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Attwood D, Hope SV, Spicer SG, Gordon AL, Boorer J, Ellis W, Earley M, Denovan J, Hart G, Williams M, Burdett N, Lemon M. Does proactive care in care homes improve survival? A quality improvement project. BMJ Open Qual 2024; 13:e002771. [PMID: 38834371 PMCID: PMC11163642 DOI: 10.1136/bmjoq-2024-002771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 05/10/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND NHS England's 'Enhanced Health in Care Homes' specification aims to make the healthcare of care home residents more proactive. Primary care networks (PCNs) are contracted to provide this, but approaches vary widely: challenges include frailty identification, multidisciplinary team (MDT) capability/capacity and how the process is structured and delivered. AIM To determine whether a proactive healthcare model could improve healthcare outcomes for care home residents. DESIGN AND SETTING Quality improvement project involving 429 residents in 40 care homes in a non-randomised crossover cohort design. The headline outcome was 2-year survival. METHOD All care home residents had healthcare coordinated by the PCN's Older Peoples' Hub. A daily MDT managed the urgent healthcare needs of residents. Proactive healthcare, comprising information technology-assisted comprehensive geriatric assessment (i-CGA) and advanced care planning (ACP), were completed by residents, with prioritisation based on clinical needs.Time-dependent Cox regression analysis was used with patients divided into two groups:Control group: received routine and urgent (reactive) care only.Intervention group: additional proactive i-CGA and ACP. RESULTS By 2 years, control group survival was 8.6% (n=108), compared with 48.1% in the intervention group (n=321), p<0.001. This represented a 39.6% absolute risk reduction in mortality, 70.2% relative risk reduction and the number needed to treat of 2.5, with little changes when adjusting for confounding variables. CONCLUSION A PCN with an MDT-hub offering additional proactive care (with an i-CGA and ACP) in addition to routine and urgent/reactive care may improve the 2-year survival in older people compared with urgent/reactive care alone.
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Affiliation(s)
| | - Suzy V Hope
- College of Medicine and Health, University of Exeter, Exeter, UK
- Healthcare for Older People, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Stuart G Spicer
- Community and Primary Care Research Group, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Adam L Gordon
- Academic Unit of Injury, Recovery and Inflammation Sciences, School of Medicine, University of Nottingham, Nottingham, UK
- NIHR Applied Research Collaboration East Midlands (ARC-EM), Nottingham, UK
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Nouvenne A, Ticinesi A, Siniscalchi C, Rendo M, Cerundolo N, Parise A, Castaldo G, Chiussi G, Carrassi R, Guerra A, Meschi T. The Multidisciplinary Mobile Unit (MMU) Program Bringing Hospital Specialist Geriatric Competencies at Home: A Feasible Alternative to Admission in Older Patients with Urgent Complaints. J Clin Med 2024; 13:2720. [PMID: 38731249 PMCID: PMC11084740 DOI: 10.3390/jcm13092720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 05/01/2024] [Accepted: 05/03/2024] [Indexed: 05/13/2024] Open
Abstract
Background/Objectives: Older patients are subject to a high number of Emergency Department (ED) visits and hospitalizations. Innovative strategies to manage geriatric urgencies in the community are thus needed. Methods: In this prospective observational study, we examined the case mix of a hospital-based domiciliary urgent care service tailored to older patients, called Multidisciplinary Mobile Unit (MMU), from January to September 2023. The service, activated by general practitioners or territorial specialists during workdays, provided domiciliary geriatric assessment, point-of-care diagnostics, including multi-site ultrasound and lab tests, and therapeutical measures, including intravenous treatment and insertion of invasive devices, with the goal of reaching on-site stabilization and avoiding ED referral. We collected data regarding multimorbidity, polypharmacy, and frailty according to the Clinical Frailty Scale (CFS), reasons for MMU activation, and diagnostic and therapeutical services provided. The assessed outcomes were immediate hospitalization after a visit, 30-day admission, and 30-day mortality. Results: Participants (n = 205, 102 M) were mostly aged (median age 83 years old), with multimorbidity and frailty (CFS median 6). The most frequent reasons for MMU activation were dyspnea (49%), cough (34%), and musculoskeletal pain (17%), while the commonest diagnostic test provided was thoracic ultrasound (81%). Only five patients (2.4%) were hospitalized immediately after MMU visit. The 30-day rate of hospitalization was 10.2%, with age, cancer, and abdominal pain as independent predictors on a stepwise binary logistic regression model. 30-day mortality was 4.9%. Conclusions: The MMU model is a feasible strategy to manage geriatric urgencies, especially involving the cardiorespiratory system, is associated with good outcomes and may prevent ED visits.
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Affiliation(s)
- Antonio Nouvenne
- Department of Medicine and Surgery, University of Parma, Via Antonio Gramsci 14, 43126 Parma, Italy; (A.N.); (A.T.); (R.C.); (A.G.); (T.M.)
- Parma University Hospital—Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126 Parma, Italy; (N.C.); (A.P.); (G.C.); (G.C.)
| | - Andrea Ticinesi
- Department of Medicine and Surgery, University of Parma, Via Antonio Gramsci 14, 43126 Parma, Italy; (A.N.); (A.T.); (R.C.); (A.G.); (T.M.)
- Parma University Hospital—Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126 Parma, Italy; (N.C.); (A.P.); (G.C.); (G.C.)
| | - Carmine Siniscalchi
- Parma University Hospital—Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126 Parma, Italy; (N.C.); (A.P.); (G.C.); (G.C.)
| | - Martina Rendo
- Primary Care Department, Parma District, Azienda Unità Sanitaria Locale di Parma, Strada del Quartiere 2/A, 43125 Parma, Italy;
| | - Nicoletta Cerundolo
- Parma University Hospital—Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126 Parma, Italy; (N.C.); (A.P.); (G.C.); (G.C.)
| | - Alberto Parise
- Parma University Hospital—Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126 Parma, Italy; (N.C.); (A.P.); (G.C.); (G.C.)
| | - Giampiero Castaldo
- Parma University Hospital—Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126 Parma, Italy; (N.C.); (A.P.); (G.C.); (G.C.)
| | - Giulia Chiussi
- Parma University Hospital—Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126 Parma, Italy; (N.C.); (A.P.); (G.C.); (G.C.)
| | - Richard Carrassi
- Department of Medicine and Surgery, University of Parma, Via Antonio Gramsci 14, 43126 Parma, Italy; (A.N.); (A.T.); (R.C.); (A.G.); (T.M.)
| | - Angela Guerra
- Department of Medicine and Surgery, University of Parma, Via Antonio Gramsci 14, 43126 Parma, Italy; (A.N.); (A.T.); (R.C.); (A.G.); (T.M.)
- Parma University Hospital—Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126 Parma, Italy; (N.C.); (A.P.); (G.C.); (G.C.)
| | - Tiziana Meschi
- Department of Medicine and Surgery, University of Parma, Via Antonio Gramsci 14, 43126 Parma, Italy; (A.N.); (A.T.); (R.C.); (A.G.); (T.M.)
- Parma University Hospital—Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126 Parma, Italy; (N.C.); (A.P.); (G.C.); (G.C.)
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Liu Y, Du S, Liu C, Xue T, Tang Y. Preference of primary care patients for home-based healthcare and support services: a discrete choice experiment in China. Front Public Health 2024; 12:1324776. [PMID: 38699415 PMCID: PMC11063295 DOI: 10.3389/fpubh.2024.1324776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 04/08/2024] [Indexed: 05/05/2024] Open
Abstract
Importance This research, utilizing discrete choice experiments, examines the preferences and willingness to pay for home-based healthcare and support services among residents in China, a country grappling with severe aging population, an area often underexplored in international scholarship. Objectives This study aims to solicit the preferences of primary care patients for home-based healthcare and support services in China. Design setting and participants A discrete choice experiment (DCE) was conducted on 312 primary care patients recruited from 13 community health centers in Wuhan and Kunming between January and May 2023. The experimental choice sets were generated using NGene, covering five attributes: Scope of services, health professionals, institutions, insurance reimbursements, and visiting fees. Main outcomes and measures The choice sets were further divided into three blocks, and each participant was asked to complete one block containing 12 choice tasks. Mixed logit models were established to estimate the relevant importance coefficients of and willingness to pay for different choices, while Latent Class Logit (LCL) modeling was conducted to capture possible preferences heterogeneity. Results The relevant importance of the scope of services reached 67.33%, compared with 19.84% for service institutions and 12.42% for health professionals. Overall, respondents preferred physician-led diagnostic and treatment services. LCL categorized the respondents into three groups: Group one (60.20%) was most concerned about the scope of services, prioritizing disease diagnosis and treatment over preventive care and mental health, while group two (16.60%) was most concerned about care providers (hospitals and medical doctors were preferred), and group three (23.20%) was most concerned about financial burdens. Conclusion Primary care patients prefer physical health and medical interventions for home-based healthcare and support services. However, heterogeneity in preferences is evident, indicating potential disparities in healthcare and support at home services in China.
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Affiliation(s)
- Yaqing Liu
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Sixian Du
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Chaojie Liu
- Department of Public Health, La Trobe University, Melbourne, VIC, Australia
| | - Tianqin Xue
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yuqing Tang
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Key Research Institute of Humanities and Social Sciences of Hubei Provincial Department of Education, Wuhan, Hubei, China
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Shi C, Dumville J, Rubinstein F, Norman G, Ullah A, Bashir S, Bower P, Vardy ERLC. Inpatient-level care at home delivered by virtual wards and hospital at home: a systematic review and meta-analysis of complex interventions and their components. BMC Med 2024; 22:145. [PMID: 38561754 PMCID: PMC10986022 DOI: 10.1186/s12916-024-03312-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/22/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Technology-enabled inpatient-level care at home services, such as virtual wards and hospital at home, are being rapidly implemented. This is the first systematic review to link the components of these service delivery innovations to evidence of effectiveness to explore implications for practice and research. METHODS For this review (registered here https://osf.io/je39y ), we searched Cochrane-recommended multiple databases up to 30 November 2022 and additional resources for randomised and non-randomised studies that compared technology-enabled inpatient-level care at home with hospital-based inpatient care. We classified interventions into care model groups using three key components: clinical activities, workforce, and technology. We synthesised evidence by these groups quantitatively or narratively for mortality, hospital readmissions, cost-effectiveness and length of stay. RESULTS We include 69 studies: 38 randomised studies (6413 participants; largely judged as low or unclear risk of bias) and 31 non-randomised studies (31,950 participants; largely judged at serious or critical risk of bias). The 69 studies described 63 interventions which formed eight model groups. Most models, regardless of using low- or high-intensity technology, may have similar or reduced hospital readmission risk compared with hospital-based inpatient care (low-certainty evidence from randomised trials). For mortality, most models had uncertain or unavailable evidence. Two exceptions were low technology-enabled models that involve hospital- and community-based professionals, they may have similar mortality risk compared with hospital-based inpatient care (low- or moderate-certainty evidence from randomised trials). Cost-effectiveness evidence is unavailable for high technology-enabled models, but sparse evidence suggests the low technology-enabled multidisciplinary care delivered by hospital-based teams appears more cost-effective than hospital-based care for those with chronic obstructive pulmonary disease (COPD) exacerbations. CONCLUSIONS Low-certainty evidence suggests that none of technology-enabled care at home models we explored put people at higher risk of readmission compared with hospital-based care. Where limited evidence on mortality is available, there appears to be no additional risk of mortality due to use of technology-enabled at home models. It is unclear whether inpatient-level care at home using higher levels of technology confers additional benefits. Further research should focus on clearly defined interventions in high-priority populations and include comparative cost-effectiveness evaluation. TRIAL REGISTRATION https://osf.io/je39y .
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Affiliation(s)
- Chunhu Shi
- School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Manchester, UK.
| | - Jo Dumville
- School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Manchester, UK
| | - Fernando Rubinstein
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Manchester, UK
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Gill Norman
- School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Manchester, UK
- Evidence Synthesis Group, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
- NIHR Innovation Observatory, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Akbar Ullah
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Manchester, UK
- Manchester Centre for Health Economics, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
| | - Saima Bashir
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Manchester, UK
- Manchester Centre for Health Economics, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
| | - Peter Bower
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Manchester, UK
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Emma R L C Vardy
- School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Manchester, UK
- Oldham Care Organisation, Northern Care Alliance NHS Foundation Trust, Oldham, UK
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Ribbink ME, MacNeil Vroomen JL, Franssen R, Kolk D, Ben ÂJ, Willems HC, Buurman BM. Investigating the Effectiveness of Care Delivery at an Acute Geriatric Community Hospital for Older Adults in the Netherlands: A Prospective Controlled Observational Study. J Am Med Dir Assoc 2024; 25:704-710. [PMID: 38159913 DOI: 10.1016/j.jamda.2023.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 11/20/2023] [Accepted: 11/22/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVES Hospital admission in older adults is associated with unwanted outcomes such as readmission, institutionalization, and functional decline. To reduce these outcomes, the Netherlands introduced an alternative to hospital-based care: the Acute Geriatric Community Hospital (AGCH). The AGCH is an acute care unit situated outside of a hospital focusing on early rehabilitation and comprehensive geriatric assessment. The objective of this study was to evaluate if AGCH care is associated with decreasing unplanned readmissions or death compared with hospital-based care. DESIGN Prospective cohort study controlled with a historic cohort. SETTING AND PARTICIPANTS A (sub)acute care unit (AGCH) and 6 hospitals in the Netherlands; participants were acutely ill older adults. METHODS We used inverse propensity score weighting to account for baseline differences. The primary outcome was 90-day readmission or death. Secondary outcomes included 30-day readmission or death, time to death, admission to long-term residential care, occurrence of falls and functioning over time. Generalized logistic regression models and multilevel regression analyses were used to estimate effects. RESULTS AGCH patients (n = 206) had lower 90-day readmission or death rates [odds ratio (OR) 0.39, 95% CI 0.23-0.67] compared to patients treated in hospital (n = 401). AGCH patients had a lower risk of 90-day readmission (OR 0.38, 95% CI 0.21-0.67) but did not differ on all-cause mortality (OR 0.89, 95% CI 0.44-1.79) compared with the hospital control group. AGCH patients had lower 30-day readmission or death rates. Secondary outcomes did not differ. CONCLUSIONS AND IMPLICATIONS AGCH patients had lower rates of readmission and/or death than patients treated in a hospital. Our results support further research on the implementation and cost-effectiveness of AGCH in the Netherlands and other countries seeking alternatives to hospital-based care.
