A comparison of 3 frailty measures and adverse outcomes in the intake home care population: a retrospective cohort study

The Integrated Care Team: A primary care based-approach to support older adults with complex health needs

Many older adults have complex needs and experience high rates of acute care use and institutionalization. Comprehensive Geriatric Assessment (CGA) is a specialized multidimensional interprofessional intervention to prevent such outcomes, but access to CGA in the community is limited. The Integrated Care Team (ICT) is a proactive case-finding intervention to support older adults with complex needs in primary care. The ICT provides nurse practitioner-led shared-care supported by a pharmacist, family physician, and geriatrician. Patients undergo a CGA, and a person-centred plan of care is implemented. We conducted a mixed-methods evaluation of the ICT. Patients were 81 ± 9.2 years old, 71% were women. Patients had a high burden of dementia and multimorbidity and received 12.8 ± 5.8 prescriptions daily. The ICT improved prescribing and reduced emergency department visits by 49.5% (P = 0.0001). Patients, care partners, and referring physicians reported high satisfaction with care. The ICT is currently being expanded to support additional primary care providers.

Frailty Index Based on Common Laboratory Tests for Patients Starting Home-Based Medical Care

OBJECTIVES

To determine whether a Frailty Index based on laboratory tests (FI-lab) is associated with clinical outcomes independently of a standard nonlaboratory Frailty Index (FI-clinical) in older patients starting home-based medical care.

DESIGN

Secondary analysis of data from a multicenter prospective cohort study.

SETTING AND PARTICIPANTS

Patients aged ≥65 years who were starting home-based medical care services provided by doctors and nurses at Nagoya, Japan.

METHODS

We calculated FI-lab (proportion of abnormal results out of 25 commonly tested laboratory parameters) and FI-clinical using 42 items based on data obtained at enrollment. The primary outcome was mortality within 2 years after starting home-based medical care. A sensitivity analysis was also conducted with 1-year mortality as the outcome. Other outcomes included hospitalization and nursing home admission within 2 years.

RESULTS

In total, 188 patients (mean age 79.9 ± 10.2 years, 57.5% male) were included. The median FI-lab was 0.40 [interquartile range (IQR) 0.29-0.50] and the median FI-clinical was 0.32 (IQR 0.24-0.43). Sixty-nine patients (36.7%) died within 2 years of starting home-based medical care. A Cox proportional hazards regression analysis including age, sex, FI-lab, and FI-clinical as independent variables revealed that FI-lab was associated with 2-year mortality independently of FI-clinical [FI-lab per 0.1 unit, odds ratio (OR) 1.49, 95% CI 1.25-1.77; FI-clinical per 0.1 unit, OR 1.13, 95% CI 0.90-1.41]. The sensitivity analysis showed similar results for 1-year mortality. Neither FI-lab nor FI-clinical was associated with hospitalization or nursing home admission within 2 years.

CONCLUSIONS AND IMPLICATIONS

FI-lab was associated with 2-year mortality in patients starting home-based medical care, independently of FI-clinical, and may be useful for risk assessment in this population. Studies with larger sample sizes are needed.

Integrating a Standardized Self-Report Tool into Geriatric Medicine Practice during the COVID-19 Pandemic: A Mixed-Methods Study

Specialized geriatric services care for older adults (≥ 65 years of age) with dementia and other progressive neurological disorders, frailty, and mental health conditions were provided both virtually and in person during the pandemic. The objective of this study was to implement a software-enabled standardized self-report instrument - the interRAI Check-Up Self-Report - to remotely assess patients. A convergent, mixed-methods research design was employed. Staff found the instrument easy to use and the program-level metrics helpful for planning. Most patients urgently needed a geriatrician assessment (72%) and had moderate to severe cognitive (34%) and functional impairments (34%), depressive symptoms (53%), loneliness (57%), daily pain (32%), and distressed caregivers (46%). Implementation considerations include providing ongoing support and facilitating intersectoral collaboration. The Check Up enhanced the geriatric assessment process by creating a system to track all needs for immediate and future care at both the patient and program level.

A prospective, observational study of frailty, quality of life and dialysis in older people with advanced chronic kidney disease

BACKGROUND

Frailty is prevalent in older people with chronic kidney disease (CKD) and robust evidence supporting the benefit of dialysis in this setting is lacking. We aimed to measure frailty and quality of life (QOL) longitudinally in older people with advanced CKD and assess the impact of dialysis initiation on frailty, QOL and mortality.

