Risk factors for hospital re-presentation among older adults following fragility fractures: a systematic review and meta-analysis

Longitudinal trajectories of functional recovery after hip fracture

BACKGROUND

There is limited evidence regarding predictors of functional trajectories after hip fracture. We aimed to identify groups with different trajectories of functional recovery the first year after hip fracture, and to determine predictors for belonging to such groups.

METHODS

This longitudinal study combined data from two large randomized controlled trials including patients with hip fracture. Participants were assessed at baseline, four and 12 months. We used the Nottingham Extended Activities of Daily Living (NEADL) as a measure of instrumental ADL (iADL) and Barthel Index for personal ADL (pADL). A growth mixture model was estimated to identify groups of patients following distinct trajectories of functioning. Baseline characteristics potentially predicting group-belonging were assessed by multiple nominal regression.

RESULTS

Among 726 participants (mean age 83.0; 74.7% women), we identified four groups of patients following distinct ADL trajectories. None of the groups regained their pre-fracture ADL. For one of the groups identified in both ADL outcomes, a steep decline in function was shown the first four months after surgery, and none of the groups showed functional recovery between four and 12 months after surgery.

CONCLUSIONS

No groups regained their pre-fracture ADL. Some of the patients with relatively high pre-fracture function, had a steep ADL decline. For this group there is a potential for recovery, but more knowledge and research is needed in this group. These findings could be useful in uncovering groups of patients with different functioning after a hip fracture, and aid in discharge planning.

Derivation and validation of a 90-day unplanned hospital readmission score in older patients discharged form a geriatric ward

PURPOSE

To derive and validate a 90-day unplanned hospital readmission (UHR) score based on information available to non-hospital based care providers.

METHODS

Retrospective longitudinal study with cross-validation method. Participants were older adults (≥ 65 years) admitted to a geriatric short-stay department in a general hospital in France. Patients were split into a derivation cohort and a validation cohort. We recorded demographic information, medical history, and concurrent clinical characteristics. The main outcome was 90-day UHR. Data obtained from hospital discharge letters were used in a logistic regression model to construct a predictive score, and to identify risk groups for 90-day UHR.

RESULTS

In total, 750 and 250 aged adults were included in both the derivation and the validation cohorts. Mean age was 87.2 ± 5.2 years, most were women (68.1%). Independent risk factors for 90-day UHR were: use of mobility aids (p = .02), presence of dementia syndrome (p = .02), history of recent hospitalisation (p = .03), and discharge to domiciliary home (p = .005). From these four risk factors, three groups were determined: low-risk group (score < 4), medium-risk group (score between 4 and 6), and high-risk group (score ≥ 6). In the derivation cohort the 90-day UHR rates increased significantly across risk groups (14%, 22%, and 30%, respectively). The 90-day UHR score had the same discriminant power in the derivation cohort (c-statistic = 0.63) as in the validation cohort (c-statistic = 0.63).

CONCLUSIONS

This score makes it possible to identify aged adults at risk of 90-day UHR and to target multidisciplinary interventions to limit UHR for patients discharged from a Geriatric Short-Stay Unit.

Percutaneous Cement-Augmented Screws Short Fixation for the treatment of Severe Osteoporotic Vertebral Burst Fractures

OBJECTIVE (BACKGROUND)

This study aims to evaluate the therapeutic reliability of posterior percutaneous cement-augmented screws short fixation(PASF) in patients with severe osteoporotic vertebral burst fractures(OVBFs).

METHODS

Single-level OVBFs with an anterior vertebral body height(VBH) reduction equal or superior to 60% were included. A frailty index was employed for preoperative frailty assessment. Back pain and related disability were assessed through the VAS scale and Oswestry low-back pain disability index(ODI), being administered at injury time, preoperative, postoperative, twelfth-month and last patient follow-up evaluations. The main radiological outcomes were represented by Cobb angle(CA) and anterior vertebral body compression percentage(AVBC%), being measured at injury time, preoperative, postoperative and twelfth-month examinations. Among the others, the incidence of cement leakages and hardware failures was assessed.