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Affiliation(s)
- Marthe E Ribbink
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Janet L MacNeil Vroomen
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Remco Franssen
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Daisy Kolk
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ângela Jornada Ben
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, the Netherlands
| | - Hanna C Willems
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Bianca M Buurman
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; ACHIEVE - Center of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands
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Attwood D, Vafidis J, Boorer J, Long S, Ellis W, Earley M, Denovan J, Hart G', Williams M, Burdett N, Lemon M, Hope S. IT-assisted comprehensive geriatric assessment for residents in care homes: quasi-experimental longitudinal study. BMC Geriatr 2024; 24:269. [PMID: 38504155 PMCID: PMC10949740 DOI: 10.1186/s12877-024-04824-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/19/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND Frailty interventions such as Comprehensive Geriatric Assessment (CGA) can provide significant benefits for older adults living with frailty. However, incorporating such proactive interventions into primary care remains a challenge. We developed an IT-assisted CGA (i-CGA) process, which includes advance care planning (ACP). We assessed if, in older care home residents, particularly those with severe frailty, i-CGA could improve access to advance care planning discussions and reduce unplanned hospitalisations. METHOD As a quality improvement project we progressively incorporated our i-CGA process into routine primary care for older care home residents, and used a quasi-experimental approach to assess its interim impact. Residents were assessed for frailty by General Practitioners. Proactive i-CGAs were completed, including consideration of traditional CGA domains, deprescribing and ACP discussions. Interim analysis was conducted at 1 year: documented completion, preferences and adherence to ACPs, unplanned hospital admissions, and mortality rates were compared for i-CGA and control (usual care) groups, 1-year post-i-CGA or post-frailty diagnosis respectively. Documented ACP preferences and place of death were compared using the Chi-Square Test. Unplanned hospital admissions and bed days were analysed using the Mann-Whitney U test. Survival was estimated using Kaplan-Meier survival curves. RESULTS At one year, the i-CGA group comprised 196 residents (severe frailty 111, 57%); the control group 100 (severe frailty 56, 56%). ACP was documented in 100% of the i-CGA group, vs. 72% of control group, p < 0.0001. 85% (94/111) of severely frail i-CGA residents preferred not to be hospitalised if they became acutely unwell. For those with severe frailty, mean unplanned admissions in the control (usual care) group increased from 0.87 (95% confidence interval ± 0.25) per person year alive to 2.05 ± 1.37, while in the i-CGA group they fell from 0.86 ± 0.24 to 0.68 ± 0.37, p = 0.22. Preferred place of death was largely adhered to in both groups, where documented. Of those with severe frailty, 55% (62/111) of the i-CGA group died, vs. 77% (43/56) of the control group, p = 0.0013. CONCLUSIONS Proactive, community-based i-CGA can improve documentation of care home residents' ACP preferences, and may reduce unplanned hospital admissions. In severely frail residents, a mortality reduction was seen in those who received an i-CGA.
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Affiliation(s)
| | - Jim Vafidis
- University of the West of England, Bristol, UK
| | | | | | | | | | | | | | | | | | | | - Suzy Hope
- University of Exeter, Exeter, UK
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
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Edgar K, Iliffe S, Doll HA, Clarke MJ, Gonçalves-Bradley DC, Wong E, Shepperd S. Admission avoidance hospital at home. Cochrane Database Syst Rev 2024; 3:CD007491. [PMID: 38438116 PMCID: PMC10911897 DOI: 10.1002/14651858.cd007491.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
BACKGROUND Admission avoidance hospital at home provides active treatment by healthcare professionals in the patient's home for a condition that would otherwise require acute hospital inpatient care, and always for a limited time period. This is the fourth update of this review. OBJECTIVES To determine the effectiveness and cost of managing patients with admission avoidance hospital at home compared with inpatient hospital care. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and CINAHL on 24 February 2022, and checked the reference lists of eligible articles. We sought ongoing and unpublished studies by searching ClinicalTrials.gov and WHO ICTRP, and by contacting providers and researchers involved in the field. SELECTION CRITERIA Randomised controlled trials recruiting participants aged 18 years and over. Studies comparing admission avoidance hospital at home with acute hospital inpatient care. DATA COLLECTION AND ANALYSIS We followed the standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care (EPOC) Group. We performed meta-analysis for trials that compared similar interventions, reported comparable outcomes with sufficient data, and used individual patient data when available. We used the GRADE approach to assess the certainty of the body of evidence for the most important outcomes. MAIN RESULTS We included 20 randomised controlled trials with a total of 3100 participants; four trials recruited participants with chronic obstructive pulmonary disease; two trials recruited participants recovering from a stroke; seven trials recruited participants with an acute medical condition who were mainly older; and the remaining trials recruited participants with a mix of conditions. We assessed the majority of the included studies as at low risk of selection, detection, and attrition bias, and unclear for selective reporting and performance bias. For an older population, admission avoidance hospital at home probably makes little or no difference on mortality at six months' follow-up (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.68 to 1.13; P = 0.30; I2 = 0%; 5 trials, 1502 participants; moderate-certainty evidence); little or no difference on the likelihood of being readmitted to hospital after discharge from hospital at home or inpatient care within 3 to 12 months' follow-up (RR 1.14, 95% CI 0.97 to 1.34; P = 0.11; I2 = 41%; 8 trials, 1757 participants; moderate-certainty evidence); and probably reduces the likelihood of living in residential care at six months' follow-up (RR 0.53, 95% CI 0.41 to 0.69; P < 0.001; I2 = 67%; 4 trials, 1271 participants; moderate-certainty evidence). Hospital at home probably results in little to no difference in patient's self-reported health status (2006 patients; moderate-certainty evidence). Satisfaction with health care received may be improved with admission avoidance hospital at home (1812 participants; low-certainty evidence); few studies reported the effect on caregivers. Hospital at home reduced the initial average hospital length of stay (2036 participants; low-certainty evidence), which ranged from 4.1 to 18.5 days in the hospital group and 1.2 to 5.1 days in the hospital at home group. Hospital at home length of stay ranged from an average of 3 to 20.7 days (hospital at home group only). Admission avoidance hospital at home probably reduces costs to the health service compared with hospital admission (2148 participants; moderate-certainty evidence), though by a range of different amounts and using different methods to cost resource use, and there is some evidence that it decreases overall societal costs to six months' follow-up. AUTHORS' CONCLUSIONS Admission avoidance hospital at home, with the option of transfer to hospital, may provide an effective alternative to inpatient care for a select group of older people who have been referred for hospital admission. The intervention probably makes little or no difference to patient health outcomes; may improve satisfaction; probably reduces the likelihood of relocating to residential care; and probably decreases costs.
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Affiliation(s)
- Kate Edgar
- Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Steve Iliffe
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Helen A Doll
- Clinical Outcomes Assessments, ICON Commercialisation and Outcomes, Dublin, Ireland
| | - Mike J Clarke
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | | | - Eric Wong
- St. Michael's Hospital and Unity Health Toronto, University of Toronto, Toronto, Canada
| | - Sasha Shepperd
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Wallis JA, Shepperd S, Makela P, Han JX, Tripp EM, Gearon E, Disher G, Buchbinder R, O'Connor D. Factors influencing the implementation of early discharge hospital at home and admission avoidance hospital at home: a qualitative evidence synthesis. Cochrane Database Syst Rev 2024; 3:CD014765. [PMID: 38438114 PMCID: PMC10911892 DOI: 10.1002/14651858.cd014765.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
BACKGROUND Worldwide there is an increasing demand for Hospital at Home as an alternative to hospital admission. Although there is a growing evidence base on the effectiveness and cost-effectiveness of Hospital at Home, health service managers, health professionals and policy makers require evidence on how to implement and sustain these services on a wider scale. OBJECTIVES (1) To identify, appraise and synthesise qualitative research evidence on the factors that influence the implementation of Admission Avoidance Hospital at Home and Early Discharge Hospital at Home, from the perspective of multiple stakeholders, including policy makers, health service managers, health professionals, patients and patients' caregivers. (2) To explore how our synthesis findings relate to, and help to explain, the findings of the Cochrane intervention reviews of Admission Avoidance Hospital at Home and Early Discharge Hospital at Home services. SEARCH METHODS We searched MEDLINE, CINAHL, Global Index Medicus and Scopus until 17 November 2022. We also applied reference checking and citation searching to identify additional studies. We searched for studies in any language. SELECTION CRITERIA We included qualitative studies and mixed-methods studies with qualitative data collection and analysis methods examining the implementation of new or existing Hospital at Home services from the perspective of different stakeholders. DATA COLLECTION AND ANALYSIS Two authors independently selected the studies, extracted study characteristics and intervention components, assessed the methodological limitations using the Critical Appraisal Skills Checklist (CASP) and assessed the confidence in the findings using GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research). We applied thematic synthesis to synthesise the data across studies and identify factors that may influence the implementation of Hospital at Home. MAIN RESULTS From 7535 records identified from database searches and one identified from citation tracking, we included 52 qualitative studies exploring the implementation of Hospital at Home services (31 Early Discharge, 16 Admission Avoidance, 5 combined services), across 13 countries and from the perspectives of 662 service-level staff (clinicians, managers), eight systems-level staff (commissioners, insurers), 900 patients and 417 caregivers. Overall, we judged 40 studies as having minor methodological concerns and we judged 12 studies as having major concerns. Main concerns included data collection methods (e.g. not reporting a topic guide), data analysis methods (e.g. insufficient data to support findings) and not reporting ethical approval. Following synthesis, we identified 12 findings graded as high (n = 10) and moderate (n = 2) confidence and classified them into four themes: (1) development of stakeholder relationships and systems prior to implementation, (2) processes, resources and skills required for safe and effective implementation, (3) acceptability and caregiver impacts, and (4) sustainability of services. AUTHORS' CONCLUSIONS Implementing Admission Avoidance and Early Discharge Hospital at Home services requires early development of policies, stakeholder engagement, efficient admission processes, effective communication and a skilled workforce to safely and effectively implement person-centred Hospital at Home, achieve acceptance by staff who refer patients to these services and ensure sustainability. Future research should focus on lower-income country and rural settings, and the perspectives of systems-level stakeholders, and explore the potential negative impact on caregivers, especially for Admission Avoidance Hospital at Home, as this service may become increasingly utilised to manage rising visits to emergency departments.
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Affiliation(s)
- Jason A Wallis
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Cabrini Health, Malvern, Australia
| | - Sasha Shepperd
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Petra Makela
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Jia Xi Han
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Evie M Tripp
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Emma Gearon
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Gary Disher
- New South Wales Ministry of Health, St Leonards, Australia
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Denise O'Connor
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Bostock C. Hospital at home: Opportunity knocks or opportunity costs? J R Coll Physicians Edinb 2024; 54:94-97. [PMID: 38433584 DOI: 10.1177/14782715241234082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024] Open
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10
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Westby M, Ijaz S, Savović J, McLeod H, Dawson S, Welsh T, Le Roux H, Walsh N, Bradley N. Virtual wards for people with frailty: what works, for whom, how and why-a rapid realist review. Age Ageing 2024; 53:afae039. [PMID: 38482985 PMCID: PMC10938537 DOI: 10.1093/ageing/afae039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND Virtual wards (VWs) deliver multidisciplinary care at home to people with frailty who are at high risk of a crisis or in crisis, aiming to mitigate the risk of acute hospital admission. Different VW models exist, and evidence of effectiveness is inconsistent. AIM We conducted a rapid realist review to identify different VW models and to develop explanations for how and why VWs could deliver effective frailty management. METHODS We searched published and grey literature to identify evidence on multidisciplinary VWs. Information on how and why VWs might 'work' was extracted and synthesised into context-mechanism-outcome configurations with input from clinicians and patient/public contributors. RESULTS We included 17 peer-reviewed and 11 grey literature documents. VWs could be short-term and acute (1-21 days), or longer-term and preventative (typically 3-7 months). Effective VW operation requires common standards agreements, information sharing processes, an appropriate multidisciplinary team that plans patient care remotely, and good co-ordination. VWs may enable delivery of frailty interventions through appropriate selection of patients, comprehensive assessment including medication review, integrated case management and proactive care. Important components for patients and caregivers are good communication with the VW, their experience of care at home, and feeling involved, safe and empowered to manage their condition. CONCLUSIONS Insights gained from this review could inform implementation or evaluation of VWs for frailty. A combination of acute and longer-term VWs may be needed within a whole system approach. Proactive care is recommended to avoid frailty-related crises.