METHODS

Outpatients aged ≥65 with an eGFR ≤ 20ml/minute/1.73m2 were enrolled in a prospective observational study and followed up four years later. Frailty status was measured using a Frailty Index (FI), and QOL was evaluated using the EuroQol 5D-5L instrument. Mortality and dialysis status were determined through inspection of electronic records.

RESULTS

Ninety-eight participants were enrolled. Between enrolment and follow-up, 36% of participants commenced dialysis and 59% died. Frailty prevalence increased from 47% at baseline to 86% at follow-up (change in median FI = 0.22, p < 0.001). Initiating dialysis was not significantly associated with change in FI. QOL declined from baseline to follow-up (mean EQ-5D-5L visual analogue score of 70 vs 63, p = 0.034), though commencing dialysis was associated with less decline in QOL. Each 0.1 increment in baseline FI was associated with 59% increased mortality hazard (HR = 1.59, 95%CI = 1.20 to 2.12, p = 0.001), and commencing dialysis was associated with 59% reduction in mortality hazard (HR = 0.41, 95%CI = 0.20 to 0.87, p = 0.020) irrespective of baseline FI.

CONCLUSIONS

Frailty increased substantially over four years, and higher baseline frailty was associated with greater mortality. Commencing dialysis did not affect the trajectory of FI but positively influenced the trajectory of QOL from baseline to follow-up. Within the limitations of small sample size, our data suggests that frail participants received similar survival benefit from dialysis as non-frail participants.

Determinants of access of frail, community-residing older adults to geriatricians in Ontario

OBJECTIVES

Little is known about determinants of access to community-based geriatricians. The Geriatric 5Ms™ describe geriatricians' core competencies and inform referrals to specialists for older adults with complex needs. We explored the association of the Geriatric 5Ms™ and other characteristics with outpatient access to geriatricians by home care (HC) clients.

METHODS

This was a population-based, retrospective cohort study of frail community-dwelling HC clients (≥60 years) with complex needs (n = 196,444). Health assessment information was linked to health services data in Ontario, Canada, 2012-2015. Multivariable generalized estimating equations were used to identify characteristics associated with geriatrician contact (≥1 visit in 90 days post-HC admission), including derived Geriatric 5Ms™ score, and predisposing, enabling, and need factors obtained from clinical assessments.

RESULTS

Only 5.2% of the cohort had outpatient geriatrician contact in Ontario, Canada. Derived Geriatric 5Ms™ score was associated with higher odds of contact, but the model had modest discriminatory power (c-statistic = 0.67). In the broader multivariable model, based on empirically included factors and adjusted for regional differences, age, worsening of decision-making, dementia, hallucinations, Parkinsonism, osteoporosis, and caregiver distress/institutionalization risk were associated with higher odds of geriatrician contact. Female sex, difficulties accessing home, impaired locomotion, recovery potential, hemiplegia/hemiparesis, and cancer, were associated with lower odds of contact. This model had good discriminatory power (c-statistic = 0.77).

CONCLUSIONS

Few frail, community-dwelling older adults receiving HC had any outpatient geriatrician contact. While the derived Geriatric 5Ms™ score was associated with contact, a broader empirical model performed better than the Geriatric 5Ms™ in predicting contact with an outpatient geriatrician. Contact was mainly driven by conditions common in older adults, but evidence suggests that geriatricians are not evaluating the most medically complex and unstable older adults in the community. These findings suggest a need to re-examine the referral process for geriatricians and the allocation of limited specialized resources.

The hospital-to-home care transition experience of home care clients: an exploratory study using patient journey mapping

BACKGROUND

Care transitions have a significant impact on patient health outcomes and care experience. However, there is limited research on how clients receiving care in the home care sector experience the hospital-to-home transition. An essential strategy for improving client care and experience is through client engagement efforts. The study's aim was to provide insight into the care transition experiences and perspectives of home care clients and caregivers of those receiving home care who experienced a hospital admission and returned to home care services by thematically and illustratively mapping their collective journey.

METHODS

This study applied a qualitative descriptive exploratory design using a patient journey mapping approach. Home care clients and their caregivers with a recent experience of a hospital discharge back to the community were recruited. A conventional inductive approach to analysis enabled the identification of categories and a collective patient journey map. Follow-up interviews supported the validation of the map.

