Geriatric Consultation Reduces High-risk Medication Usage at Discharge in Elderly Trauma Patients

A scoping review of hospital-based geriatric-centered interventions on trauma surgery services

BACKGROUND

Millions of older adults (≥65) present to emergency departments for injury annually. As the population increases, so will the number of older adults admitted for trauma. Although treatment guidelines for older adults who sustain trauma exist, the evidence for quality improvement is limited. The purpose of this scoping review was to identify hospital-based geriatric-centered interventions that improve care for older adults admitted to trauma services.

METHODS

We searched MEDLINE, EMBASE, and CINAHL to identify studies related to geriatric-centered interventions on trauma surgery services (1993-2023). Five reviewers screened studies for full-text review based on these inclusion criteria: (1) older injured adults and/or their caregivers; (2) hospital-based clinical interventions directed to geriatric trauma patients (e.g., frailty assessments, geriatric co-management, triage criteria); and (3) measuring outcomes associated with geriatric trauma. We used the Donabedian quality improvement framework to categorize interventions as structures or processes.

RESULTS

Of 2243 abstracts, 66 studies met the criteria for full-text review, and 47 were included in the analysis. Most (64%) were single-site retrospective cohort studies at Level 1 trauma centers. The most frequent interventions (not mutually exclusive) included geriatric-centered teams (26%), geriatric consultation (23%), interdisciplinary rounds (17%), and medication review (11%). The most frequently measured clinical outcomes were length of stay (47%), discharge location (26%), and in-hospital mortality (21%). Two studies (4%) measured outcomes beyond 3 months. Patient-reported outcomes were rarely included (4%), and caregiver-specific outcomes were not measured.

CONCLUSIONS

This scoping review demonstrates the variability in the types of geriatric-centered interventions on trauma surgery services and their associated outcome measures. Furthermore, this review highlights evidence gaps in existing long-term, post-discharge outcomes and patient-/caregiver-reported outcomes. Given the increasing demand for high-quality geriatric trauma care, our findings emphasize the need for evidence-based national standards for geriatric trauma care and targeted study of outcomes germane to older adults and their caregivers.

Impact of the Charlson Comorbidity Index on Delirium Outcomes

Introduction Delirium is a significant inpatient healthcare challenge and has a greater incidence among older adults with adverse healthcare outcomes. Yet there are limited established models for risk stratification. The objective is to determine the effectiveness of implementing the Charlson comorbidity index (CCI) score, which is calculated based on the assigned weight for various disease conditions, and to analyze the healthcare outcomes in older hospitalized adults with delirium. Methodology A retrospective cohort study of 214 elderly hospitalized patients between January 1, 2015, and December 31, 2016, with the diagnosis of delirium, was analyzed by grouping based on the severity of diseases as defined in CCI. The primary analysis outcome was to analyze all-cause inpatient mortality, length of hospital stay (in days), 30-day readmissions, and discharge destination in patients with delirium based on CCI scores using regression analysis and nonparametric tests. Secondary analysis included the prevalence and characteristics of delirium patients in different severity levels of CCI. Results Patients with the severe CCI category (with a total score of five and above) spent 10 days longer in the hospital than those who were categorized with mild delirium (p = 0.011). There is a strong association between in-hospital mortality and the severe CCI category (odds ratio (OR), 4.566; 95% CI, 1.17- 1.86 (p = 0.035)). Also, patients with severe CCI scores were 4.6 times more likely to die during hospitalization compared to patients with less severe comorbidities. There were no significant differences found for discharge destination (OR, 0.702; 95% CI, 371- 1.328 (p = 0.277)) and readmission risk (OR, 1.660; 95% CI, 0.664- 4.149 (p = 0.278)) among different CCI groups.  Conclusions Length of stay and inpatient mortality were significantly higher among the severe CCI category compared to the mild category. Our study suggests that CCI can help clinicians, patients, and their families in prognostication and better understanding of goals of care conversations.

Impact of inpatient geriatrics consultation on hospital outcomes in older adults with trauma

BACKGROUND

Older adults presenting with trauma have worse outcomes than younger adults. Starting in 2016, we provided geriatrics consultation (GC) to older adults admitted to the trauma service. We aimed to analyze the impact of GC on patient outcomes.

METHODS

We performed a retrospective pre-post study and year-matched cohort study. We identified patients from the trauma registry at our level 1 trauma center. In the pre-post study, we compared patients who received GC (2016-2022) with controls (2011-2015). In the cohort study (2016-2022), we compared patients who received GC with controls. We matched for age, race, sex, and injury severity score (ISS) in both studies, as well as admission year in the cohort study. Outcome variables included mortality (in-hospital, 30-day, 90-day), length of stay (LOS), discharge disposition, and hospital readmission rates (30-day, 90-day).