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Affiliation(s)
- Maggie Westby
- The National Institute for Health and Care Research, Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol BS1 2NT, UK
- Bristol Medical School, University of Bristol, Bristol BS8 2PS, UK
| | - Sharea Ijaz
- The National Institute for Health and Care Research, Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol BS1 2NT, UK
- Bristol Medical School, University of Bristol, Bristol BS8 2PS, UK
| | - Jelena Savović
- The National Institute for Health and Care Research, Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol BS1 2NT, UK
- Bristol Medical School, University of Bristol, Bristol BS8 2PS, UK
| | - Hugh McLeod
- The National Institute for Health and Care Research, Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol BS1 2NT, UK
- Bristol Medical School, University of Bristol, Bristol BS8 2PS, UK
| | - Sarah Dawson
- The National Institute for Health and Care Research, Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol BS1 2NT, UK
- Bristol Medical School, University of Bristol, Bristol BS8 2PS, UK
| | - Tomas Welsh
- Bristol Medical School, University of Bristol, Bristol BS8 2PS, UK
- RICE – The Research Institute for the Care of Older People, Bath, UK
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Hein Le Roux
- Churchdown Surgery, Parton Rd, Churchdown, Gloucester GL3 2JH, UK
- NHS England and NHS Improvement South West, Somerset, UK
- One Gloucestershire Integrated Care System Quality Improvement, Gloucester, UK
| | - Nicola Walsh
- The National Institute for Health and Care Research, Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol BS1 2NT, UK
- Centre for Health & Clinical Research, University of the West of England, Bristol BS16 1DD, UK
| | - Natasha Bradley
- School of Nursing and Midwifery, Queens University Belfast, Belfast BT7 1NN, UK
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11
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Pandit JA, Pawelek JB, Leff B, Topol EJ. The hospital at home in the USA: current status and future prospects. NPJ Digit Med 2024; 7:48. [PMID: 38413704 PMCID: PMC10899639 DOI: 10.1038/s41746-024-01040-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 02/14/2024] [Indexed: 02/29/2024] Open
Abstract
The annual cost of hospital care services in the US has risen to over $1 trillion despite relatively worse health outcomes compared to similar nations. These trends accentuate a growing need for innovative care delivery models that reduce costs and improve outcomes. HaH-a program that provides patients acute-level hospital care at home-has made significant progress over the past two decades. Technological advancements in remote patient monitoring, wearable sensors, health information technology infrastructure, and multimodal health data processing have contributed to its rise across hospitals. More recently, the COVID-19 pandemic brought HaH into the mainstream, especially in the US, with reimbursement waivers that made the model financially acceptable for hospitals and payors. However, HaH continues to face serious challenges to gain widespread adoption. In this review, we evaluate the peer-reviewed evidence and discuss the promises, challenges, and what it would take to tap into the future potential of HaH.
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Affiliation(s)
- Jay A Pandit
- Scripps Translational Research Institute, Scripps Research, La Jolla, CA, USA.
| | - Jeff B Pawelek
- Scripps Translational Research Institute, Scripps Research, La Jolla, CA, USA
| | - Bruce Leff
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Eric J Topol
- Scripps Translational Research Institute, Scripps Research, La Jolla, CA, USA
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12
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van Goor HMR, de Hond TAP, van Loon K, Breteler MJM, Kalkman CJ, Kaasjager KAH. Designing a Virtual Hospital-at-Home Intervention for Patients with Infectious Diseases: A Data-Driven Approach. J Clin Med 2024; 13:977. [PMID: 38398291 PMCID: PMC10889708 DOI: 10.3390/jcm13040977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/25/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Virtual hospital-at-home care might be an alternative to standard hospital care for patients with infectious diseases. In this study, we explore the potential for virtual hospital-at-home care and a potential design for this population. METHODS This was a retrospective cohort study of internal medicine patients suspected of infectious diseases, admitted between 1 January and 31 December 2019. We collected information on delivered care during emergency department visits, the first 24 h, between 24 and 72 h, and after 72 h of admission. Care components that could be delivered at home were combined into care packages, and the potential number of eligible patients per package was described. The most feasible package was described in detail. RESULTS 763 patients were included, mostly referred for general internal medicine (35%), and the most common diagnosis was lower respiratory tract infection (27%). The most frequently administered care components were laboratory tests, non-oral medication, and intercollegiate consultation. With a combination of telemonitoring, video consultation, non-oral medication administration, laboratory tests, oxygen therapy, and radiological diagnostics, 48% of patients were eligible for hospital-at-home care, with 35% already eligible directly after emergency department visits. CONCLUSION While the potential for virtual hospital-at-home care is high, it depends greatly on which care can be arranged.
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Affiliation(s)
- Harriët M. R. van Goor
- Department of Internal Medicine, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
- Department of Anesthesiology, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
| | - Titus A. P. de Hond
- Department of Internal Medicine, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
| | - Kim van Loon
- Department of Internal Medicine, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
- Department of Anesthesiology, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
| | - Martine J. M. Breteler
- Department of Internal Medicine, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
- Department of Anesthesiology, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
- Department of Digital Health, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
| | - Cor J. Kalkman
- Department of Anesthesiology, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
| | - Karin A. H. Kaasjager
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
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13
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Chen H, Ignatowicz A, Skrybant M, Lasserson D. An integrated understanding of the impact of hospital at home: a mixed-methods study to articulate and test a programme theory. BMC Health Serv Res 2024; 24:163. [PMID: 38308304 PMCID: PMC10835828 DOI: 10.1186/s12913-024-10619-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 01/18/2024] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND Hospital at Home (HaH) provides intensive, hospital-level care in patients' homes for acute conditions that would normally require hospitalisation, using multidisciplinary teams. As a programme of complex medical-social interventions, a HaH programme theory has not been fully articulated although implicit in the structures, functions, and activities of the existing HaH services. We aimed to unearth the tacit theory from international evidence and test the soundness of it by studying UK HaH services. METHODS We conducted a literature review (29 articles) adopting a 'realist review' approach (theory articulation) and examined 11 UK-based services by interviewing up to 3 staff members from each service (theory testing). The review and interview data were analysed using Framework Analysis and Purposive Text Analysis. RESULTS The programme theory has three components- the organisational, utilisation and impact theories. The impact theory consists of key assumptions about the change processes brought about by HaH's activities and functions, as detailed in the organisational and utilisation theories. HaH teams should encompass multiple disciplines to deliver comprehensive assessments and have skill sets for physically delivering hospital-level processes of care in the home. They should aim to treat a broad range of conditions in patients who are clinically complex and felt to be vulnerable to hospital acquired harms. Services should cover 7 days a week, have plans for 24/7 response and deliver relational continuity of care through consistent staffing. As a result, patients' and carers' knowledge, skills, and confidence in disease management and self-care should be strengthened with a sense of safety during HaH treatment, and carers better supported to fulfil their role with minimal added care burden. CONCLUSIONS There are organisational factors for HaH services and healthcare processes that contribute to better experience of care and outcomes for patients. HaH services should deliver care using hospital level processes through teams that have a focus on holistic and individually tailored care with continuity of therapeutic relationships between professionals and patients and carers resulting in less complexity and fragmentation of care. This analysis informs how HaH services can organise resources and design processes of care to optimise patient satisfaction and outcomes.
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Affiliation(s)
- Hong Chen
- Warwick Medical School, Gibbet Hill Campus, University of Warwick, Coventry, CV4 7AL, UK
| | - Agnieszka Ignatowicz
- Murray Learning Centre, Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TTT, UK
| | - Magdalena Skrybant
- Murray Learning Centre, Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TTT, UK
| | - Daniel Lasserson
- Warwick Medical School, Gibbet Hill Campus, University of Warwick, Coventry, CV4 7AL, UK.
- Department of Geriatric Medicine, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, UK.
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14
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Chen H, Ignatowicz A, Lasserson DS. The Essentials for Implementing and Operating Hospital at Home: Lessons Learned from UK Health Care Professionals. J Am Med Dir Assoc 2024; 25:279-281. [PMID: 38122826 DOI: 10.1016/j.jamda.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 11/08/2023] [Indexed: 12/23/2023]
Affiliation(s)
- Hong Chen
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Agnieszka Ignatowicz
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Daniel S Lasserson
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, United Kingdom.
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15
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Elias TCN, Jacklin C, Bowen J, Lasserson DS, Pendlebury ST. Care pathways in older patients seen in a multidisciplinary same day emergency care (SDEC) unit. Age Ageing 2024; 53:afad257. [PMID: 38275098 PMCID: PMC10811520 DOI: 10.1093/ageing/afad257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Same day emergency care (SDEC) services are being advocated in the UK for frail, older patients in whom hospitalisation may be associated with harm but there are few data on the 'ambulatory pathway'. We therefore determined the patient pathways pre- and post-first assessment in a SDEC unit focussed on older people. METHODS In consecutive patients, we prospectively recorded follow-up SDEC service reviews (face-to-face, telephone, Hospital-at-Home domiciliary visits), outpatient referrals (e.g. to specialist clinics, imaging, and community/voluntary/social services), and hospital admissions <30 days. In the first 67 patients, we also recorded healthcare interactions (except GP attendances) in the 180 days pre- and post-first assessment. RESULTS Among 533 patients (mean/SD age = 75.0/17.5 years, 246, 46% deemed frail) assessed in an SDEC unit, 210 were admitted within 30 days (152 immediately). In the 381(71%) remaining initially ambulatory, there were 587 SDEC follow-up reviews and 747 other outpatient referrals (mean = 3.5 per patient) with only 34 (9%) patients being discharged with no further follow-up. In the subset (n = 67), the number of 'healthcare days' was greater in the 180 days post- versus pre-SDEC assessment (mean/SD = 26/27 versus 13/22 days, P = 0.003) even after excluding hospital admission days, with greater healthcare days in frail versus non-frail patients. DISCUSSION AND CONCLUSION SDEC assessment in older, frail patients was associated with a 2-fold increase in frequency of healthcare interactions with complex care pathways involving multiple services. Our findings have implications for the development of admission-avoidance models including cost-effectiveness and optimal delivery of the multi-dimensional aspects of acute geriatric care in the ambulatory setting.
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Affiliation(s)
- Tania C N Elias
- Departments of Acute Internal Medicine and Older Persons' Services, Great Western Hospital NHS Foundation Trust, Swindon SN3 6BB, UK
| | - Chloe Jacklin
- Departments of Care of the Elderly and Stroke Medicine, North Middlesex University Hospital NHS Trust, Sterling Way, London N18 1QX, UK
| | - Jordan Bowen
- Department of Acute Internal Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Daniel S Lasserson
- Department of Acute Internal Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK
- NIHR Applied Research Collaboration (ARC) West Midlands, Warwick Medical School, University of Warwick, Coventry, Warwickshire CV4 3AL, UK
- Department of Acute Medicine, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham B18 7QH, UK
| | - Sarah T Pendlebury
- Department of Acute Internal Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK
- Nuffield Department of Clinical Neurosciences, Wolfson Centre for Prevention of Stroke and Dementia, John Radcliffe Hospital, and the University of Oxford, Oxford, UK
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Knight T, Kamwa V, Atkin C, Green C, Ragunathan J, Lasserson D, Sapey E. Acute care models for older people living with frailty: a systematic review and taxonomy. BMC Geriatr 2023; 23:809. [PMID: 38053044 PMCID: PMC10699071 DOI: 10.1186/s12877-023-04373-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 10/03/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND The need to improve the acute care pathway to meet the care needs of older people living with frailty is a strategic priority for many healthcare systems. The optimal care model for this patient group is unclear. METHODS A systematic review was conducted to derive a taxonomy of acute care models for older people with acute medical illness and describe the outcomes used to assess their effectiveness. Care models providing time-limited episodes of care (up to 14 days) within 48 h of presentation to patients over the age of 65 with acute medical illness were included. Care models based in hospital and community settings were eligible. Searches were undertaken in Medline, Embase, CINAHL and Cochrane databases. Interventions were described and classified in detail using a modified version of the TIDIeR checklist for complex interventions. Outcomes were described and classified using the Core Outcome Measures in Effectiveness Trials (COMET) taxonomy. Risk of bias was assessed using RoB2 and ROBINS-I. RESULTS The inclusion criteria were met by 103 articles. Four classes of acute care model were identified, acute-bed based care, hospital at home, emergency department in-reach and care home models. The field is dominated by small single centre randomised and non-randomised studies. Most studies were judged to be at risk of bias. A range of outcome measures were reported with little consistency between studies. Evidence of effectiveness was limited. CONCLUSION Acute care models for older people living with frailty are heterogenous. The clinical effectiveness of these models cannot be conclusively established from the available evidence. TRIAL REGISTRATION PROSPERO registration (CRD42021279131).
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Affiliation(s)
- Thomas Knight
- Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK.
| | - Vicky Kamwa
- Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
| | - Catherine Atkin
- Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
| | - Catherine Green
- Department of Geriatric Medicine, Whiston Hospital, Mersey and West Lancashire Teaching Hospital NHS Trust, Prescot, L35 5DR, UK
| | - Janahan Ragunathan
- Department of Geriatric Medicine, Royal Bolton NHS Foundation Trust, Bolton, BL4 0JR, UK
| | - Daniel Lasserson
- Warwick Medical School, Professor of Acute and Ambulatory Care, University of Warwick, Coventry, CV4 7AL, UK
| | - Elizabeth Sapey
- Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
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Gagliano M, Bula CJ, Seematter-Bagnoud L, Michalski-Monnerat C, Nguyen S, Carron PN, Mabire C. Older patients referred for geriatric consultation in the emergency department: characteristics and healthcare utilization. BMC Geriatr 2023; 23:642. [PMID: 37817072 PMCID: PMC10565963 DOI: 10.1186/s12877-023-04321-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 09/15/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Comprehensive geriatric assessment (CGA) is difficult to perform in the emergency department (ED) environment and performance of screening tools in identifying vulnerable older ED patients who are best candidates for a geriatric consultation remain questionable. AIM To determine the characteristics of older patients referred for a geriatric consultation by ED staff and to investigate these patients' subsequent healthcare utilization. METHODS Secondary analysis of data previously collected for a prospective observational study of patients aged 75 + years visiting the ED of an academic hospital in Switzerland over four months (Michalski-Monnerat et al., J Am Geriatr Soc 68(12):2914-20, 2020). Socio-demographic, health, functional (basic activities of daily living; BADL), cognitive, and affective status data were collected at admission by a research nurse using a standardized brief geriatric assessment. Information on geriatric consultations, hospitalization, discharge destination, and 30-day readmission were retrieved from hospital database. Bivariable and multivariable analyses were performed using this data set collected previously. RESULTS Thirty-two (15.8%) of the 202 enrolled patients were referred for a geriatric consultation. Compared to the others, they were older (84.9 ± 5.4 vs 82.9 ± 5.4 years, p = .03), more impaired in BADL (4.8 ± 1.6 vs 5.5 ± 1.0, p = .01), with more comorbid conditions (5.3 ± 1.5 vs 4.5 ± 1.9, p = .03), more frequently admitted after a fall (43.7% vs 19.4%, p = .01), and hospitalized over the previous 6-month period (53.1% vs 30.6%, p = .02). Multivariable analyses that adjusted for variables significantly associated with outcomes in bivariable analysis found that being admitted after a fall (AdjOR 4.0, 95%CI 1.7-9.4, p < .01) and previously hospitalized (AdjOR 2.7, 95% CI 1.2-6.2, p = .02) remained associated with increased odds of consultation, whereas the inverse association with BADL performance remained (AdjOR 0.7, 95%CI 0.5-0.9, p = .01). Patients referred for geriatric consultation had higher odds of hospitalization (84.4% vs 49.4%; AdjOR 5.9, 95%CI 2.1-16.8, p < .01), but similar odds of home discharge when admitted, and of 30-day readmission. CONCLUSION About one in six older ED patients were referred for a geriatric consultation who appeared to be those most vulnerable, as suggested by their increased hospitalization rate. Alternative strategies are needed to enhance access to geriatric consultation in the ED.