RESULTS

Seven participants (five clients and two caregivers) participated in 11 interviews. Participants contributed to the production of a collective journey map and the following four categories and themes: (1) Touchpoints as interactions with the health system; Life is changing; (2) Pain points as barriers in the health system: Sensing nobody is listening and Trying to find a good fit; (3) Facilitators to positive care transitions: Developing relationships and gaining some continuity and Trying to advocate, and (4) Emotional impact: Having only so much emotional capacity.

CONCLUSIONS

The patient journey map enabled a collective illustration of the care transition depicted in touchpoints, pain points, enablers, and feelings experienced by home care recipients and their caregivers. Patient journey mapping offers an opportunity to acknowledge home care clients and their caregivers as critical to quality care delivery across the continuum.

Association of admission frailty and frailty changes during cardiac rehabilitation with 5-year outcomes

AIMS

Examine the association between (1) admission frailty and (2) frailty changes during cardiac rehabilitation (CR) with 5-year outcomes (i.e. time to mortality, first hospitalization, first emergency department (ED) visit, and number of hospitalizations, hospital days, and ED visits).

METHODS AND RESULTS

Data from patients admitted to a 12-week CR programme in Halifax, Nova Scotia, from May 2005 to April 2015 (n = 3371) were analysed. A 25-item frailty index (FI) estimated frailty levels at CR admission and completion. FI improvements were determined by calculating the difference between admission and discharge FI. CR data were linked to administrative health data to examine 5-year outcomes [due to all causes and cardiovascular diseases (CVDs)]. Cox regression, Fine-Gray models, and negative binomial hurdle models were used to determine the association between FI and outcomes. On average, patients were 61.9 (SD: 10.7) years old and 74% were male. Mean admission FI scores were 0.34 (SD: 0.13), which improved by 0.07 (SD: 0.09) by CR completion. Admission FI was associated with time to mortality [HRs/IRRs per 0.01 FI increase: all causes = 1.02(95% CI 1.01,1.04); CVD = 1.03(1.02,1.05)], hospitalization [all causes = 1.02(1.01,1.02); CVD = 1.02(1.01,1.02)], ED visit [all causes = 1.01(1.00,1.01)], and the number of hospitalizations [all causes = 1.02(95% CI 1.01,1.03); CVD = 1.02(1.00,1.04)], hospital days [all causes = 1.01(1.01,1.03)], and ED visits [all causes = 1.02(1.02,1.03)]. FI improvements during CR had a protective effect regarding time to all-cause hospitalization [0.99(0.98,0.99)] but were not associated with other outcomes.

CONCLUSION

Frailty status at CR admission was related to long-term adverse outcomes. Frailty improvements during CR were associated with delayed all-cause hospitalization, in which a larger effect was associated with a greater chance of improved outcome.

The interRAI COVID-19 vulnerability screener: Results of a health surveillance initiative for vulnerable adults in the community during the COVID-19 pandemic

During the pandemic, the interRAI COVID-19 Vulnerability Screener (CVS) was used to identify community-dwelling older adults or adults with disabilities at risk of negative outcomes and facilitate triage for follow-up with health/social services. The interRAI CVS, a standardized self-report instrument administered virtually by a lay-person, includes COVID-19-related items and psychosocial and physical vulnerability. Our objective was to describe those assessed and identify sub-groups at highest risk of adverse outcomes. Seven community-based organizations in Ontario, Canada, implemented the interRAI CVS. We used descriptive statistics to report results and created a priority indicator for monitoring and/or intervention based on possible COVID-19 symptoms and psychosocial/physical vulnerabilities. We used logistic regression to examine the association between priority level and risk of poor outcomes using fair/poor self-rated health as a proxy measure. The sample included 942 adults assessed (April-November 2020; mean age=79). About 10% of individuals reported potential COVID-19 symptoms and <1% had a positive COVID-19 test/diagnosis. Of those with psychosocial/physical vulnerabilities (73.1%), most common were depressed mood (20.9%), loneliness (21.6%), and limited access to food/medications (7.5%). Overall, 45.7% had a recent doctor or nurse practitioner visit. Odds of fair/poor self-reported health were highest among those who reported both possible symptoms of COVID-19 and psychosocial/physical vulnerabilities (OR 10.9, 95% CI 5.96-20.12) compared to those with neither symptoms nor psychosocial/physical vulnerabilities. The sample represents a population largely unaffected by COVID-19 itself but with identified vulnerabilities. The interRAI CVS allows community providers to stay connected and obtain a better understanding of vulnerable individuals' needs during the pandemic.

