all in need. We describe the characteristics of these initiatives and suggest how to develop a comprehensive and integrated palliative approach in primary and hospital care and to design public health and community-oriented practices to assess and respond to the needs in the whole population. Additionally, we report ethical challenges and prognostic issues raised and emphasize the need for research to test the various tools and models to generate evidence about the benefits of these approaches to patients, their families, and to the health system.
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Affiliation(s)
- Xavier Gómez-Batiste
- The "Qualy" Observatory/WHO Collaborating Center for Palliative Care Public Health Programs, Catalan Institute of Oncology, Barcelona, Spain; Chair in Palliative Care, University of Vic, Barcelona, Spain.
| | - Scott A Murray
- Primary Palliative Care Research Group, The Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Keri Thomas
- End of Life Care, University of Birmingham, Birmingham, UK
| | - Carles Blay
- Chair in Palliative Care, University of Vic, Barcelona, Spain; Chronic Care Program, Catalan Department of Health, Government of Catalonia, Barcelona, Spain
| | - Kirsty Boyd
- Primary Palliative Care Research Group, The Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Sebastien Moine
- Education and Health Practices Laboratory, University Paris 13, Sorbonne Paris Cité, Bobigny, France; Health Simulation CenterSimUSanté®, Amiens University Hospital, Amiens, France
| | - Maxime Gignon
- Education and Health Practices Laboratory, University Paris 13, Sorbonne Paris Cité, Bobigny, France; Health Simulation CenterSimUSanté®, Amiens University Hospital, Amiens, France
| | - Bart Van den Eynden
- Research Group Palliative Care, Department of Primary and Interdisciplinary Care, Faculty of Medicine and Health Care, University of Antwerp, Antwerp, Belgium
| | - Bert Leysen
- Research Group Palliative Care, Department of Primary and Interdisciplinary Care, Faculty of Medicine and Health Care, University of Antwerp, Antwerp, Belgium
| | - Johan Wens
- Research Group Palliative Care, Department of Primary and Interdisciplinary Care, Faculty of Medicine and Health Care, University of Antwerp, Antwerp, Belgium
| | - Yvonne Engels
- Department of Anaesthesiology, Pain, Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marianne Dees
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Massimo Costantini
- Palliative Care Unit, IRCCS Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
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Meschi T, Ticinesi A, Prati B, Montali A, Ventura A, Nouvenne A, Borghi L. A novel organizational model to face the challenge of multimorbid elderly patients in an internal medicine setting: a case study from Parma Hospital, Italy. Intern Emerg Med 2016; 11:667-76. [PMID: 26846233 DOI: 10.1007/s11739-016-1390-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 01/09/2016] [Indexed: 11/25/2022]
Abstract
Continuous increase of elderly patients with multimorbidity and Emergency Department (ED) overcrowding are great challenges for modern medicine. Traditional hospital organizations are often too rigid to solve them without consistently rising healthcare costs. In this paper we present a new organizational model achieved at Internal Medicine and Critical Subacute Care Unit of Parma University Hospital, Italy, a 106-bed internal medicine area organized by intensity of care and specifically dedicated to such patients. The unit is partitioned into smaller wards, each with a specific intensity level of care, including a rapid-turnover ward (mean length of stay <4 days) admitting acutely ill patients from the ED, a subacute care ward for chronic critically ill subjects and a nurse-managed ward for stable patients who have socio-economic trouble preventing discharge. A very-rapid-turnover ("come'n'go") ward has also been instituted to manage sudden ED overflows. Continuity, effectiveness, safety and appropriateness of care are guaranteed by an innovative figure called "flow manager," with skilled clinical experience and managerial attitude, and by elaboration of an early personalized discharge plan anticipating every patient's needs according to lean methodology principles. In 2012-2014, this organizational model, compared with other peer units of the hospital and of other teaching hospitals of the region, showed a better performance, efficacy and effectiveness indexes calculated on Regional Hospital Discharge Records database system, allowing a capacity to face a massive (+22 %) rise in medical admissions from the ED. Further studies are needed to validate this model from a patient outcome point of view.