RESULTS

Thirty-three patients met the inclusion criteria. All patients resulted frail(76%) or semi-frail(24%). Significant VBH restoration and segmental kyphosis improvement after PASF was documented (AVBC%:-40(-43;-37) VS -67(-70;-65), P = 0.0001; CA: 10(8-12) VS 24(23-26), P = 0.0001). The mean VAS and ODI scores documented optimal and long-enduring pain relief and related disability reduction after PASF (VAS: 2(2-3) VS 8(7-8), P = 0.0001; ODI: 22(17-26) VS 64(60-69), P = 0.0001). Only one cement leakage (3%), asymptomatic, occurred. After a mean follow-up of 33 months, no early/late hardware failures were reported.

CONCLUSIONS

The clinical and radiological results of this study suggest that PASF could be a safe and effective treatment option for severe OVBFs when conservative treatments failed.

Balancing standardisation and individualisation in transitional care pathways: a meta-ethnography of the perspectives of older patients, informal caregivers and healthcare professionals

BACKGROUND

Transitional care implies the transfer of patients within or across care settings in a seamless and safe way. For frail, older patients with complex health issues, high-quality transitions are especially important as these patients typically move more frequently within healthcare settings, requiring treatment from different providers. As transitions of care for frail people are considered risky, securing the quality and safety of these transitions is of great international interest. Nevertheless, despite efforts to improve quality in transitional care, research indicates that there is a lack of clear guidance to deal with practical challenges that may arise. The aim of this article is to synthesise older patients, informal caregivers and healthcare professionals' experiences of challenges to achieving high-quality transitional care.

METHODS

We used the seven-step method for meta-ethnography originally developed by Noblit and Hare. In four different but connected qualitative projects, the authors investigated the challenges to transitional care for older people in the Norwegian healthcare system from the perspectives of older patients, informal caregivers and healthcare professionals. In this paper, we highlight and discuss the cruciality of these challenging issues by synthesising the results from twelve articles.

RESULTS

The analysis resulted in four themes: i) balancing person-centred versus efficient care, ii) balancing everyday patient life versus the treatment of illness, iii) balancing user choice versus "What Matters to You", and iv) balancing relational versus practical care. These expressed challenges represent tensions at the system, organisation and individual levels based on partial competing assumptions on person-centred-care-inspired individualisation endeavours and standardisation requirements in transitional care.

CONCLUSIONS

There is an urgent need for a clearer understanding of the tension between standardisation and individualisation in transitional care pathways for older patients to ensure better healthcare quality for patients and more realistic working environments for healthcare professionals. Incorporating a certain professional flexibility within the wider boundary of standardisation may give healthcare professionals room for negotiation to meet patients' individual needs, while at the same time ensuring patient flow, equity and evidence-based practice.

Risk of incident fractures in individuals hospitalised due to unexplained syncope and orthostatic hypotension

BACKGROUND

Impaired orthostatic blood pressure response and syncope confer a high risk of falls and trauma. The relationship between a history of unexplained syncope and orthostatic hypotension (OH) with subsequent fractures, however, has not been thoroughly examined. In this study, we aimed to investigate the relationship between previous hospital admissions due to unexplained syncope and OH and incident fractures in a middle-aged population.

METHODS

We analysed a large population-based prospective cohort of 30,399 middle-aged individuals (age, 57.5 ± 7.6; women, 60.2%). We included individuals hospitalised due to unexplained syncope or OH as the main diagnosis. Multivariable-adjusted Cox regression analysis was applied to assess the impact of unexplained syncope and OH hospitalisations on subsequent incident fractures.