Prognostic Association Between Frailty and Post-Arrest Health Outcomes in Patients Receiving Home Care: A Population-Based Retrospective Cohort Study

AIM

To evaluate the association between frailty and post-cardiac arrest survival, functional decline, and cognitive decline, among patients receiving home care METHODS: Frailty was measured using the Clinical Frailty Scale (CFS) and a valid frailty index. We used multivariable logistic regression to measure the association between frailty and post-arrest outcomes after adjusting for age, sex, and arrest setting. Functional independence and cognitive performance were measured using the interRAI ADL Long-Form and Cognitive Performance Scale, respectively. We conducted sub-group analytics of in-hospital and out-of-hospital arrests RESULTS: Our cohort consisted of 7,901 home care clients; most patients arrested out-of-hospital (55.4%) and were 75 years or older (66.3%). Most of the cohort was classified as frail (94.2%), with a CFS score of 5 or greater. The 30-day survival rate was higher for in-hospital (26.6%) than out-of-hospital cardiac arrests (5.2%). Most patients who survived to discharge had declines in post-arrest functional independence (65.8%) and cognitive performance (46.5%). A one-point increase in the CFS decreased the odds of 30-day survival by 8% (aOR=0.92; 95%CI = 0.87-0.97). A 0.1 unit increase in the frailty index reduced 30-day survival odds by 9% (aOR = 0.91; 95%CI = 0.86-0.96). The frailty index was associated with declines in functional independence (OR = 1.16; 95%CI = 1.02-1.31) and cognitive performance (OR = 1.24; 95%CI = 1.09-1.42), while the CFS was not.

CONCLUSION

Frailty is associated with cardiac arrest survival and post-arrest cognitive and functional status in patients receiving home care. Post-cardiac arrest cognitive and functional status are best predicted using more comprehensive frailty indices.

Agreement and prognostic accuracy of three ED vulnerability screeners: findings from a prospective multi-site cohort study

OBJECTIVES

To evaluate the agreement between three emergency department (ED) vulnerability screeners, including the InterRAI ED Screener, ER2, and PRISMA-7. Our secondary objective was to evaluate the discriminative accuracy of screeners in predicting discharge home and extended ED lengths-of-stay (> 24 h).

METHODS

We conducted a nested sub-group study using data from a prospective multi-site cohort study evaluating frailty in older ED patients presenting to four Quebec hospitals. Research nurses assessed patients consecutively with the three screeners. We employed Cohen's Kappa to determine agreement, with high-risk cut-offs of three and four for the PRISMA-7, six for the ER2, and five for the interRAI ED Screener. We used logistic regression to evaluate the discriminative accuracy of instruments, testing them in their dichotomous, full, and adjusted forms (adjusting for age, sex, and hospital academic status).

RESULTS

We evaluated 1855 older ED patients across the four hospital sites. The mean age of our sample was 84 years. Agreement between the interRAI ED Screener and the ER2 was fair (K = 0.37; 95% CI 0.33-0.40); agreement between the PRISMA-7 and ER2 was also fair (K = 0.39; 95% CI = 0.36-0.43). Agreement between interRAI ED Screener and PRISMA-7 was poor (K = 0.19; 95% CI 0.16-0.22). Using a cut-off of four for PRISMA-7 improved agreement with the ER2 (K = 0.55; 95% CI 0.51-0.59) and the ED Screener (K = 0.32; 95% CI 0.2-0.36). When predicting discharge home, the concordance statistics among models were similar in their dichotomous (c = 0.57-0.61), full (c = 0.61-0.64), and adjusted forms (c = 0.63-0.65), and poor for all models when predicting extended length-of-stay.

CONCLUSION

ED vulnerability scores from the three instruments had a fair agreement and were associated with important patient outcomes. The interRAI ED Screener best identifies older ED patients at greatest risk, while the PRISMA-7 and ER2 are more sensitive instruments.

External validation of the hospital frailty risk score among hospitalised home care clients in Canada: a retrospective cohort study

BACKGROUND

The Hospital Frailty Risk Score (HFRS) is scored using ICD-10 diagnostic codes in administrative hospital records. Home care clients in Canada are routinely assessed with Resident Assessment Instrument-Home Care (RAI-HC) which can calculate the Clinical Frailty Scale (CFS) and the Frailty Index (FI).

OBJECTIVE

Measure the correlation between the HFRS, CFS and FI and compare prognostic utility for frailty-related outcomes.