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Affiliation(s)
- Mariangela Gagliano
- Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital and University of Lausanne, Chemin de Mont Paisible 16, Lausanne, CH-1011, Switzerland.
- Department of Geriatrics, Rehabilitation and Palliative Care, Neuchâtel Hospital Network, Rue du Chasseral 20, La Chaux-de-Fonds, CH-2300, Switzerland.
| | - Christophe J Bula
- Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital and University of Lausanne, Chemin de Mont Paisible 16, Lausanne, CH-1011, Switzerland
| | - Laurence Seematter-Bagnoud
- Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital and University of Lausanne, Chemin de Mont Paisible 16, Lausanne, CH-1011, Switzerland
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Route de la Corniche 10, Lausanne, CH-1010, Switzerland
| | - Carole Michalski-Monnerat
- Department of Internal Medicine, Neuchâtel Hospital Network, Rue de la Maladière 45, Neuchâtel, CH-2000, Switzerland
- Institute of Higher Education and Research in Healthcare-IUFRS, Lausanne University Hospital and University of Lausanne, Route de la Corniche 10, Lausanne, CH-1010, Switzerland
| | - Sylvain Nguyen
- Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital and University of Lausanne, Chemin de Mont Paisible 16, Lausanne, CH-1011, Switzerland
| | - Pierre-Nicolas Carron
- Emergency Department, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, Lausanne, CH-1011, Switzerland
| | - Cédric Mabire
- Institute of Higher Education and Research in Healthcare-IUFRS, Lausanne University Hospital and University of Lausanne, Route de la Corniche 10, Lausanne, CH-1010, Switzerland
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Böttinger MJ, Litz E, Gordt-Oesterwind K, Jansen CP, Memmer N, Mychajliw C, Radeck L, Bauer JM, Becker C. Co-Creating a Digital Life-Integrated Self-Assessment for Older Adults: User Experience Study. JMIR Aging 2023; 6:e46738. [PMID: 37751274 PMCID: PMC10565622 DOI: 10.2196/46738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 07/10/2023] [Accepted: 08/04/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Older adults are at increased risk of developing health disorders and functional decline. However, owing to time constraints and considerable effort, physicians rarely conduct comprehensive assessments to detect early signs of negative trajectories. If designed properly, digital technologies could identify health risks already at a preclinical stage, thereby facilitating preventive efforts and targeted intervention. For this purpose, a Life-integrated Self-Assessment (LiSA) tablet system will be developed through a structured co-creation process. OBJECTIVE This study aims to investigate older adults' perceptions of different self-assessment domains, components affecting user experience, risks and benefits associated with LiSA, characteristics of potential LiSA users, and the LiSA concept in general. METHODS A total of 10 community-dwelling older adults aged ≥70 years were recruited. In total, 6 co-creation workshops were held and started with expert input followed by semistructured discussion rounds. Participants performed hands-on activities with a tablet, including testing of preinstalled self-assessment apps. All workshops were audio recorded and additionally documented by the researchers using flipcharts, notes, and photos. Qualitative content analysis was used to analyze the data following a deductive-inductive approach guided by the Optimized Honeycomb Model for user experience. RESULTS The group (mean age 77.8, SD 5.1 years) was heterogeneous in terms of previous technology experience and health status. The mean workshop duration was 2 hours (122.5, SD 4.43 min), and an average of 8 (SD 1.15) participants attended each workshop. A total of 11 thematic categories were identified, covering results on all research questions. Participants emphasized a strong interest in conducting a digital self-assessment of physical activity and function and sensory and cognitive functions and requested additional features such as recommendations for actions or reminders. LiSA was perceived as empowering and a motivator to engage in active health care planning as well as enabling shared and informed decision-making. Concerns and barriers included the lack of technical competence, feelings of frustration, and fear of being left alone, with negative assessment results. In essence, participants expressed a positive attitude toward using LiSA repeatedly and identified it as an option to increase the chances of maintaining independence when growing older. CONCLUSIONS The co-creation participants supported the LiSA approach and were interested in performing regular self-assessments on a long-term basis. In their opinion, LiSA should include relevant assessments capturing physical activity and function and sensory and cognitive functions as well as recommendations for actions. It should be customizable to individual needs. These results will form the basis for a prototype. Iterative development and validation will aim to make LiSA accessible in the public domain as a reliable tablet-based system for self-assessment.
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Affiliation(s)
- Melissa J Böttinger
- Digital Unit, Center for Geriatric Medicine, Heidelberg University Hospital, Heidelberg, Germany
- Network Aging Research, Heidelberg University, Heidelberg, Germany
| | - Elena Litz
- Digital Unit, Center for Geriatric Medicine, Heidelberg University Hospital, Heidelberg, Germany
- Network Aging Research, Heidelberg University, Heidelberg, Germany
| | - Katharina Gordt-Oesterwind
- Digital Unit, Center for Geriatric Medicine, Heidelberg University Hospital, Heidelberg, Germany
- Network Aging Research, Heidelberg University, Heidelberg, Germany
- Institute of Sports and Sports Sciences, Heidelberg University, Heidelberg, Germany
| | - Carl-Philipp Jansen
- Digital Unit, Center for Geriatric Medicine, Heidelberg University Hospital, Heidelberg, Germany
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert Bosch Hospital, Stuttgart, Germany
| | - Nicole Memmer
- Network Aging Research, Heidelberg University, Heidelberg, Germany
| | - Christian Mychajliw
- Geriatric Center, University Hospital of Tübingen, Tübingen, Germany
- Department of Psychiatry and Psychotherapy, University Hospital of Tübingen, Tübingen, Germany
| | - Leon Radeck
- Institute for Computer Science, Heidelberg University, Heidelberg, Germany
| | - Jürgen M Bauer
- Digital Unit, Center for Geriatric Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Clemens Becker
- Digital Unit, Center for Geriatric Medicine, Heidelberg University Hospital, Heidelberg, Germany
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert Bosch Hospital, Stuttgart, Germany
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Conroy S, Brailsford S, Burton C, England T, Lalseta J, Martin G, Mason S, Maynou-Pujolras L, Phelps K, Preston L, Regen E, Riley P, Street A, van Oppen J. Identifying models of care to improve outcomes for older people with urgent care needs: a mixed methods approach to develop a system dynamics model. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-183. [PMID: 37830206 DOI: 10.3310/nlct5104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
Background We aimed to understand urgent and emergency care pathways for older people and develop a decision support tool using a mixed methods study design. Objective(s), study design, settings and participants Work package 1 identified best practice through a review of reviews, patient, carer and professional interviews. Work package 2 involved qualitative case studies of selected urgent and emergency care pathways in the Yorkshire and Humber region. Work package 3 analysed linked databases describing urgent and emergency care pathways identifying patient, provider and pathway factors that explain differences in outcomes and costs. Work package 4 developed a system dynamics tool to compare emergency interventions. Results A total of 18 reviews summarising 128 primary studies found that integrated social and medical care, screening and assessment, follow-up and monitoring of service outcomes were important. Forty patient/carer participants described emergency department attendances; most reported a reluctance to attend. Participants emphasised the importance of being treated with dignity, timely and accurate information provision and involvement in decision-making. Receiving care in a calm environment with attention to personal comfort and basic physical needs were key. Patient goals included diagnosis and resolution, well-planned discharge home and retaining physical function. Participants perceived many of these goals of care were not attained. A total of 21 professional participants were interviewed and 23 participated in focus groups, largely confirming the review evidence. Implementation challenges identified included the urgent and emergency care environment, organisational approaches to service development, staff skills and resources. Work package 2 involved 45 interviews and 30 hours of observation in four contrasting emergency departments. Key themes relating to implementation included: intervention-related staff: frailty mindset and behaviours resources: workforce, space, and physical environment operational influences: referral criteria, frailty assessment, operating hours, transport. context-related links with community, social and primary care organisation and management support COVID-19 pandemic. approaches to implementation service/quality improvement networks engaging staff and building relationships education about frailty evidence. The linked databases in work package 3 comprised 359,945 older people and 1,035,045 observations. The most powerful predictors of four-hour wait and transfer to hospital were age, previous attendance, out-of-hours attendance and call handler designation of urgency. Drawing upon the previous work packages and working closely with a wide range of patient and professional stakeholders, we developed an system dynamics tool that modelled five evidence-based urgent and emergency care interventions and their impact on the whole system in terms of reducing admissions, readmissions, and hospital related mortality. Limitations Across the reviews there was incomplete reporting of interventions. People living with severe frailty and from ethnic minorities were under-represented in the patient/carer interviews. The linked databases did not include patient reported outcomes. The system dynamics model was limited to evidence-based interventions, which could not be modelled conjointly. Conclusions We have reaffirmed the poor outcomes frequently experienced by many older people living with urgent care needs. We have identified interventions that could improve patient and service outcomes, as well as implementation tools and strategies to help including clinicians, service managers and commissioners improve emergency care for older people. Future work Future work will focus on refining the system dynamics model, specifically including patient-reported outcome measures and pre-hospital services for older people living with frailty who have urgent care needs. Study registrations This study is registered as PROSPERO CRD42018111461. WP 1.2: University of Leicester ethics: 17525-spc3-ls:healthsciences, WP 2: IRAS 262143, CAG 19/CAG/0194, WP 3: IRAS 215818, REC 17/YH/0024, CAG 17/CAG/0024. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme [project number 17/05/96 (Emergency Care for Older People)] and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 14. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Simon Conroy
- Geriatrician, George Davies Centre, University of Leicester, Leichester, UK
| | - Sally Brailsford
- Southampton Business School, University of Southampton, Southampton, UK
| | - Christopher Burton
- Academic Unit of Medical Education, University of Sheffield, Sheffield, UK
| | - Tracey England
- Health Sciences, University of Southampton, Southampton, UK
| | - Jagruti Lalseta
- Leicester Older Peoples' Research Forum, University of Leicester, Leicester, UK
| | - Graham Martin
- Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK
| | - Suzanne Mason
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Kay Phelps
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Louise Preston
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Emma Regen
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Peter Riley
- Leicester older peoples' research forum, University of Leicester, Leicester, UK
| | - Andrew Street
- Department of Health Policy, London School of Economics, London, UK
| | - James van Oppen
- Department of Health Sciences, University of Leicester, Leicester, UK
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González Anglada MI, Garmendia Fernández C, Moreno Núñez L. [Home hospitalisation: Opportunities and needs]. J Healthc Qual Res 2023; 38:195-196. [PMID: 36872155 DOI: 10.1016/j.jhqr.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 02/03/2023] [Indexed: 03/06/2023]
Affiliation(s)
- María Isabel González Anglada
- Hospitalización a Domicilio, Unidad de Medicina Interna, Hospital Universitario Fundación Alcorcón, Alorcón, Madrid, España.