RESULTS

During a follow-up period of 17.8 + 6.5 years, 8201 (27%) subjects suffered incident fractures. The mean time from baseline and first admission for syncope (n = 493) or OH (n = 406) was 12.6 ± 4.2 years, and the mean age of the first hospitalisation was 74.6 ± 7.4 years. Individuals with incident fractures were older, more likely to be women, and had lower BMI, higher prevalence of prevalent fractures, and family history of fractures. Multivariable-adjusted Cox regression showed an increased risk of incident fractures following hospitalisations due to unexplained syncope (HR 1.20; 95% CI 1.02-1.40; p = 0.025) and OH (HR 1.42; 95% CI 1.21-1.66; p < 0.001) compared with unaffected individuals.

CONCLUSIONS

Individuals hospitalised due to unexplained syncope and orthostatic hypotension have an increased risk of subsequent fractures. Our findings suggest that such individuals should be clinically assessed for their syncope aetiology, with preventative measures aimed at fall and fracture risk assessment and management.

Trauma patients returning to the emergency department after discharge

BACKGROUND

While readmission rates of trauma patients are well described, little has been reported on rates of re-presentation to the emergency department (ED) after discharge. This study aimed to determine rates and contributing factors of re-presentation of trauma patients to the ED.

METHODS

One-year retrospective analysis of discharged adult trauma patients at a county-funded safety-net level one trauma center.

RESULTS

Of 1416 trauma patients, 195 (13.8%) re-presented to the ED within 30 days. Of those that re-presented, 47 (24.1%) were re-admitted (3.3% overall). The most common reasons for re-presentation were pain control and wound complications. Patients with Medicare (AOR 2.6, 95% CI 1.3 to 5.2) or other government insurance (AOR 2.5, 95% CI 1.6 to 4.1) were more likely to re-present than patients with private insurance.

CONCLUSION

A considerable number of trauma patients re-presented to the ED after discharge for reasons that did not require hospitalization. Discharge planning for certain vulnerable groups should emphasize wound care, pain control and scheduled follow-up to decrease the reliance on the ED.

Delivering exceptionally safe transitions of care to older people: a qualitative study of multidisciplinary staff perspectives

BACKGROUND

Transitions of care are often risky, particularly for older people, and shorter hospital stays mean that patients can go home with ongoing care needs. Most previous research has focused on fundamental system flaws, however, care generally goes right far more often than it goes wrong. We explored staff perceptions of how high performing general practice and hospital specialty teams deliver safe transitional care to older people as they transition from hospital to home.

METHODS

We conducted a qualitative study in six general practices and four hospital specialties that demonstrated exceptionally low or reducing readmission rates over time. Data were also collected across four community teams that worked into or with these high-performing teams. In total, 157 multidisciplinary staff participated in semi-structured focus groups or interviews and 9 meetings relating to discharge were observed. A pen portrait approach was used to explore how teams across a variety of different contexts support successful transitions and overcome challenges faced in their daily roles.

RESULTS

Across healthcare contexts, staff perceived three key themes to facilitate safe transitions of care: knowing the patient, knowing each other, and bridging gaps in the system. Transitions appeared to be safest when all three themes were in place. However, staff faced various challenges in doing these three things particularly when crossing boundaries between settings. Due to pressures and constraints, staff generally felt they were only able to attempt to overcome these challenges when delivering care to patients with particularly complex transitional care needs.

CONCLUSIONS

It is hypothesised that exceptionally safe transitions of care may be delivered to patients who have particularly complex health and/or social care needs. In these situations, staff attempt to know the patient, they exploit existing relationships across care settings, and act to bridge gaps in the system. Systematically reinforcing such enablers may improve the delivery of safe transitional care to a wider range of patients.

TRIAL REGISTRATION

The study was registered on the UK Clinical Research Network Study Portfolio (references 35272 and 36174 ).

Medical Comorbidities of Dementia: Links to Caregivers' Emotional Difficulties and Gains

OBJECTIVES

To evaluate how eight major medical comorbidities of dementia (arthritis, cancer, diabetes, heart disease, hypertension, lung disease, osteoporosis, and stroke) are associated with caregivers' perceptions of emotional caregiving difficulties and caregiving gains (ie, benefits or rewards from the care role).