DESIGN

Retrospective cohort study.

SETTING

Alberta, British Columbia and Ontario, Canada.

SUBJECTS

Home care clients aged 65+ admitted to hospital within 180 days (median 65 days) of a RAI-HC assessment (n = 167,316).

METHODS

Correlation between the HFRS, CFS and FI was measured using the Spearman correlation coefficient. Prognostic utility of each measure was assessed by comparing measures of association, discrimination and calibration for mortality (30 days), prolonged hospital stay (10+ days), unplanned hospital readmission (30 days) and long-term care admission (1 year).

RESULTS

The HFRS was weakly correlated with the FI (ρ 0.21) and CFS (ρ 0.28). Unlike the FI and CFS, the HFRS was unable to discriminate for 30-day mortality (area under the receiver operator characteristic curve (AUC) 0.506; confidence interval (CI) 0.502-0.511). It was the only measure that could discriminate for prolonged hospital stay (AUC 0.666; CI 0.661-0.673). The HFRS operated like the FI and CFI when predicting unplanned readmission (AUC 0.530 CI 0.526-0.536) and long-term care admission (AUC 0.600; CI 0.593-0.606).

CONCLUSIONS

The HFRS identifies a different subset of older adult home care clients as frail than the CFS and FI. It has prognostic utility for several frailty-related outcomes in this population, except short-term mortality.

Examining the utility and accuracy of the interRAI Emergency Department Screener in identifying high-risk older emergency department patients: A Canadian multiprovince prospective cohort study

Objectives

We set out to determine the accuracy of the interRAI Emergency Department (ED) Screener in predicting the need for detailed geriatric assessment in the ED. Our secondary objective was to determine the discriminative ability of the interRAI ED Screener for predicting the odds of discharge home and extended ED length of stay (>24 hours).

Methods

We conducted a multiprovince prospective cohort study in Canada. The need for detailed geriatric assessment was determined using the interRAI ED Screener and the interRAI ED Contact Assessment as the reference standard. A score of ≥5 was used to classify high-risk patients. Assessments were conducted by emergency and research nurses. We calculated the sensitivity, positive predictive value, and false discovery rate of the interRAI ED Screener. We employed logistic regression to predict ED outcomes while adjusting for age, sex, academic status, and the province of care.

Results

A total of 5629 older ED patients across 11 ED sites were evaluated using the interRAI ED Screener and 1061 were evaluated with the interRAI ED Contact Assessment. Approximately one-third of patients were discharged home or experienced an extended ED length of stay. The interRAI ED Screener had a sensitivity of 93%, a positive predictive value of 82%, and a false discovery rate of 18%. The interRAI ED Screener predicted discharge home and extended ED length of stay with fair accuracy.

Conclusion

The interRAI ED Screener is able to accurately and rapidly identify individuals with medical complexity. The interRAI ED Screener predicts patient-important health outcomes in older ED patients, highlighting its value for vulnerability screening.

Implementation evaluation of a stepped approach to home care assessment using interRAI systems in Ontario, Canada

In Ontario, new home care clients are screened with the interRAI Contact Assessment and only those expected to require longer-term services receive the comprehensive RAI-Home Care assessment. Although Ontario adopted this two-step approach in 2010, it is unknown whether the assessment guidelines were implemented as intended. To evaluate implementation fidelity, the purpose of this study is to compare expected to actual client profiles and care co-ordinator practice patterns. We linked interRAI CA and RAI-HC assessments and home care referrals and services data for a retrospective cohort of adult home care clients admitted in FY 2016/17. All assessments were done by trained health professionals as part of routine practice. Descriptive analyses were used to evaluate congruency between recommended and actual practice. Adjusted cause-specific hazards and logistic approaches were used to examine time to RAI-HC assessment and being a high-priority client. Of 225,989 unique home care clients admitted to the publicly funded home care program, about three-quarters of clients were assessed with the interRAI CA only (27.9% completed the Preliminary Screener only and 46.6% completed both the Preliminary Screener and Clinical Evaluation). There was substantial agreement between the skip logic and completion of the Clinical Evaluation section (Cohen's kappa = 0.67 [95% CI: 0.66-0.67]). One-quarter of clients were assessed with both the interRAI CA and RAI-HC. As expected, RAI-HC assessed clients were older, reported more health needs, and often received home care services for >6 months. Clients in higher Assessment Urgency Algorithm (AUA) levels were significantly more likely to receive a RAI-HC assessment and be assigned to a higher home care priority level; however, 28.3% of clients in the highest AUA level did not receive a RAI-HC assessment. We conclude that the use of the interRAI CA and RAI-HC balances the investment of time and resources with the information and tools to deliver high-quality, holistic, and client-centred care. The interRAI CA guides the care co-ordinator to screen every client for a broad range of possible needs and tailor further assessment to each client's unique needs. We recommend integrating the AUA into provincial assessment guidelines as well as developing a new quality indicator focused on measuring access to the home care system.