| | - Cristina Garmendia Fernández
- Hospitalización a Domicilio, Unidad de Medicina Interna, Hospital Universitario Fundación Alcorcón, Alorcón, Madrid, España
| | - Leonor Moreno Núñez
- Hospitalización a Domicilio, Unidad de Medicina Interna, Hospital Universitario Fundación Alcorcón, Alorcón, Madrid, España
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Sadler E, Khadjesari Z, Ziemann A, Sheehan KJ, Whitney J, Wilson D, Bakolis I, Sevdalis N, Sandall J, Soukup T, Corbett T, Gonçalves-Bradley DC, Walker DM. Case management for integrated care of older people with frailty in community settings. Cochrane Database Syst Rev 2023; 5:CD013088. [PMID: 37218645 PMCID: PMC10204122 DOI: 10.1002/14651858.cd013088.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
BACKGROUND Ageing populations globally have contributed to increasing numbers of people living with frailty, which has significant implications for use of health and care services and costs. The British Geriatrics Society defines frailty as "a distinctive health state related to the ageing process in which multiple body systems gradually lose their inbuilt reserves". This leads to an increased susceptibility to adverse outcomes, such as reduced physical function, poorer quality of life, hospital admissions, and mortality. Case management interventions delivered in community settings are led by a health or social care professional, supported by a multidisciplinary team, and focus on the planning, provision, and co-ordination of care to meet the needs of the individual. Case management is one model of integrated care that has gained traction with policymakers to improve outcomes for populations at high risk of decline in health and well-being. These populations include older people living with frailty, who commonly have complex healthcare and social care needs but can experience poorly co-ordinated care due to fragmented care systems. OBJECTIVES To assess the effects of case management for integrated care of older people living with frailty compared with usual care. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, Health Systems Evidence, and PDQ Evidence and databases from inception to 23 September 2022. We also searched clinical registries and relevant grey literature databases, checked references of included trials and relevant systematic reviews, conducted citation searching of included trials, and contacted topic experts. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared case management with standard care in community-dwelling people aged 65 years and older living with frailty. DATA COLLECTION AND ANALYSIS We followed standard methodological procedures recommended by Cochrane and the Effective Practice and Organisation of Care Group. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS We included 20 trials (11,860 participants), all of which took place in high-income countries. Case management interventions in the included trials varied in terms of organisation, delivery, setting, and care providers involved. Most trials included a variety of healthcare and social care professionals, including nurse practitioners, allied healthcare professionals, social workers, geriatricians, physicians, psychologists, and clinical pharmacists. In nine trials, the case management intervention was delivered by nurses only. Follow-up ranged from three to 36 months. We judged most trials at unclear risk of selection and performance bias; this consideration, together with indirectness, justified downgrading the certainty of the evidence to low or moderate. Case management compared to standard care may result in little or no difference in the following outcomes. • Mortality at 12 months' follow-up (7.0% in the intervention group versus 7.5% in the control group; risk ratio (RR) 0.98, 95% confidence interval (CI) 0.84 to 1.15; I2 = 11%; 14 trials, 9924 participants; low-certainty evidence) • Change in place of residence to a nursing home at 12 months' follow-up (9.9% in the intervention group versus 13.4% in the control group; RR 0.73, 95% CI 0.53 to 1.01; I2 = 0%; 4 trials, 1108 participants; low-certainty evidence) • Quality of life at three to 24 months' follow-up (results not pooled; mean differences (MDs) ranged from -6.32 points (95% CI -11.04 to -1.59) to 6.1 points (95% CI -3.92 to 16.12) when reported; 11 trials, 9284 participants; low-certainty evidence) • Serious adverse effects at 12 to 24 months' follow-up (results not pooled; 2 trials, 592 participants; low-certainty evidence) • Change in physical function at three to 24 months' follow-up (results not pooled; MDs ranged from -0.12 points (95% CI -0.93 to 0.68) to 3.4 points (95% CI -2.35 to 9.15) when reported; 16 trials, 10,652 participants; low-certainty evidence) Case management compared to standard care probably results in little or no difference in the following outcomes. • Healthcare utilisation in terms of hospital admission at 12 months' follow-up (32.7% in the intervention group versus 36.0% in the control group; RR 0.91, 95% CI 0.79 to 1.05; I2 = 43%; 6 trials, 2424 participants; moderate-certainty evidence) • Change in costs at six to 36 months' follow-up (results not pooled; 14 trials, 8486 participants; moderate-certainty evidence), which usually included healthcare service costs, intervention costs, and other costs such as informal care. AUTHORS' CONCLUSIONS We found uncertain evidence regarding whether case management for integrated care of older people with frailty in community settings, compared to standard care, improved patient and service outcomes or reduced costs. There is a need for further research to develop a clear taxonomy of intervention components, to determine the active ingredients that work in case management interventions, and identify how such interventions benefit some people and not others.
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Affiliation(s)
- Euan Sadler
- School of Health Sciences, University of Southampton, Southampton, UK
- Southern Health NHS Foundation Trust, Southampton, UK
| | | | - Alexandra Ziemann
- Department of Social & Policy Sciences, University of Bath, Bath, UK
| | - Katie J Sheehan
- School of Life Course & Population Sciences, King's College London, London, UK
| | - Julie Whitney
- School of Life Course & Population Sciences, King's College London, London, UK
- Department of Clinical Gerontology, King's College Hospital NHS Foundation Trust, London, UK
| | - Dan Wilson
- Department of Clinical Gerontology, King's College Hospital NHS Foundation Trust, London, UK
| | - Ioannis Bakolis
- Health Service & Population Research Department, King's College London, London, UK
| | - Nick Sevdalis
- Centre for Behavioural & Implementation Science Interventions (BISI), National University of Singapore, Singapore, Singapore
| | - Jane Sandall
- Department of Women and Children's Health, King's College London, London, UK
| | - Tayana Soukup
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Teresa Corbett
- Faculty of Sport, Health and Social Sciences, Solent University, Southampton, UK
| | | | - Dawn-Marie Walker
- School of Health Sciences, University of Southampton, Southampton, UK
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22
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Boucher EL, Gan JM, Rothwell PM, Shepperd S, Pendlebury ST. Prevalence and outcomes of frailty in unplanned hospital admissions: a systematic review and meta-analysis of hospital-wide and general (internal) medicine cohorts. EClinicalMedicine 2023; 59:101947. [PMID: 37138587 PMCID: PMC10149337 DOI: 10.1016/j.eclinm.2023.101947] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/17/2023] [Accepted: 03/21/2023] [Indexed: 05/05/2023] Open
Abstract
Background Guidelines recommend routine frailty screening for all hospitalised older adults to inform care decisions, based mainly on studies in elective or speciality-specific settings. However, most hospital bed days are accounted for by acute non-elective admissions, in which the prevalence and prognostic value of frailty might differ, and uptake of screening is limited. We therefore did a systematic review and meta-analysis of frailty prevalence and outcomes in unplanned hospital admissions. Methods We searched MEDLINE, EMBASE and CINAHL up to 31/01/2023 and included observational studies using validated frailty measures in adult hospital-wide or general medicine admissions. Summary data on the prevalence of frailty and associated outcomes, measurement tools, study setting (hospital-wide vs general medicine), and design (prospective vs retrospective) were extracted and risk of bias assessed (modified Joanna Briggs Institute checklists). Unadjusted relative risks (RR; moderate/severe frailty vs no/mild) for mortality (within one year), length of stay (LOS), discharge destination and readmission were calculated and pooled, where appropriate, using random-effects models. PROSPERO CRD42021235663. Findings Among 45 cohorts (median/SD age = 80/5 years; n = 39,041,266 admissions, n = 22 measurement tools) moderate/severe frailty ranged from 14.3% to 79.6% overall (and in the 26 cohorts with low-moderate risk of bias) with considerable heterogeneity between studies (phet < 0.001) preventing pooling of results but with rates <25% in only 3 cohorts. Moderate/severe vs no/mild frailty was associated with increased mortality (n = 19 cohorts; RR range = 1.08-3.70), more consistently among cohorts using clinically administered tools (n = 11; RR range = 1.63-3.70; phet = 0.08; pooled RR = 2.53, 95% CI = 2.15-2.97) vs cohorts using (retrospective) administrative coding data (n = 8; RR range = 1.08-3.02; phet < 0.001). Clinically administered tools also predicted increasing mortality across the full range of frailty severity in each of the six cohorts that allowed ordinal analysis (all p < 0.05). Moderate/severe vs no/mild frailty was also associated with a LOS >8 days (RR range = 2.14-3.04; n = 6) and discharge to a location other than home (RR range = 1.97-2.82; n = 4) but was inconsistently related to 30-day readmission (RR range = 0.83-1.94; n = 12). Associations remained clinically significant after adjustment for age, sex and comorbidity where reported. Interpretation Frailty is common in older patients with acute, non-elective hospital admission and remains predictive of mortality, LOS and discharge home with more severe frailty associated with greater risk, justifying more widespread implementation of screening using clinically administered tools. Funding None.
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Affiliation(s)
- Emily L. Boucher
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Jasmine M. Gan
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Peter M. Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Sasha Shepperd
- Nuffield Department of Population Health, University of Oxford, UK
| | - Sarah T. Pendlebury
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
- NIHR Oxford Biomedical Research Centre and Departments of Acute General (Internal) Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, UK
- Corresponding author. Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, John Radcliffe Hospital, Oxford, OX3 9DU, UK.
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Kristensen GS, Kjeldgaard AH, Søndergaard J, Andersen-Ranberg K, Pedersen AK, Mogensen CB. Associations between care home residents' characteristics and acute hospital admissions - a retrospective, register-based cross-sectional study. BMC Geriatr 2023; 23:234. [PMID: 37072701 PMCID: PMC10114422 DOI: 10.1186/s12877-023-03895-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 03/15/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Care home residents are frail, multi-morbid, and have an increased risk of experiencing acute hospitalisations and adverse events. This study contributes to the discussion on preventing acute admissions from care homes. We aim to describe the residents' health characteristics, survival after care home admission, contacts with the secondary health care system, patterns of admissions, and factors associated with acute hospital admissions. METHOD Data on all care home residents aged 65 + years living in Southern Jutland in 2018-2019 (n = 2601) was enriched with data from highly valid Danish national health registries to obtain information on characteristics and hospitalisations. Characteristics of care home residents were assessed by sex and age group. Factors associated with acute admissions were analysed using Cox Regression. RESULTS Most care home residents were women (65.6%). Male residents were younger at the time of care home admission (mean 80.6 vs. 83.7 years), had a higher prevalence of morbidities, and shorter survival after care home admission. The 1-year survival was 60.8% and 72.3% for males and females, respectively. Median survival was 17.9 months and 25.9 months for males and females, respectively. The mean rate of acute hospitalisations was 0.56 per resident-year. One in four (24.4%) care home residents were discharged from the hospital within 24 h. The same proportion was readmitted within 30 days of discharge (24.6%). Admission-related mortality was 10.9% in-hospital and 13.0% 30 days post-discharge. Male sex was associated with acute hospital admissions, as was a medical history of various cardiovascular diseases, cancer, chronic obstructive pulmonary disease, and osteoporosis. In contrast, a medical history of dementia was associated with fewer acute admissions. CONCLUSION This study highlights some of the major characteristics of care home residents and their acute hospitalisations and contributes to the ongoing discussion on improving or preventing acute admissions from care homes. TRIAL REGISTRATION Not relevant.
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Affiliation(s)
- Gitte Schultz Kristensen
- Emergency Department, Aabenraa Hospital, Department of Regional Health Research, Faculty of Health Science, University Hospital of Southern Jutland, University of Southern Denmark, Odense, Denmark.
| | | | - Jens Søndergaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Karen Andersen-Ranberg
- Geriatric Research Unit, Department of Clinical Research, Department of Public Health, Department of Regional Health Research, Faculty of Health Science, Clinical research Department, Aabenraa Hospital, University of Southern Denmark University Hospital of Southern Denmark, Odense, Denmark
| | - Andreas Kristian Pedersen
- Department of Regional Health Research, Faculty of Health Science, Emergency Department, Aabenraa Hospital, The University of Southern Denmark, University Hospital of Southern Denmark, Odense, Denmark
| | - Christian Backer Mogensen
- Department of Regional Health Research, Faculty of Health Science, Emergency Department, Aabenraa Hospital, The University of Southern Denmark, University Hospital of Southern Denmark, Odense, Denmark
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Pepping RMC, van Aken MO, Vos RC, Numans ME, van den Berg JMW, Kroon I, van Nieuwkoop C. Using Design Thinking for Co-Creating an Integrated Care Pathway Including Hospital at Home for Older Adults with an Acute Moderate-Severe Respiratory Infection in the Netherlands. Int J Integr Care 2023; 23:30. [PMID: 37360876 PMCID: PMC10289046 DOI: 10.5334/ijic.6991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 06/01/2023] [Indexed: 06/28/2023] Open
Abstract
Introduction Acute respiratory infections are common in frail, community-dwelling older people and are accompanied by considerable diagnostic and prognostic uncertainties. Inadequately coordinated care is associated with unnecessary hospital referral and admission with potential iatrogenic harm. Therefore, we aimed to co-create a regional integrated care pathway (ICP), including a hospital at home journey. Developing the ICP Tasked with using design thinking methodology, stakeholders from regional healthcare facilities, together with patient representatives, were assigned to different focus groups based on their expertise. The focus of each session was to co-create ideal patient journeys suitable for embedding in the ICP. Results Based on these sessions, a regional cross-domain ICP was developed that comprises three patient journeys. The first journey included a hospital at home track, the second a tailored visit, with priority assessment, to regional emergency departments, and the third concerned referral to readily available nursing home 'recovery-beds' under the supervision of an elderly care medicine specialist. Conclusion Using design thinking and involving end-users during the whole process, we created an ICP for community-dwelling frail older people with moderate-severe acute respiratory infections. This resulted in three realistic patient journeys, including a hospital at home track, which will be implemented and evaluated in the near future.
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Affiliation(s)
- Rianne M. C. Pepping
- Department of Public Health & Primary Care/Health Campus The Hague, Leiden University Medical Center, The Hague, The Netherlands
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Maarten O. van Aken
- Department of Public Health & Primary Care/Health Campus The Hague, Leiden University Medical Center, The Hague, The Netherlands
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Rimke C. Vos
- Department of Public Health & Primary Care/Health Campus The Hague, Leiden University Medical Center, The Hague, The Netherlands
| | - Mattijs E. Numans
- Department of Public Health & Primary Care/Health Campus The Hague, Leiden University Medical Center, The Hague, The Netherlands
| | | | - Ingrid Kroon
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
- Elderly Care Medicine, Florence Health & Care, The Hague, The Netherlands
| | - Cees van Nieuwkoop
- Department of Public Health & Primary Care/Health Campus The Hague, Leiden University Medical Center, The Hague, The Netherlands
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
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van Oppen J, Conroy S. Improving outcomes for older people with emergency care needs. Br J Hosp Med (Lond) 2023; 29:1-7. [PMID: 36989154 DOI: 10.12968/hmed.2022.0495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
This article describes work on emergency care for older people. It summarises patient experience in emergency care settings, the evidence base relating to improvement of outcomes and emerging interventions and describes tools that can support teams as they work on service improvement. Finally, it calls for the measurement of outcomes that matter to older people, as a mechanism to drive more person-centred approaches to emergency care.