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Affiliation(s)
- Tiziana Meschi
- Internal Medicine and Critical Subacute Care Unit, Geriatric-Rehabilitation Department, Parma University Hospital and Clinical and Experimental Medicine Department, University of Parma, Via A. Gramsci 14, 43126, Parma, Italy.
| | - Andrea Ticinesi
- Internal Medicine and Critical Subacute Care Unit, Geriatric-Rehabilitation Department, Parma University Hospital and Clinical and Experimental Medicine Department, University of Parma, Via A. Gramsci 14, 43126, Parma, Italy
| | - Beatrice Prati
- Internal Medicine and Critical Subacute Care Unit, Geriatric-Rehabilitation Department, Parma University Hospital and Clinical and Experimental Medicine Department, University of Parma, Via A. Gramsci 14, 43126, Parma, Italy
| | | | - Antonio Ventura
- Business Management Control Unit, General Management Direction, Parma University Hospital, Parma, Italy
| | - Antonio Nouvenne
- Internal Medicine and Critical Subacute Care Unit, Geriatric-Rehabilitation Department, Parma University Hospital and Clinical and Experimental Medicine Department, University of Parma, Via A. Gramsci 14, 43126, Parma, Italy
| | - Loris Borghi
- Internal Medicine and Critical Subacute Care Unit, Geriatric-Rehabilitation Department, Parma University Hospital and Clinical and Experimental Medicine Department, University of Parma, Via A. Gramsci 14, 43126, Parma, Italy
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8
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Wang CL, Ding ST, Hsieh MJ, Shu CC, Hsu NC, Lin YF, Chen JS. Factors associated with emergency department visit within 30 days after discharge. BMC Health Serv Res 2016; 16:190. [PMID: 27225191 PMCID: PMC4879744 DOI: 10.1186/s12913-016-1439-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 05/24/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Post-discharge care remains a challenge because continuity of care is often interrupted and adverse events frequently occur. Previous studies have focused on early readmission but few have investigated emergency department (ED) visit after discharge. METHODS This retrospective observational study was conducted between April 2011 and March 2012 in a referral center in Taiwan. Patients discharged from the general medical wards during the study period were analyzed and their characteristics, hospital course, and associated factors were collected. An ED visit within 30 days of discharge was the primary outcome while readmission or death at home were secondary outcomes. RESULTS There were 799 discharged patients analyzed, including 96 (12 %) with an ED visit of 12.4 days post-discharge and 111 (14 %) with readmissions at 13.3 days post-discharge. Sixty patients were admitted after their ED visit. Underlying chronic illnesses were associated with 72 % of ED visits. By multivariate analysis, Charlson score and the use of naso-gastric tube were independent risk factors for ED visit within 30 days after discharge. CONCLUSIONS Early ED visit after discharge is as high as 12 %. Patients with chronic illness and those requiring a naso-gastric tube or external biliary drain are at high risk for post-discharge ED visit.
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Affiliation(s)
- Chuan-Lan Wang
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan.,Department of Traumatology, Hospital Medicine Group, National Taiwan University Hospital, #7, Chung-Shan South Road, Taipei, 100, Taiwan
| | - Shih-Tan Ding
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan.,Department of Traumatology, Hospital Medicine Group, National Taiwan University Hospital, #7, Chung-Shan South Road, Taipei, 100, Taiwan
| | - Ming-Ju Hsieh
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chin-Chung Shu
- Department of Traumatology, Hospital Medicine Group, National Taiwan University Hospital, #7, Chung-Shan South Road, Taipei, 100, Taiwan. .,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan. .,College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - Nin-Chieh Hsu
- Department of Traumatology, Hospital Medicine Group, National Taiwan University Hospital, #7, Chung-Shan South Road, Taipei, 100, Taiwan.,College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yu-Feng Lin
- Department of Traumatology, Hospital Medicine Group, National Taiwan University Hospital, #7, Chung-Shan South Road, Taipei, 100, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.,College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Jin-Shing Chen
- Department of Traumatology, Hospital Medicine Group, National Taiwan University Hospital, #7, Chung-Shan South Road, Taipei, 100, Taiwan.,College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
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9