DESIGN

Nationally representative cross-sectional surveys of community-dwelling persons living with dementia (PLWDs) and their co-resident family caregivers in the United States.

SETTING

The 2011 National Health and Aging Trends Study and National Study of Caregiving.

PARTICIPANTS

Total of 356 co-resident family caregivers of community-dwelling PLWDs.

MEASUREMENTS

Caregivers' sociodemographic and health characteristics, caregiving stressors, emotional caregiving difficulties, caregiving gains, and chronic health conditions of PLWDs.

RESULTS

Caregivers most commonly cared for a PLWD with arthritis (65.5%), followed by hypertension (64.9%), diabetes (30.1%), stroke (28.8%), osteoporosis (27.1%), heart disease (23.3%), cancer (21.5%), and lung disease (17.2%). Logistic regressions revealed that caregivers were 2.63 and 2.32 times more likely to report higher than median emotional caregiving difficulties when PLWDs had diagnoses of diabetes and osteoporosis, respectively, controlling for caregiver sex, relationship to the PLWD (spouse vs non-spouse), educational attainment, self-rated health, and assistance with activities of daily living and medical care activities. Caregivers were also 2.10 times more likely to report lower than median caregiving gains when PLWDs had a diagnosis of osteoporosis.

CONCLUSION

Comorbid health conditions among PLWDs have distinct implications for caregiving outcomes. Clinical care and interventions to improve the well-being of both care dyad members should support caregivers in managing medical comorbidities of dementia. J Am Geriatr Soc 68:609-613, 2020.

The role of frailty in predicting mortality and readmission in older adults in acute care wards: a prospective study

Few studies have focused on frailty as a predictor of mortality and readmission among inpatients in the acute care setting, especially over long follow-up periods. We conducted this study to determine the impact of the frailty on subsequent mortality and readmission in this setting. This study was a prospective observational study conducted in the acute geriatric wards, with a three-year follow-up duration. We assessed frailty via the 36-item Frailty Index (FI), and a cut-off value of 0.25 was used to identify the presence or absence of frailty. We collected survival and readmission information through telephone interviews at 12, 24, and 36 months. We used the Cox regression model to examine the association between frailty and outcomes interested (death and readmission). The present study included 271 patients (mean age: 81.1 years old; 20.3% females), of whom 21.4% died during the 3-year follow-up period. One hundred and thirty-three patients (49.1%) were identified as being frail. The prevalence of frailty was similar in men and women (46.8% vs.58.2%, P = 0.130). Compared with non-frail patients, death and hospital readmission rates of frail patients were increased. Frailty was an independent predictor of 3-year death (adjusted hazard ratio (HR): 2.09; 95% confidence interval (CI): 1.20 to 3.63) and readmission (adjusted HR: 1.40; 95% CI: 1.04 to 1.88) after adjusting for several potential confounders. Frailty is prevalent among older inpatients and is a valuable predictor of 3-year mortality and hospital readmission in an acute care setting.

Cardiovascular biomarkers predict fragility fractures in older adults

OBJECTIVE

To assess the role of four biomarkers of neuroendocrine activation and endothelial dysfunction in the longitudinal prediction of fragility fractures.

METHODS

We analysed a population-based prospective cohort of 5415 community-dwelling individuals (mean age, 68.9±6.2 years) enrolled in the Malmö Preventive Project followed during 8.1±2.9 years, and investigated the longitudinal association between C-terminal pro-arginine vasopressin (CT-proAVP), C-terminal endothelin-1 precursor fragment (CT-proET-1), the mid-regional fragments of pro-adrenomedullin (MR-proADM) and pro-atrial natriuretic peptide (MR-proANP), and incident vertebral, pelvic and extremity fractures.