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Affiliation(s)
- James van Oppen
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Simon Conroy
- MRC Unit for Lifelong Health and Ageing at UCL, University College London, London, UK
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Goldstein J, Lajeunesse D, Abawajy K, Luan A, Hancock K, Carter A, Greene JA, McVey J, Lee JS. Paramedic supportive discharge programmes to improve health system efficiency and patient outcomes: a scoping review protocol. BMJ Open 2023; 13:e066645. [PMID: 36797012 PMCID: PMC9936280 DOI: 10.1136/bmjopen-2022-066645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2023] Open
Abstract
INTRODUCTION Discharging older adults with frailty home from the emergency department (ED) poses unique challenges due to multiple interacting physical and social problems. Paramedic supportive discharge services help overcome these challenges by adding in-home assessment and/or interventions. Our objective is to describe existing paramedic programmes designed to support discharge from the ED or hospital to avoid unnecessary hospital admissions. A comprehensive description of paramedic supportive discharge services will be conducted by mapping the literature to describe: (1) why such programmes are needed; (2) who is being targeted, making referrals and delivering the services and (3) what assessments and interventions are offered. METHODS AND ANALYSIS We will include studies that focus on expanded paramedic roles (community paramedicine) and extended scope postdischarge from the ED or hospital. All study designs will be included with no limit by language. We will include peer-reviewed articles and preprints and a targeted search of grey literature from January 2000 to June 2022. The proposed scoping review will be conducted in accordance with the Joanna Briggs Institute methodology. We will use a search strategy designed by a health science librarian to search MEDLINE All (Ovid), CINAHL Full Text (EBSCO), Embase (Elsevier) and Scopus (Elsevier) for eligible studies from 2000 to present. Two independent reviewers will conduct screening and full-text review. Data extraction will be conducted by one reviewer and verified by another. We will report our findings descriptively by charting trends in the research. ETHICS AND DISSEMINATION Research ethics review is not required as this is a scoping review comprised published studies. The results of this research will be published in a manuscript and presented at national and international geriatric and emergency medicine conferences. This research will inform future implementation studies on community paramedic supportive discharge services. REGISTRATION This scoping review protocol was registered in Open Science Framework and can be found here: https://doi.org/10.17605/OSF.IO/X52P7.
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Affiliation(s)
- Judah Goldstein
- Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Dominic Lajeunesse
- System Performance, Emergency Health Services, Halifax, Nova Scotia, Canada
| | - Khadija Abawajy
- Dalhousie Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Angela Luan
- Emergency Medicine, Sinai Health/ Schwartz/Reisman Emergency Medicine Institute, Toronto, Ontario, Canada
| | - Kristy Hancock
- Nova Scotia Health, Maritime SPOR SUPPORT Unit, Halifax, Nova Scotia, Canada
| | - Alix Carter
- Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jennifer Anne Greene
- Division of EMS, Dalhousie University Faculty of Medicine, Halifax, Nova Scotia, Canada
| | - Jen McVey
- System Performance, Emergency Health Services, Halifax, Nova Scotia, Canada
| | - Jacques Simon Lee
- Emergency Medicine, Schwartz Reisman Emergency Medicine Institute, Toronto, Ontario, Canada
- Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada
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Ribbink ME, de Vries-Mols WCBM, MacNeil Vroomen JL, Franssen R, Resodikromo MN, Buurman BM. Facilitators and barriers to implementing an acute geriatric community hospital in the Netherlands: a qualitative study. Age Ageing 2023; 52:6754358. [PMID: 36729468 PMCID: PMC9894102 DOI: 10.1093/ageing/afac206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 05/04/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND there is a trend across Europe to enable more care at the community level. The Acute Geriatric Community Hospital (AGCH) in the Netherlands in an acute geriatric unit situated in a skilled nursing facility (SNF). It provides hospital-level care for older adults with acute medical conditions. The aim of this study is to identify barriers and facilitators associated with implementing the AGCH in a SNF. METHODS semi-structured interviews (n = 42) were carried out with clinical and administrative personnel at the AGCH and university hospital and stakeholders from the partnering care organisations and health insurance company. Data were analysed using thematic analysis. RESULTS facilitators to implementing the AGCH concept were enthusiasm for the AGCH concept, organising preparatory sessions, starting with low-complex patients, good team leadership and ongoing education of the AGCH team. Other facilitators included strong collaboration between stakeholders, commitment to shared investment costs and involvement of regulators.Barriers to implementation were providing hospital care in an SNF, financing AGCH care, difficulties selecting patients at the emergency department, lack of protocols and guidelines, electronic health records unsuited for hospital care, department layout on two different floors and complex shared business operations. Furthermore, transfer of acute care to the community care meant that some care was not reimbursed. CONCLUSIONS the AGCH concept was valued by all stakeholders. The main facilitators included the perceived value of the AGCH concept and enthusiasm of stakeholders. Structural financing is an obstacle to the expansion and continuation of this care model.
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Affiliation(s)
- Marthe E Ribbink
- Address correspondence to: Marthe E. Ribbink, Amsterdam UMC, University of Amsterdam, Department of Internal Medicine, Section of Geriatric Medicine, Room D3-335, PO Box 22600, 1100 DD Amsterdam, The Netherlands. Tel: (+31) 20 5661647.
| | - Wieteke C B M de Vries-Mols
- Amsterdam University Medical Centre, University of Amsterdam, Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Janet L MacNeil Vroomen
- Amsterdam University Medical Centre, University of Amsterdam, Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Remco Franssen
- Amsterdam University Medical Centre, University of Amsterdam, Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Melissa N Resodikromo
- Amsterdam University Medical Centre, University of Amsterdam, Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Bianca M Buurman
- Amsterdam University Medical Centre, University of Amsterdam, Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands,ACHIEVE- Centre of Applied Research, Amsterdam University of Applied Sciences, Faculty of Health, Amsterdam, The Netherlands
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England T, Brailsford S, Evenden D, Street A, Maynou L, Mason SM, Preston L, Burton C, Van Oppen J, Conroy S. Examining the effect of interventions in emergency care for older people using a system dynamics decision support tool. Age Ageing 2023; 52:6998041. [PMID: 36702512 PMCID: PMC9879714 DOI: 10.1093/ageing/afac336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Rising demand for Emergency and Urgent Care is a major international issue and outcomes for older people remain sub-optimal. Embarking upon large-scale service development is costly in terms of time, energy and resources with no guarantee of improved outcomes; computer simulation modelling offers an alternative, low risk and lower cost approach to explore possible interventions. METHOD A system dynamics computer simulation model was developed as a decision support tool for service planners. The model represents patient flow through the emergency care process from the point of calling for help through ED attendance, possible admission, and discharge or death. The model was validated against five different evidence-based interventions (geriatric emergency medicine, front door frailty, hospital at home, proactive care and acute frailty units) on patient outcomes such as hospital-related mortality, readmission and length of stay. RESULTS The model output estimations are consistent with empirical evidence. Each intervention has different levels of effect on patient outcomes. Most of the interventions show potential reductions in hospital admissions, readmissions and hospital-related deaths. CONCLUSIONS System dynamics modelling can be used to support decisions on which emergency care interventions to implement to improve outcomes for older people.
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Affiliation(s)
- Tracey England
- Address correspondence to: Tracey England, Southampton Business School, University of Southampton, Highfield, Southampton SO17 1BJ, UK.
| | - Sally Brailsford
- Southampton Business School, University of Southampton, Highfield, Southampton, UK
| | - Dave Evenden
- Southampton Business School, University of Southampton, Highfield, Southampton, UK
| | - Andrew Street
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Laia Maynou
- Department of Health Policy, London School of Economics and Political Science, London, UK,Department of Economics, Econometrics and Applied Economics, Universitat de Barcelona, Barcelona, Spain,Center for Research in Health and Economics is a research unit within the Universitat Pompeu Fabra, Barcelona, Spain
| | - Suzanne M Mason
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Louise Preston
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Christopher Burton
- Academic Unit of Primary Medical Care, University of Sheffield, Samuel Fox House, Northern General Hospital, Sheffield, UK
| | - James Van Oppen
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Simon Conroy
- MRC Unit for Lifelong Health and Ageing at University College London, London, UK
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Norman G, Bennett P, Vardy ERLC. Virtual wards: a rapid evidence synthesis and implications for the care of older people. Age Ageing 2023; 52:afac319. [PMID: 36633298 PMCID: PMC9835137 DOI: 10.1093/ageing/afac319] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 11/11/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Virtual wards are being rapidly developed within the National Health Service in the UK, and frailty is one of the first clinical pathways. Virtual wards for older people and existing hospital at home services are closely related. METHODS In March 2022, we searched Medline, CINAHL, the Cochrane Database of Systematic Reviews and medRxiv for evidence syntheses which addressed clinical-effectiveness, cost-effectiveness, barriers and facilitators, or staff, patient or carer experience for virtual wards, hospital at home or remote monitoring alternatives to inpatient care. RESULTS We included 28 evidence syntheses mostly relating to hospital at home. There is low to moderate certainty evidence that clinical outcomes including mortality (example pooled RR 0.77, 95% CI 0.60-0.99) were probably equivalent or better for hospital at home. Subsequent residential care admissions are probably reduced (example pooled RR 0.35, 95% CI 0.22-0.57). Cost-effectiveness evidence demonstrated methodological issues which mean the results are uncertain. Evidence is lacking on cost implications for patients and carers. Barriers and facilitators operate at multiple levels (organisational, clinical and patient). Patient satisfaction may be improved by hospital at home relative to inpatient care. Evidence for carer experience is limited. CONCLUSIONS There is substantial evidence for the clinical effectiveness of hospital at home but less evidence for virtual wards. Guidance for virtual wards is lacking on key aspects including team characteristics, outcome selection and data protection. We recommend that research and evaluation is integrated into development of virtual ward models. The issue of carer strain is particularly relevant.
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Affiliation(s)
- Gill Norman
- Division of Nursing, Midwifery & Social Work; School of Health Sciences; Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
- NIHR Applied Research Collaboration Greater Manchester, University of Manchester, Oxford Road, Manchester, UK
| | - Paula Bennett
- Health Innovation Manchester, City Labs, Nelson Street, Manchester, UK
| | - Emma R L C Vardy
- Salford Care Organisation, Northern Care Alliance NHS Foundation Trust, Stott Lane, Salford, UK
- Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Oxford Road, Manchester, UK
- NIHR Applied Research Collaboration Greater Manchester, University of Manchester, Oxford Road, Manchester, UK
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McGlen S, Crowley C, Lasserson D, Qamariat ZAL, Lim RHM. Hospital at home: A systematic review of how medication management is conceptualised, described and implemented in practice-A study protocol. PLoS One 2023; 18:e0268846. [PMID: 36701265 PMCID: PMC9879423 DOI: 10.1371/journal.pone.0268846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 01/04/2023] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Hospital at Home (H@H) is a method of healthcare delivery, where hospital level interventions are conducted in the patient's usual place of residence, offering an alternative to hospital admission. This often includes the ability to perform point of care diagnostics and treat conditions using a range of treatments traditionally associated with hospital admission, including intravenous medicines and oxygen. H@H services have been established worldwide but there is a wide variation in definition and delivery models and currently no documented evidence supporting the delivery of medicines and medicines management within the H@H model. Therefore, this study aims to 1) describe how medication management in H@H is conceptulised, 2) describe and identify key components of medication management in H@H and 3) describe and identify variability in the implementation of medication management services within H@H models. METHODS AND ANALYSIS We will search a range of databases (PubMed, Medline, Embase, CINAHL), publicly accessible documents and expert recommendations. Studies, reports and policy documents published between 1st January 2000 and 31st January 2022 will be included. Two independent reviewers will 1) screen and select studies based on a priori inclusion/exclusion, 2) conduct quality assessment using the Mixed Methods Appraisal Tool on included studies and 3) extract data. Inductive thematic analysis (objectives 1 and 2), the SEIPS 2.0 model (objective 2) and the Consolidated Framework for Implementation Research (objective 3) will be used to synthesise data. ETHICS AND DISSEMINATION This systematic review will use secondary data sources from published documents, and as such research ethical approval was not required. We will disseminate the findings of this study in a peer-reviewed journal and national/international conference(s). TRIAL REGISTRATION PROSPERO registration number: CRD42022300691. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022300691.
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Affiliation(s)
- Sophie McGlen
- Oxford University Hospitals NHS Foundation Trusts, Oxford, United Kingdom
| | - Clare Crowley
- Reading School of Pharmacy, University of Reading, Reading, Berkshire, United Kingdom
| | - Daniel Lasserson
- Oxford University Hospitals NHS Foundation Trusts, Oxford, United Kingdom
- Warwick Medical School, University of Warwick, Warwick, United Kingdom
| | - Zahra A. L. Qamariat
- Pharmaceutical Affairs, Critical Care, Dammam Medical Complex, Eastern Health Cluster, Dammam, Saudi Arabia
| | - Rosemary H. M. Lim
- Reading School of Pharmacy, University of Reading, Reading, Berkshire, United Kingdom
- * E-mail:
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Smith H, Grindey C, Hague I, Newbould L, Brown L, Clegg A, Thompson C, Lawton R. Reducing delayed transfer of care in older people: A qualitative study of barriers and facilitators to shorter hospital stays. Health Expect 2022; 25:2628-2644. [PMID: 36193616 DOI: 10.1111/hex.13588] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 07/11/2022] [Accepted: 08/09/2022] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Growing numbers of older patients occupy hospital beds despite being 'medically fit' for discharge. These Delayed Transfers of Care amplify inefficiencies in care and can cause harm. Delayed transfer because of family or patient choice is common; yet, research on patient and family perspectives is scarce. To identify barriers to, and facilitators of, shorter hospital stays, we sought to understand older people's and caregivers' thoughts and feelings about the benefits and harms of being in hospital and the decisions made at discharge. METHODS A multimethod qualitative study was carried out. Content analysis was carried out of older people's experiences of health or care services submitted to the Care Opinion online website, followed by telephone and video interviews with older people and family members of older people experiencing a hospital stay in the previous 12 months. RESULTS Online accounts provide insight into how care was organized for older people in the hospital, including deficiencies in care organization, the discharge process and communication, as well as how care was experienced by older people and family members. Interview-generated themes included shared meanings of hospitalization and discharge experiences and the context of discharge decisions including failure in communication systems, unwarranted variation and lack of confidence in care and lack of preparation for ongoing care. CONCLUSION Poor quality and availability of information, and poor communication, inhibit effective transfer of care. Communication is fundamental to patient-centred care and even more important in discharge models characterized by limited assessments and quicker discharge. Interventions at the service level and targeted patient information about what to expect in discharge assessments and after discharge could help to address poor communication and support for improving discharge of older people from hospital. PATIENT OR PUBLIC CONTRIBUTION The Frailty Oversight Group, a small group of older people providing oversight of the Community Aging Research 75+ study, provided feedback on the research topic and level of interest, the draft data collection tools and the feasibility of collecting data with older people during the COVID-19 pandemic. The group also reviewed preliminary findings and provided feedback on our interpretation.