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Kennelly SP, Drumm B, Coughlan T, Collins R, O'Neill D, Romero-Ortuno R. Characteristics and outcomes of older persons attending the emergency department: a retrospective cohort study. QJM 2014; 107:977-87. [PMID: 24935811 DOI: 10.1093/qjmed/hcu111] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The analysis of routinely collected hospital data informs the design of specialist services for at-risk older people. AIM Describe the outcomes of a cohort of older emergency department (ED) attendees and identify predictors of these outcomes. DESIGN retrospective cohort study. METHODS All patients aged 65 years or older attending an urban university hospital ED in January 2012 were included (N = 550). Outcomes were retrospectively followed for 12 months. Statistical analyses were based on multivariate binary logistic regression models and classification trees. RESULTS Of N = 550, 40.5% spent ≤6 h in the ED, but the proportion was 22.4% among those older than 81 years and not presenting with musculoskeletal problems/fractures. N = 349 (63.5%) were admitted from the ED. A significant multivariate predictor of in-hospital mortality was Charlson comorbidity index [CCI; odds ratio = 1.19, 95% confidence interval: 1.07, 1.34, P = 0.002]. Among patients who were discharged from ED without admission or after their first in-patient admission (N = 499), 232 (46.5%) re-attended ED within 1 year, with CCI being the best predictor of re-attendance (CCI ≤ 4: 25.8%, CCI > 5: 60.4%). Among N = 499, 34 (6.8%) had died after 1 year of initial ED presentation. The subgroup (N = 114) with the highest mortality (17.5%) was composed by those aged >77 years and brought in by ambulance on initial presentation. CONCLUSIONS Advanced age and comorbidity are important drivers of outcomes among older ED attendees. There is a need to embed specialist geriatric services within frontline services to make them more gerontologically attuned. Our results predate the opening of an acute medical unit with specialist geriatric input.
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Affiliation(s)
- S P Kennelly
- From the Department of Age-Related Health Care, Tallaght Hospital, Dublin, Ireland
| | - B Drumm
- From the Department of Age-Related Health Care, Tallaght Hospital, Dublin, Ireland
| | - T Coughlan
- From the Department of Age-Related Health Care, Tallaght Hospital, Dublin, Ireland
| | - R Collins
- From the Department of Age-Related Health Care, Tallaght Hospital, Dublin, Ireland
| | - D O'Neill
- From the Department of Age-Related Health Care, Tallaght Hospital, Dublin, Ireland
| | - R Romero-Ortuno
- From the Department of Age-Related Health Care, Tallaght Hospital, Dublin, Ireland
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10
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Unplanned admissions and readmissions in older people: a review of recent evidence on identifying and managing high-risk individuals. ACTA ACUST UNITED AC 2014. [DOI: 10.1017/s0959259814000082] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
SummaryRising unplanned hospital admissions are a problem in ageing populations worldwide. These admissions are associated with poor outcomes for older people, contribute to rising health care costs and impede the provision of planned care. Policy and practice in recent years has focused on identification of those at risk of unplanned admission and early intervention via a range of admission avoidance services. Despite this, unplanned admissions in older people continue to rise, and managing demand for unplanned care remains a priority. Questions remain about the risk factors for unplanned admission and the best approaches to identifying and intervening with those at risk. This review explores recent evidence on admission rates, risk factors for unplanned admission in older people, identification of those at highest risk and interventions to avert unplanned admission.
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11
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Reducing hospital bed use by frail older people: results from a systematic review of the literature. Int J Integr Care 2013; 13:e048. [PMID: 24363636 PMCID: PMC3860583 DOI: 10.5334/ijic.1148] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 07/25/2013] [Accepted: 09/04/2013] [Indexed: 11/20/2022] Open
Abstract
Introduction Numerous studies have been conducted in developed countries to evaluate the impact of interventions designed to reduce hospital admissions or length of stay (LOS) amongst frail older people. In this study, we have undertaken a systematic review of the recent international literature (2007-present) to help improve our understanding about the impact of these interventions. Methods We systematically searched the following databases: PubMed/Medline, PsycINFO, CINAHL, BioMed Central and Kings Fund library. Studies were limited to publications from the period 2007-present and a total of 514 studies were identified. Results A total of 48 studies were included for full review consisting of 11 meta-analyses, 9 systematic reviews, 5 structured literature reviews, 8 randomised controlled trials and 15 other studies. We classified interventions into those which aimed to prevent admission, interventions in hospital, and those which aimed to support early discharge. Conclusions Reducing unnecessary use of acute hospital beds by older people requires an integrated approach across hospital and community settings. A stronger evidence base has emerged in recent years about a broad range of interventions which may be effective. Local agencies need to work together to implement these interventions to create a sustainable health care system for older people.