RESULTS

Overall, 1030 (19.0%) individuals suffered vertebral, pelvic or extremity fracture. They were older (70.7±5.8 vs 68.4±6.3 years), more likely women (46.9% vs 26.3%), had lower body mass index and diastolic blood pressure, were more often on antihypertensive treatment (44.1% vs 38.4%) and had more frequently history of fracture (16.3% vs 8.1%). Higher levels of MR-proADM (adjusted HR (aHR) per 1 SD: 1.51, 95% CI 1.01 to 2.28, p<0.001) and MR-proANP (aHR: 1.23, 95% CI 1.05 to 1.45, p<0.001) were independently associated with increased risk of any fracture. The fracture risk increased linearly across MR-proANP quartiles. Individuals who were in the top quartile of all four biomarkers had a significant higher risk of fracture at any site (aHR: 2.32, 95% CI 1.86 to 2.91), vertebral fracture (aHR: 3.16, 95% CI 1.97 to 5.07) and femoral fracture (aHR: 2.35, 95% CI 1.64 to 3.36).

CONCLUSIONS

Elevated levels of MR-proADM and MR-proANP independently predict fragility fractures in older adults. In subjects with top quartile levels of all four biomarkers there is a twofold to threefold increase in risk of vertebral and femoral fractures.

External validation of the Rapid Assessment Prioritisation and Referral Tool for multidisciplinary teams in medical assessment and planning units

OBJECTIVE

The Rapid Assessment Prioritisation and Referral Tool (RAPaRT) was developed for identifying appropriate referrals to allied members of the multidisciplinary team in hospital medical assessment and planning units (MAPUs). This study examined the performance of the RAPaRT for identifying appropriate referrals as well as predicting requirement for admission to hospital and length of stay.

METHODS

A prospective cohort study was conducted. The RAPaRT, inclusive of seven mandatory items, was completed by nurses for 195 patients presenting to a hospital ED and assessed in a MAPU external to the instrument development site. Members of the multidisciplinary team (dietetics, occupational therapy, physiotherapy, social work and speech pathology) assessed participants to determine whether a referral to their profession was warranted and this was compared to RAPaRT responses.

RESULTS

All health professionals reviewed n = 175/195 (90%) participants, with n = 117/195 (60%) considered appropriate for referral to an allied health professional. At least one positive response to the RAPaRT items was recorded for n = 123 (63%) participants. Patterns of sensitivity and specificity for each item, and the instrument as a whole were consistent with the development study. The RAPaRT also predicted which patients required admission to an acute hospital ward (odds ratio = 1.22; 95% CI 1.01, 1.47) and their length of stay in hospital (coefficient = 0.18; 95% CI 0.14, 0.22).

CONCLUSION

Findings supported the external validation of the RAPaRT. In addition, this investigation made a novel contribution in demonstrating that positive RAPaRT responses were associated with requirement for admission to an acute hospital ward and length of stay.

Iatrogenic risk factors associated with hospital readmission of elderly patients: A matched case-control study using a clinical data warehouse

WHAT IS KNOWN

Hospital readmission within 30 days of patient discharge has become a standard to judge the quality of hospitalizations. It is estimated that 14% of the elderly, people over 75 years old or those over 65 with comorbidities, are at risk of readmission, of which 23% are avoidable. It may be possible to identify elderly patients at risk of readmission and implement steps to reduce avoidable readmissions.

OBJECTIVE

The aim of this study was to identify iatrogenic risk factors for readmission. The secondary objective was to evaluate the rate of drug-related readmissions (DRRs) among all readmissions and compare it to the rate of readmissions for other reasons.

METHODS

We conducted a retrospective, matched, case-control study to identify non-demographic risk factors for avoidable readmission, specifically DRRs. The study included patients hospitalized between 1 September 2014 and 31 October 2015 in an 800-bed university hospital. We included patients aged 75 and over. Cases consisted of patients readmitted to the emergency department within 30 days of initial discharge. Controls did not return to the emergency department within 30 days. Cases and controls were matched on sex and age because they are known as readmissions risk factors. After comparison of the mean or percentage between cases and controls for each variable, we conducted a conditional logistic regression.