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Affiliation(s)
- Helen Smith
- Improvement Science Theme, NIHR Applied Research Collaboration Yorkshire and Humber, Bradford Institute for Health Research, Bradford, UK
| | - Chloe Grindey
- Improvement Science Theme, NIHR Applied Research Collaboration Yorkshire and Humber, Bradford Institute for Health Research, Bradford, UK
| | - Isabel Hague
- Improvement Science Theme, NIHR Applied Research Collaboration Yorkshire and Humber, Bradford Institute for Health Research, Bradford, UK
| | - Louise Newbould
- Social Policy Research Unit (SPRU), University of York, York, UK
| | - Lesley Brown
- Academic Unit for Aging and Stroke Research, Bradford Institute for Health Research, Bradford, UK
| | - Andrew Clegg
- Academic Unit for Aging and Stroke Research, Bradford Institute for Health Research, Bradford, UK
| | - Carl Thompson
- School of Healthcare, Faculty of Medicine and Health, University of Leeds, Leeds, UK
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Hosoi T, Yamana H, Tamiya H, Matsui H, Fushimi K, Akishita M, Yasunaga H, Ogawa S. Association between comprehensive geriatric assessment and polypharmacy at discharge in patients with ischaemic stroke: A nationwide, retrospective, cohort study. EClinicalMedicine 2022; 50:101528. [PMID: 35784439 PMCID: PMC9241103 DOI: 10.1016/j.eclinm.2022.101528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 06/01/2022] [Accepted: 06/06/2022] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Polypharmacy and its adverse drug events are a major healthcare challenge related to falls, hospitalisations and mortality. Comprehensive geriatric assessment (CGA) may contribute to polypharmacy improvement, however, there is no clear evidence so far. METHODS Using a national inpatient database in Japan from April 1, 2014 to March 31, 2018, we investigated the association between CGA and polypharmacy. We identified patients aged ≥65 years admitted for ischaemic stroke who could receive oral medications. Propensity score matching was conducted for patients with and without CGA during hospitalisation. The outcomes were polypharmacy (defined as use of five or more types of oral medications) at discharge, the number of medication types prescribed at discharge, and the difference between the numbers of medication types prescribed on admission and at discharge. FINDINGS A total of 162,443 patients were analysed, of whom 39,356 (24·2%) received CGA, and propensity score matching identified 39,349 pairs. Compared with non-CGA group, the CGA group had a significantly lower proportion of polypharmacy at discharge (34·3% vs. 32·9%, p < 0·001) and a smaller number of medication types prescribed at discharge (3·84 vs. 3·76, p < 0·001). INTERPRETATION This study shows the clear evidence that there is a positive relationship between CGA and a reduction in the number of medications in older inpatients with ischaemic stroke. FUNDING The Ministry of Health, Labour and Welfare, Japan and the Ministry of Education, Culture, Sports, Science and Technology, Japan.
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Affiliation(s)
- Tatsuya Hosoi
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Hayato Yamana
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Hiroyuki Tamiya
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Masahiro Akishita
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Sumito Ogawa
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
- Corresponding author at: Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
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Leary A. Saved bed days: the ultimate currency. BMJ 2022; 378:o1686. [PMID: 35798355 DOI: 10.1136/bmj.o1686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Dean J, Jones M, Dyer P, Moulton C, Price V, Lasserson D. Possible futures of acute medical care in the NHS: a multispecialty approach. Future Healthc J 2022; 9:125-132. [DOI: 10.7861/fhj.2022-0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ko SQ, Goh J, Tay YK, Nashi N, Hooi BMY, Luo N, Kuan WS, Soong JTY, Chan D, Lai YF, Lim YW. Treating acutely ill patients at home: Data from Singapore. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022; 51:392-399. [PMID: 35906938 DOI: 10.47102/annals-acadmedsg.2021465] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Hospital-at-home programmes are well described in the literature but not in Asia. We describe a home-based inpatient substitutive care programme in Singapore, with clinical and patient-reported outcomes. METHODS We conducted a retrospective cohort study of patients admitted to a hospital-at-home programme from September 2020 to September 2021. Suitable patients, who otherwise required hospitalisation, were admitted to the programme. They were from inpatient wards, emergency department and community nursing teams in the western part of Singapore, where a multidisciplinary team provided hospital-level care at home. Electronic health record data were extracted from all patients admitted to the programme. Patient satisfaction surveys were conducted post-discharge. RESULTS A total of 108 patients enrolled. Mean age was 67.9 (standard deviation 16.7) years, and 46% were male. The main diagnoses were skin and soft tissue infections (35%), urinary tract infections (29%) and fluid overload (18%). Median length of stay was 4 (interquartile range 3-7) days. Seven patients were escalated back to the hospital, of whom 2 died after escalation. One patient died at home. There was 1 case of adverse drug reaction and 1 fall at home, and no cases of hospital-acquired infections. Patient satisfaction rates were high and 94% of contactable patients would choose to participate again. CONCLUSION Hospital-at-home programmes appear to be safe and feasible alternatives to inpatient care in Singapore. Further studies are warranted to compare clinical outcomes and cost to conventional inpatient care.
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Affiliation(s)
- Stephanie Q Ko
- Department of Medicine, National University Hospital, Singapore
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Bove DG, Christensen PE, Gjersøe P, Lavesen M. Patients' experiences of being treated for acute illness at home as an alternative to hospital admission: a qualitative study in Denmark. BMJ Open 2022; 12:e060490. [PMID: 35613764 PMCID: PMC9174770 DOI: 10.1136/bmjopen-2021-060490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE We aimed to investigate the experiences of Danish patients treated at home for an acute illness instead of being hospitalised. DESIGN This study had a qualitative design inspired by the methodology of interpretive description. Data were collected through semistructured interviews. SETTING Home treatment was conducted by a team of nurses (n=10-15) supported by physiotherapists and physicians, all affiliated with an emergency department, located in the capital region of Denmark. Interviews were conducted between August 2020 and April 2021. PARTICIPANTS Twenty-one patients, aged 34-94 years, narrated their experiences of being treated at home for an acute illness. RESULTS The overarching theme in our analyses was that 'being the centre of the nurses' attention provided safety, patient involvement and quality of life during home treatment'. The following six themes emerged from analyses: (1) exclusive attention facilitates involvement and activity; (2) hospitals are for the sick; (3) maintaining a meaningful everyday life; (4) the hospital exudes productivity and busyness; (5) family relations and roles are maintained; (6) and concerns of deterioration. CONCLUSIONS From a patient's perspective, home treatment made sense and was perceived as a quality improvement. Being the centre of nurses' attention induced a sense of safety, involvement and enhanced quality of life among patients during the treatment course for an acute illness.
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Affiliation(s)
- Dorthe Gaby Bove
- Department of Clinical Research, Nordsjællands Hospital, Hillerod, Denmark
- Centre for Nursing, University College Absalon, Campus Roskilde, Roskilde, Denmark
| | | | - Peter Gjersøe
- Department of Emergency Medicine, Nordsjællands Hospital, Hillerod, Denmark
| | - Marie Lavesen
- Department of Emergency Medicine, Nordsjællands Hospital, Hillerod, Denmark
- Helsingør Rehabilitation and Training Center, Helsingør Municipality, Helsingør, Denmark
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Briggs R, McDonough A, Ellis G, Bennett K, O'Neill D, Robinson D. Comprehensive Geriatric Assessment for community-dwelling, high-risk, frail, older people. Cochrane Database Syst Rev 2022; 5:CD012705. [PMID: 35521829 PMCID: PMC9074104 DOI: 10.1002/14651858.cd012705.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Comprehensive Geriatric Assessment (CGA) is a multidimensional interdisciplinary diagnostic process focused on determining an older person's medical, psychological and functional capability in order to develop a co-ordinated and integrated care plan. CGA is not limited simply to assessment, but also directs a holistic management plan for older people, which leads to tangible interventions. While there is established evidence that CGA reduces the likelihood of death and disability in acutely unwell older people, the effectiveness of CGA for community-dwelling, frail, older people at risk of poor health outcomes is less clear. OBJECTIVES To determine the effectiveness of CGA for community-dwelling, frail, older adults at risk of poor health outcomes in terms of mortality, nursing home admission, hospital admission, emergency department visits, serious adverse events, functional status, quality of life and resource use, when compared to usual care. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, three trials registers (WHO ICTRP, ClinicalTrials.gov and McMaster Aging Portal) and grey literature up to April 2020; we also checked reference lists and contacted study authors. SELECTION CRITERIA We included randomised trials that compared CGA for community-dwelling, frail, older people at risk of poor healthcare outcomes to usual care in the community. Older people were defined as 'at risk' either by being frail or having another risk factor associated with poor health outcomes. Frailty was defined as a vulnerability to sudden health state changes triggered by relatively minor stressor events, placing the individual at risk of poor health outcomes, and was measured using objective screening tools. Primary outcomes of interest were death, nursing home admission, unplanned hospital admission, emergency department visits and serious adverse events. CGA was delivered by a team with specific gerontological training/expertise in the participant's home (domiciliary Comprehensive Geriatric Assessment (dCGA)) or other sites such as a general practice or community clinic (community Comprehensive Geriatric Assessment (cCGA)). DATA COLLECTION AND ANALYSIS Two review authors independently extracted study characteristics (methods, participants, intervention, outcomes, notes) using standardised data collection forms adapted from the Cochrane Effective Practice and Organisation of Care (EPOC) data collection form. Two review authors independently assessed the risk of bias for each included study and used the GRADE approach to assess the certainty of evidence for outcomes of interest. MAIN RESULTS We included 21 studies involving 7893 participants across 10 countries and four continents. Regarding selection bias, 12/21 studies used random sequence generation, while 9/21 used allocation concealment. In terms of performance bias, none of the studies were able to blind participants and personnel due to the nature of the intervention, while 14/21 had a blinded outcome assessment. Eighteen studies were at low risk of attrition bias, and risk of reporting bias was low in 7/21 studies. Fourteen studies were at low risk of bias in terms of differences of baseline characteristics. Three studies were at low risk of bias across all domains (accepting that it was not possible to blind participants and personnel to the intervention). CGA probably leads to little or no difference in mortality during a median follow-up of 12 months (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.76 to 1.02; 18 studies, 7151 participants (adjusted for clustering); moderate-certainty evidence). CGA results in little or no difference in nursing home admissions during a median follow-up of 12 months (RR 0.93, 95% CI 0.76 to 1.14; 13 studies, 4206 participants (adjusted for clustering); high-certainty evidence). CGA may decrease the risk of unplanned hospital admissions during a median follow-up of 14 months (RR 0.83, 95% CI 0.70 to 0.99; 6 studies, 1716 participants (adjusted for clustering); low-certainty evidence). The effect of CGA on emergency department visits is uncertain and evidence was very low certainty (RR 0.65, 95% CI 0.26 to 1.59; 3 studies, 873 participants (adjusted for clustering)). Only two studies (1380 participants; adjusted for clustering) reported serious adverse events (falls) with no impact on the risk; however, evidence was very low certainty (RR 0.82, 95% CI 0.58 to 1.17). AUTHORS' CONCLUSIONS CGA had no impact on death or nursing home admission. There is low-certainty evidence that community-dwelling, frail, older people who undergo CGA may have a reduced risk of unplanned hospital admission. Further studies examining the effect of CGA on emergency department visits and change in function and quality of life using standardised assessments are required.
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Affiliation(s)
- Robert Briggs
- Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
| | - Anna McDonough
- Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
| | - Graham Ellis
- Medicine for the Elderly, Monklands Hospital, Airdrie, UK
| | - Kathleen Bennett
- Department of Pharmacology and Therapeutics, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Desmond O'Neill
- Centre for Ageing, Neuroscience and the Humanities, Trinity College, Dublin, Ireland
| | - David Robinson
- Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
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Hospital at Home for Elderly COVID-19 Patients: A Preliminary Report with 100 Patients. J Clin Med 2022; 11:jcm11071850. [PMID: 35407458 PMCID: PMC8999675 DOI: 10.3390/jcm11071850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/15/2022] [Accepted: 03/23/2022] [Indexed: 12/24/2022] Open
Abstract
Hospital-at-home (HaH) care is useful for patients with COVID-19 and an alternative strategy when hospital capacity is under pressure due to patient surges. However, the efficacy and safety of HaH in elderly patients with COVID-19 remain unknown. In Kyoto city, we conducted a retrospective medical record review of HaH care focused on elderly COVID-19 patients from 4 February to 25 June 2021. Eligible patients were (1) COVID-19 patients aged ≥70 years and those who lived with them or (2) COVID-19 patients aged <70 years with special circumstances and those who lived with them. During the study period, 100 patients received HaH care. Their median age was 76 years (interquartile range 56−83), and 65% were over 70 years. Among 100 patients, 36 (36%) had hypoxia (oxygen saturation ≤ 92%), 21 (21%) received steroid medication, and 34 (34%) received intravenous fluids. Although 22 patients were admitted to the hospital and 3 patients died there, no patients died during HaH care. HaH care may be safe and effective in elderly patients with COVID-19. Our study shows that HaH provides an alternative strategy for treating COVID-19 patients and can reduce the healthcare burden at hospitals.