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12
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Chao CT, Lin YF, Tsai HB, Hsu NC, Tseng CL, Ko WJ. In nonagenarians, acute kidney injury predicts in-hospital mortality, while heart failure predicts hospital length of stay. PLoS One 2013; 8:e77929. [PMID: 24223127 PMCID: PMC3819323 DOI: 10.1371/journal.pone.0077929] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Accepted: 09/06/2013] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND/AIMS The elderly constitute an increasing proportion of admitted patients worldwide. We investigate the determinants of hospital length of stay and outcomes in patients aged 90 years and older. METHODS We retrospectively analyzed all admitted patients aged >90 years from the general medical wards in a tertiary referral medical center between August 31, 2009 and August 31, 2012. Patients' clinical characteristics, admission diagnosis, concomitant illnesses at admission, and discharge diagnosis were collected. Each patient was followed until discharge or death. Multivariate logistic regression analysis was utilized to study factors associated with longer hospital length of stay (>7 days) and in-hospital mortality. RESULTS A total of 283 nonagenarian in-patients were recruited, with 118 (41.7%) hospitalized longer than one week. Nonagenarians admitted with pneumonia (p = 0.04) and those with lower Barthel Index (p = 0.012) were more likely to be hospitalized longer than one week. Multivariate logistic regression analysis revealed that patients with lower Barthel Index (odds ratio [OR] 0.98; p = 0.021) and those with heart failure (OR 3.05; p = 0.046) had hospital stays >7 days, while patients with lower Barthel Index (OR 0.93; p = 0.005), main admission nephrologic diagnosis (OR 4.83; p = 0.016) or acute kidney injury (OR 30.7; p = 0.007) had higher in-hospital mortality. CONCLUSION In nonagenarians, presence of heart failure at admission was associated with longer hospital length of stay, while acute kidney injury at admission predicted higher hospitalization mortality. Poorer functional status was associated with both prolonged admission and higher in-hospital mortality.
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Affiliation(s)
- Chia-Ter Chao
- Nephrology division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
- Hospitalist in National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Feng Lin
- Nephrology division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
- Hospitalist in National Taiwan University Hospital, Taipei, Taiwan
| | - Hung-Bin Tsai
- Nephrology division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
- Hospitalist in National Taiwan University Hospital, Taipei, Taiwan
- * E-mail:
| | - Nin-Chieh Hsu
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
- Hospitalist in National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Lin Tseng
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
- Hospitalist in National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Je Ko
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
- Hospitalist in National Taiwan University Hospital, Taipei, Taiwan
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13
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Hunt K, Walsh B, Voegeli D, Roberts H. Reducing avoidable hospital admission in older people: health status, frailty and predicting risk of ill-defined conditions diagnoses in older people admitted with collapse. Arch Gerontol Geriatr 2013; 57:172-6. [PMID: 23571128 DOI: 10.1016/j.archger.2013.03.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Revised: 02/19/2013] [Accepted: 03/06/2013] [Indexed: 11/16/2022]
Abstract
Emergency hospital admissions for patients with ill-defined conditions International Classification of Diseases-10 R codes (ICD-10 R codes) are rising. Policy literature has suggested that they are attributable to 'social' problems and could potentially be avoided yet there is no research evidence to support this view. Therefore, this study sought to describe patients with ill-defined conditions and determine clinical and demographic factors predicting assignment of such codes. Patients aged over 70 admitted to a hospital acute admissions unit with collapse or falls were recruited in one hospital. Measures of functional status, frailty, depression, routine blood tests, demographic and service use data were collected. 80 patients were recruited, 35 were discharged with ill-defined conditions codes. Functional limitations were common in patients with ill-defined conditions and 77% had frailty. Blood profiles did not indicate acute medical problems. Deprivation was the only significant independent predictor of assignment of ill-defined conditions codes at discharge (OR 0.64, 95% CI: 0.45-0.93). Whilst our data confirm policy suppositions that patients with ill-defined conditions have functional impairment and frailty, it is the social and organisational factors that are important in determining risk of ill-defined conditions rather than clinical indicators.
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Affiliation(s)
- Katherine Hunt
- Faculty of Health Sciences, University of Southampton, United Kingdom.
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