RESULTS

The risk factors identified were an emergency admission at the index hospitalization, returning home after discharge, a history of unplanned readmissions and prescription of nervous system drugs. Otherwise, 11.4% of the readmissions were DRRs, of which 30% were caused by an overdose of antihypertensive. The number of drugs at readmission was higher, and potentially inappropriate medications were more widely prescribed for DRRs than for readmissions for other reasons.

WHAT IS NEW AND CONCLUSION

In this matched case-control retrospective study, after controlling for gender and age, we identified the typical profile of elderly patients at risk of readmission. These patients had an unplanned admission at the index hospitalization and prescribed nervous system drugs at discharge from the index admission; they have a history of unplanned readmission within 30 days and return home after discharge.

Development of fracture liaison services: What have we learned?

Due to dramatic improvements in life expectancy we are seeing a rapidly growing population of older people. Increasing frailty and susceptibility to fragility fractures are becoming pressing issues for both the individuals that suffer them as well as society, through pressures on health and social care budgets. The success of fracture liaison services, co-ordinated programmes enhancing the management of the fracture, osteoporosis, frailty and falls risk, is undisputed. To achieve optimal outcomes, however, it is important to have a standardisation of design, scope and structure of the service. Experience has taught us that by delegating responsibility for the holistic care of the patient to a trained and adequately resourced professional/team (fracture prevention practitioner) with clear standards against which benchmarking occurs, is the optimal model of delivery. Future challenges include how best to measure the success of services in imparting a reduction in fractures at a local population level as well as how to detect those patients with unmet need who do not uniformly present to health care services, such as those with vertebral fractures. The implementation of fracture liaison services however, is a clear demonstration of how collaboration between health care, social care and charity organisations, among others, has materially improved the health and well-being of the population.

The relationship between preoperative American Society of Anesthesiologists Physical Status Classification scores and functional recovery following hip-fracture surgery

Background

Little is known about the relationship of the American Society of Anesthesiologists Physical Status Classification scores (ASA scores) on patient outcomes following hip fracture surgery in Asian countries. Therefore, this study explored the association of patients’ preoperative ASA scores on trajectories of recovery in physical functioning and health outcomes during the first year following postoperative discharge for older adults with hip-fracture surgery in Taiwan.

Methods

The data for this study was generated from three prior studies. Participants (N = 226) were older hip-fracture patients from an observational study (n = 86) and two clinical trials (n = 61 and n = 79). Participants were recruited from the trauma wards of one medical center in northern Taiwan and data was collected prior to discharge and at 1, 3, 6, and 12 months after hospital discharge. Participants were grouped as ASA class 1–2 (50.5%; ASA Class 1, n = 7; ASA Class 2, n = 107) and ASA class 3 (49.5%, n = 112). Measures for mortality, service utilization, activities of daily living (ADL), measured by the Chinese Barthel Index, and health related quality of life, measured by Medical Outcomes Study Short Form-36, were assessed for the two groups. Generalized estimating equations (GEE) were used to analyze the changes over time for the two groups.

Results

During the first year following hip-fracture surgery, ASA class 1–2 participants had significantly fewer rehospitalizations (6%, p = .02) and better scores for mental health (mean = 70.29, standard deviation = 19.03) at 6- and 12-months following discharge than those classified as ASA 3. In addition, recovery of walking ability (70%, p = .001) and general health (adjusted mean = 58.31, p = .003) was also significantly better than ASA 3 participants.

Conclusions

There was a significant association of hip-fracture patients classified as ASA 1–2 with better recovery and service utilization during the first year following surgery. Interventions for hip fractured patients with high ASA scores should be developed to improve recovery and quality of life.