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Vardy E, Roberts S, Pratt H. Delirium can be safely managed in the community through implementation of a community toolkit: a proof-of-concept pilot study. Future Healthc J 2022; 9:83-86. [DOI: 10.7861/fhj.2021-0157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Alghamry A, Lee JC. The ABCD of the comprehensive geriatric assessment. Med J Aust 2022; 216:211. [DOI: 10.5694/mja2.51405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 09/27/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Alaa Alghamry
- Northside Clinical Unit University of Queensland Brisbane QLD
| | - Joseph C Lee
- Northside Clinical Unit University of Queensland Brisbane QLD
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Mooijaart SP, Carpenter CR, Conroy SP. Geriatric emergency medicine-a model for frailty friendly healthcare. Age Ageing 2022; 51:6550832. [PMID: 35307733 DOI: 10.1093/ageing/afab280] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Indexed: 11/12/2022] Open
Abstract
As the world's population continues to age over the decades ahead, medical educators and researchers in every adult medical and surgical specialty will need to 'geriatricise' their clinical science. Many have already engaged with geriatrics. Here we describe the progress that has been made and the opportunities ahead in the field of Geriatric Emergency Medicine (GEM), a field that has taken large steps in integrating holistic care. Future opportunities exist in the three domains of evidence-based medicine: including patient preferences and needs, generating scientific evidence, and improving physician knowledge and expertise. Implementation requires new innovations also in the organisation of care. Similar strategies may be useful in other fields of medicine, in making holistic care the standard for older people.
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Affiliation(s)
- Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Christopher R Carpenter
- Emergency Care Research Core, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Simon P Conroy
- UCL MRC Unit for Lifelong Health and Ageing at UCL 5th Floor, 1-19 Torrington Place, London, WC1E7HB, UK
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Schiff R, Oyston M, Quinn M, Walters S, McEnhill P, Collins M. Hospital at Home: another piece of the armoury against COVID-19. Future Healthc J 2022; 9:90-95. [DOI: 10.7861/fhj.2021-0137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Nguyen HQ, Haupt EC, Duan L, Hou AC, Wang SE, Mariano JD, Lee JA, McMullen C. Hospital utilisation in home palliative care: caregiver health, preparedness and burden associations. BMJ Support Palliat Care 2022:bmjspcare-2021-003455. [PMID: 35078873 DOI: 10.1136/bmjspcare-2021-003455] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/06/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Prior studies show that family caregiver factors influence patient outcomes. The purpose of this analysis was to determine the association between family caregiver self-rated health, perception of preparedness and burden at the time of patient admission to home palliative care (HomePal) with downstream patient hospital utilisation and time to hospice enrolment and death. METHODS Data for this cohort study (n=441) were drawn from a trial testing two models of HomePal. Caregiver self-rated health, preparedness (Preparedness for Caregiving Scale, CPS) and burden (Zarit-12) were measured at admission to HomePal. Caregivers were categorised as having good/very good/excellent or fair/poor health, scoring above or below the CPS median score (23), or having no/mild (0-10), moderate (11-20) or high (>20) burden. Proportional hazard competing risk models assessed the association between caregiver factors with hospital utilisation (emergency department visits, observation and inpatient stays). RESULTS Patients whose caregivers reported poor health and low preparedness received more visits by home health aides and social workers, respectively (both, p<0.05). Adjusted models showed that worse caregiver health (HR: 0.69 (95% CI 0.52 to 0.92), p=0.01), low preparedness (HR: 0.73 (95% CI 0.57 to 0.94), p=0.01) and high burden (HR: 0.77 (95% CI 0.56 to 1.06), p=0.10) were associated with lower risk for hospital utilisation. There were no significant associations between caregiver factors with time to patient enrolment in hospice or death in adjusted models (both, p>0.05). CONCLUSION Prospective studies are needed to understand how greater in-home supports for family caregivers with poor health could help achieve quality palliative care that aligns with families' priorities. TRIAL REGISTRATION NUMBER NCT03694431; ClinicalTrials.gov.
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Affiliation(s)
- Huong Q Nguyen
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Eric C Haupt
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Lewei Duan
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Anthony C Hou
- Geriatrics, Palliative and Continuing Care, Kaiser Permanente Southern California, Los Angeles Medical Center, Los Angeles, California, USA
| | - Susan E Wang
- Geriatrics, Palliative and Continuing Care, Kaiser Permanente Southern California, West Los Angeles Medical Center, Los Angeles, California, USA
| | - Jeffrey D Mariano
- Geriatrics, Palliative and Continuing Care, Kaiser Permanente Southern California, West Los Angeles Medical Center, Los Angeles, California, USA
| | - Jung-Ah Lee
- Sue & Bill Gross School of Nursing, University of California Irvine, Irvine, California, USA
| | - Carmit McMullen
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
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Singh S, Gray A, Shepperd S, Stott DJ, Ellis G, Hemsley A, Khanna P, Ramsay S, Schiff R, Tsiachristas A, Wilkinson A, Young J. Is comprehensive geriatric assessment hospital at home a cost-effective alternative to hospital admission for older people? Age Ageing 2022; 51:afab220. [PMID: 34969074 PMCID: PMC8753046 DOI: 10.1093/ageing/afab220] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 07/15/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND hospital level healthcare in the home guided by comprehensive geriatric assessment (CGA) might provide a less costly alternative to hospitalisation for older people. OBJECTIVE to determine the cost-effectiveness of CGA admission avoidance hospital at home (HAH) compared with hospital admission. DESIGN/INTERVENTION a cost-effectiveness study alongside a randomised trial of CGA in an admission avoidance HAH setting, compared with admission to hospital. PARTICIPANTS/SETTING older people considered for a hospital admission in nine locations across the UK were randomised using a 2:1 randomisation schedule to admission avoidance HAH with CGA (N = 700), or admission to hospital with CGA when available (N = 355). MEASUREMENTS quality adjusted life years, resource use and costs at baseline and 6 months; incremental cost-effectiveness ratios were calculated. The main analysis used complete cases. RESULTS adjusting for baseline covariates, HAH was less costly than admission to hospital from a health and social care perspective (mean -£2,265, 95% CI: -4,279 to -252), and remained less costly with the addition of informal care costs (mean difference -£2,840, 95% CI: -5,495 to -185). There was no difference in quality adjusted survival. Using multiple imputation for missing data, the mean difference in health and social care costs widened to -£2,458 (95% CI: -4,977 to 61) and societal costs remained significantly lower (-£3,083, 95% CI: -5,880 to -287). There was little change to quality adjusted survival. CONCLUSIONS CGA HAH is a cost-effective alternative to admission to hospital for selected older people.
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Affiliation(s)
- Surya Singh
- Health Economics Research Centre, Nuffield Department of Population Health Sciences, Richard Doll Building, Old Road Campus, University of Oxford, Oxford OX3 7LF, UK
| | - Alastair Gray
- Health Economics Research Centre, Nuffield Department of Population Health Sciences, Richard Doll Building, Old Road Campus, University of Oxford, Oxford OX3 7LF, UK
| | - Sasha Shepperd
- Nuffield Department of Population Health Sciences, Richard Doll Building, Old Road Campus, University of Oxford, Oxford OX3 7LF, UK
| | - David J Stott
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, New Lister Building Glasgow Royal Infirmary G31 2ER, Glasgow, UK
| | - Graham Ellis
- University Hospital Monklands, NHS Lanarkshire, Monkscourt Avenue, Airdrie, ML6 0JS, UK
| | - Anthony Hemsley
- Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon EX2 5DW, UK
| | - Pradeep Khanna
- Aneurin Bevan University Health Board, Newport, South Wales, NP20 4SZ, UK
| | - Scott Ramsay
- St John’s Hospital, NHS Lothian, Howden W Rd, Howden, Livingston EH54 6PP, UK
| | - Rebekah Schiff
- Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Rd, Bishop's, London SE1 7EH, UK
| | - Apostolos Tsiachristas
- Health Economics Research Centre, Nuffield Department of Population Health Sciences, Richard Doll Building, Old Road Campus, University of Oxford, Oxford OX3 7LF, UK
| | - Angela Wilkinson
- Victoria Hospital, NHS Fife, Hayfield Rd, Kirkcaldy, KY2 5AH, UK
| | - John Young
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, UK
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Boone EJ, Shammash JB. Virtual Hospitalization at Home After the Covid-19 Pandemic: Time to Consider Our Future Community Healthcare Options. J Prim Care Community Health 2022; 13:21501319221112586. [PMID: 35838336 PMCID: PMC9289900 DOI: 10.1177/21501319221112586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
The concept of acute hospitalization at home has been described for over
3 decades. Its scope, however, was largely limited to small
experimental trials and pilot studies. The Covid-19 pandemic changed
these circumstances. The convergence of the critical need for acute
hospital beds along with the growing sophistication and comfort in
virtual monitoring facilitated the rapid deployment of hospitalization
at home throughout many communities in the United States. Now in the
waning times of the pandemic, community health leaders and health
systems are questioning what the future role of home virtual
hospitalization might be. Might this concept be relegated to only
future times of critical bed shortage, or might it be part of a true
change in community healthcare delivery.
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Affiliation(s)
- Emily J Boone
- Hackensack Meridian School of Medicine, Hackensack, NJ, USA
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Emergency department use and length of stay by younger and older adults: Nottingham cohort study in the emergency department (NOCED). Aging Clin Exp Res 2022; 34:2873-2885. [PMID: 36074240 PMCID: PMC9453701 DOI: 10.1007/s40520-022-02226-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 08/09/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Younger and older adults attending the Emergency Department (ED) are a heterogeneous population. Longer length of ED stay is associated with adverse outcomes and may vary by age. AIMS To evaluate the associations between age and (1) clinical characteristics and (2) length of ED stay among adults attending ED. METHODS The NOttingham Cohort study in the Emergency Department (NOCED)-a retrospective cohort study-comprises new consecutive ED attendances by adults ≥ 18 years, at a secondary/tertiary care hospital, in 2019. Length of ED stay was dichotomised as < 4 and ≥ 4 h. The associations between age and length of ED stay were analysed by binary logistic regression and adjusted for socio-demographic and clinical factors including triage acuity. RESULTS 146,636 attendances were analysed; 75,636 (51.6%) resulted in a length of ED stay ≥ 4 h. Attendances of adults aged 65 to 74 years, 75 to 84 years and ≥ 85 years, respectively, had an increased risk (odds ratio (95% confidence interval) of length of ED stay ≥ 4 h of 1.52 (1.45-1.58), 1.65 (1.58-1.72), and 1.84 (1.75-1.93), compared to those of adults 18 to 64 years (all p < 0.001). These findings remained consistent in the subsets of attendances leading to hospital admission and those leading to discharge from ED. DISCUSSION AND CONCLUSION In this real-world cohort study, older adults were more likely to have a length of ED stay ≥ 4 h, with the oldest old having the highest risk. ED target times should take into account age of attendees.
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Impact of multimorbidity and frailty on adverse outcomes among older delayed discharge patients: Implications for healthcare policy. Health Policy 2022; 126:197-206. [DOI: 10.1016/j.healthpol.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 01/08/2022] [Accepted: 01/10/2022] [Indexed: 11/22/2022]
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Nguyen HQ, Vallejo JD, Macias M, Shiffman MG, Rosen R, Mowry V, Omotunde O, Hong B, Liu ILA, Borson S. A mixed-methods evaluation of home-based primary care in dementia within an integrated system. J Am Geriatr Soc 2021; 70:1136-1146. [PMID: 34936090 DOI: 10.1111/jgs.17627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 11/07/2021] [Accepted: 12/01/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND No prior studies have examined the effects of home-based primary care (HBPC) in persons living with dementia (PLWD), within an ecosystem of serious illness care in an integrated healthcare system. Our objectives were to compare the characteristics of PLWD receiving HBPC and their hospital utilization and end-of-life care, with those of a matched comparison group, and to understand the experiences of family caregivers of PLWD receiving HBPC. METHODS This mixed-methods study used a retrospective observational cohort design with PLWD receiving HBPC (n = 287) from 2015 to 2020 and a strata-matched comparison group (n = 861), and qualitative phone interviews with 16 HBPC family caregivers in 2020. Inverse probability of treatment weighting propensity score-adjusted models were used to compare time-to-first hospital-based utilization and, for decedents, home palliative and hospice care and place of death. Care experience was captured through caregiver interviews. RESULTS Patients receiving HBPC had a similar risk of hospital utilization [adjusted hazard ratio, 1.06 (95% CI: 0.89-1.26), p = 0.51] as a matched non-HBPC comparison group after a median follow-up of 199 days. However, HBPC decedents (n = 159) were more likely to receive home palliative care or hospice [rate ratio, RR: 1.23 (95% CI: 1.07-1.42), p < 0.01] and to die at home [RR: 1.66 (95% CI: 1.35-2.05), p < 0.001] than were non-HBPC decedents (n = 423). Caregivers reported that HBPC provided coordinated, continuous, and convenient care that was aligned with families' priorities and goals; however, some expressed unmet needs, especially for help paying for personal care and medical supplies/equipment, and a desire for clearer communication about program operations and more quality oversight for contract services. CONCLUSIONS Although HBPC for PLWD was associated with a similar risk of hospital utilization compared to a matched non-HBPC comparison group, HBPC resulted in more patient-centered end-of-life care for decedents. Prospective studies of HBPC that further elicit and address unmet needs are warranted.
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Affiliation(s)
- Huong Q Nguyen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Jessica D Vallejo
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Mayra Macias
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | | | - Romina Rosen
- Woodland Hills Medical Center, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Velda Mowry
- Panorama City Medical Center, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Omotayo Omotunde
- Panorama City Medical Center, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Benjamin Hong
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - In-Lu Amy Liu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Soo Borson
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, Washington, USA.,Department of Family Medicine, University of Southern California Keck School of Medicine, Los Angeles, California, USA
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Oliver D. David Oliver: Zealotry risks making faster hospital discharge a cult. BMJ 2021; 375:n2994. [PMID: 34880070 DOI: 10.1136/bmj.n2994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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