RESULTS

We analyzed 1968 patients in the pre-post study and 2544 patients in the cohort study. Patients were similar in age, race, and sex. GC patients had a slightly higher ISS score and a higher rate of ICU stay. Delirium occurrence was lower among GC patients. GC patients had lower in-hospital mortality compared to controls (pre-post OR 0.27, p < 0.001; cohort OR 0.31, p < 0.001) and increased LOS (6 days vs 4 days, p < 0.001; both studies). GC patients in the cohort study also had lower 30- and 90-day mortality (OR 0.52 and 0.65, p < 0.01) and were less likely to return home (OR 0.81, p < 0.01); similar trends, though not statistically significant, were noted in the pre-post study. Lower readmission rates (statistically non-significant) were noted in the GC group across both studies.

CONCLUSIONS

GC in older adults with trauma has proven benefit with reduced mortality and a trend toward lower readmission rates but was associated with increased LOS and higher rates of discharge to skilled facility.

[Relationship Between Frailty and Poor Prognosis in Older Trauma Patients in the Emergency Department: A Prospective Cohort Study]

Objective

To explore the relationship between frailty and adverse outcomes in older trauma patients in the emergency department.

Methods

A prospective cohort study was conducted. Older trauma patients admitted to the emergency department of three tertiary-care hospitals in Chengdu between January 2021 and August 2021 were enrolled. The patients were divided into a frailty group and a non-frailty group according to their assessment results for Trauma-Specific Frailty Index (TSFI). The end points, including falls, readmission, and deaths, were documented during the 6-month follow-up. Cox risk regression model was used to analyze the relationship between frailty and adverse outcomes in older trauma patients in the emergency department.

Results

A total of 375 older trauma patients in the emergency department were enrolled, including 131 in the frailty group and 244 in the non-frailty group. After 6 months of follow-up, the incidences of falls, readmission and deaths in older trauma patients in the emergency department were 18.93%, 14.40%, and 7.73%, respectively. The incidences of falls (28.24% vs. 13.93%, P=0.001), readmission (25.95% vs. 8.20%, P=0.000), and deaths (12.98% vs. 4.92%, P=0.005) in older trauma patients in the emergency department in the frailty group were higher than those in the non-frailty group. After adjusting for multiple confounding factors using the Cox regression model, the risks of falls (hazard ratio [ HR]=1.859, 95% confidence interval [ CI]: 1.070-3.230, P=0.028] and readmission ( HR=2.920, 95% CI: 1.537-5.547, P=0.001) were higher in the frailty group than those in the non-frailty group, but there was no significant difference in the risk of deaths between the frailty group and the non-frailty group.

Conclusion

Frailty is a risk factor for falls and readmissions in older trauma patients in the emergency department and the association between frailty and the risk of deaths in older trauma patients in the emergency department needs to be validated by further studies.

Use of High-Risk Medications Among Older Adults Enrolled in Medicare Advantage Plans vs Traditional Medicare

Importance

Limiting the use of high-risk medications (HRMs) among older adults is a national priority to provide a high quality of care for older beneficiaries of both Medicare Advantage and traditional fee-for-service Medicare Part D plans.

Objective

To evaluate the differences in the rate of HRM prescription fills among beneficiaries of traditional Medicare vs Medicare Advantage Part D plans and to examine the extent to which these differences change over time and the patient-level factors associated with higher rates of HRMs.

Design, Setting, and Participants

This cohort study used a 20% sample of Medicare Part D data on filled drug prescriptions from 2013 to 2017 and a 40% sample from 2018. The sample comprised Medicare beneficiaries aged 66 years or older who were enrolled in Medicare Advantage or traditional Medicare Part D plans. Data were analyzed between April 1, 2022, and April 15, 2023.

Main Outcomes and Measures

The primary outcome was the number of unique HRMs prescribed to older Medicare beneficiaries per 1000 beneficiaries. Linear regression models were used to model the primary outcome, adjusting for patient characteristics and county characteristics and including hospital referral region fixed effects.

Results

The sample included 5 595 361 unique Medicare Advantage beneficiaries who were propensity score-matched on a year-by-year basis to 6 578 126 unique traditional Medicare beneficiaries between 2013 and 2018, resulting in 13 704 348 matched pairs of beneficiary-years. The traditional Medicare vs Medicare Advantage cohorts were similar in age (mean [SD] age, 75.65 [7.53] years vs 75.60 [7.38] years), proportion of males (8 127 261 [59.3%] vs 8 137 834 [59.4%]; standardized mean difference [SMD] = 0.002), and predominant race and ethnicity (77.1% vs 77.4% non-Hispanic White; SMD = 0.05). On average in 2013, Medicare Advantage beneficiaries filled 135.1 (95% CI, 128.4-142.6) unique HRMs per 1000 beneficiaries compared with 165.6 (95% CI, 158.1-172.3) HRMs per 1000 beneficiaries for traditional Medicare. In 2018, the rate of HRMs had decreased to 41.5 (95% CI, 38.2-44.2) HRMs per 1000 beneficiaries in Medicare Advantage and to 56.9 (95% CI, 54.1-60.1) HRMs per 1000 beneficiaries in traditional Medicare. Across the study period, Medicare Advantage beneficiaries received 24.3 (95% CI, 20.2-28.3) fewer HRMs per 1000 beneficiaries per year compared with traditional Medicare beneficiaries. Female, American Indian or Alaska Native, and White populations were more likely to receive HRMs than other groups.

Conclusion and Relevance

Results of this study showed that HRM rates were consistently lower among Medicare Advantage than traditional Medicare beneficiaries. Higher use of HRMs among female, American Indian or Alaska Native, and White populations is a concerning disparity that requires further attention.

Healthcare Provider Perspectives on Digital and Interprofessional Medication Management in Chronically Ill Older Adults of Turkish Descent in Germany: A Qualitative Structuring Content Analysis

Medication management for chronically ill older adults with a history of migration can be associated with specific challenges, for instance language barriers. This study examined healthcare provider perspectives on interprofessional cooperation and digital medication management tools as approaches for increasing medication safety for chronically ill older adults of Turkish descent in Germany. Semi-structured interviews were conducted with 11 healthcare providers, including general practitioners, pharmacists, a geriatric consultant, a hospital social worker, and an expert on digitalization in nursing care. The interviews were analyzed by means of qualitative structuring content analysis. This article presents selected results of the analysis relating to medication management, barriers to optimal medication management, interprofessional cooperation, and digital tools. Compliance was perceived to be high among chronically ill older adults of Turkish descent and the involvement of family members in medication management was rated positively by respondents. Barriers to medication management were identified in relation to health literacy and language barriers, systemic problems such as short appointments and generic substitution, and racism on behalf of healthcare providers. Additionally, the respondents highlighted structural barriers to interprofessional communication in the German healthcare system. Furthermore, two technology acceptance models presented in this article to illustrate the respondents' perspectives on a) a digital application for medication management to be used by chronically ill older adults of Turkish descent and b) a digital tool for interprofessional communication. The discussion highlights the implications of the results for medication management within the German healthcare system.

Older trauma patients are at high risk of delirium, especially those with underlying dementia or baseline frailty

BACKGROUND

Given the increasing numbers of older patients presenting with trauma, and the potential influence of delirium on outcomes, we sought to investigate the proportion of such patients who were diagnosed with delirium during their stay-and patient factors associated therewith-and the potential associations between delirium and hospital length of stay (LOS). We hypothesized that delirium would be common, associated with certain patient characteristics, and associated with long hospital LOS (highest quartile).

METHODS

We conducted a retrospective observational cohort study of all trauma patients aged ≥65 years presenting in September to October 2019, interrogating medical records and the institutional trauma database. The primary outcome measure was occurrence of delirium.

RESULTS

Among 99 eligible patients, delirium was common, documented in 23% (23 of 99). On multivariable analysis, adjusting for age, frailty and history of dementia, frailty (OR 4.09, 95% CI 1.08 to 15.53, p=0.04) and dementia (OR 5.23, 95% CI 1.38 to 19.90, p=0.02) were independently associated with likelihood of delirium. Standardized assessment tools were underused, with only 34% (34 of 99) screened within 4 hours of arrival. On univariate logistic regression analysis, having an episode of delirium was associated with long LOS (highest quartile), OR of 5.29 (95% CI 1.92 to 14.56, p<0.001). In the final multivariable model, adjusting for any (non-delirium) in-hospital complication, delirium was independently associated with long LOS (≥16 days; OR 4.81, p=0.005).

DISCUSSION

In this study, delirium was common. History of dementia and baseline frailty were associated with increased risk. Delirium was independently associated with long LOS. However, many patients did not undergo standardized screening at admission. Early identification and targeted management of older patients at risk of delirium may reduce incidence and improve care of this vulnerable cohort. These data are hypothesis generating, but support the need for initiatives which improve delirium care, acknowledging the complex interplay between frailty and other geriatric syndromes in the older trauma patients.

LEVEL OF EVIDENCE

III.