The interRAI CHESS scale is comparable to the palliative performance scale in predicting 90-day mortality in a palliative home care population

Background

Prognostic accuracy is important throughout all stages of the illness trajectory as it has implications for the timing of important conversations and decisions around care. Physicians often tend to over-estimate prognosis and may under-recognize palliative care (PC) needs. It is therefore essential that all relevant stakeholders have as much information available to them as possible when estimating prognosis.

Aims

The current study examined whether the interRAI Changes in Health, End-Stage Disease, Signs and Symptoms (CHESS) Scale is a good predictor of mortality in a known PC population and to see how it compares to the Palliative Performance Scale (PPS) in predicting 90-day mortality.

Methods

This retrospective cohort study used data from 2011 to 2018 on 80,261 unique individuals receiving palliative home care and assessed with both the interRAI Palliative Care instrument and the PPS. Logistic regression models were used to evaluate the relationship between the main outcome, 90-day mortality and were then replicated for a secondary outcome examining the number of nursing visits. Comparison of survival time was examined using Kaplan-Meier survival curves.

Results

The CHESS Scale was an acceptable predictor of 90-day mortality (c-statistic = 0.68; p < 0.0001) and was associated with the number of nursing days (c = 0.61; p < 0.0001) and had comparable performance to the PPS (c = 0.69; p < 0.0001). The CHESS Scale performed slightly better than the PPS in predicting 90-day mortality when combined with other interRAI PC items (c = 0.72; p < 0.0001).

Conclusion

The interRAI CHESS Scale is an additional decision-support tool available to clinicians that can be used alongside the PPS when estimating prognosis. This additional information can assist with the development of care plans, discussions, and referrals to specialist PC teams.

Patterns of home care assessment and service provision before and during the COVID-19 pandemic in Ontario, Canada

OBJECTIVE

The objective was to compare home care episode, standardised assessment, and service patterns in Ontario's publicly funded home care system during the first wave of the COVID-19 pandemic (i.e., March to September 2020) using the previous year as reference.

STUDY DESIGN AND SETTING

We plotted monthly time series data from March 2019 to September 2020 for home care recipients in Ontario, Canada. Home care episodes were linked to interRAI Home Care assessments, interRAI Contact Assessments, and home care services. Health status measures from the patient's most recent interRAI assessment were used to stratify the receipt of personal support, nursing, and occupational or physical therapy services. Significant level and slope changes were detected using Poisson, beta, and linear regression models.

RESULTS

The March to September 2020 period was associated with significantly fewer home care admissions, discharges, and standardised assessments. Among those assessed with the interRAI Home Care assessment, significantly fewer patients received any personal support services. Among those assessed with either interRAI assessment and identified to have rehabilitation needs, significantly fewer patients received any therapy services. Among patients receiving services, patients received significantly fewer hours of personal support and fewer therapy visits per month. By September 2020, the rate of admissions and services had mostly returned to pre-pandemic levels, but completion of standardised assessments lagged behind.

CONCLUSION

The first wave of the COVID-19 pandemic was associated with substantial changes in Ontario's publicly funded home care system. Although it may have been necessary to prioritise service delivery during a crisis situation, standardised assessments are needed to support individualised patient care and system-level monitoring. Given the potential disruptions to home care services, future studies should examine the impact of the pandemic on the health and well-being of home care recipients and their caregiving networks.

Before the COVID-Vaccine-Vulnerable Elderly in Homecare

BACKGROUND

At the beginning of 2020, the COVID-19 virus was spreading all over the world. Frail elderly were at risk for illness and death. Isolation seemed to be the best solution. The aim of this paper was to describe how the lockdown affected elderly homecare patients.

METHODS

We used an international self-reported screening instrument built on well-documented risk factors adapted to COVID-19. We considered ethical, legal, and practical concerns. The research included telephone interviews with 30 homecare patients.

RESULTS

Seventy percent lived alone. Seventy-three percent of the sample suffered from major comorbidity. Cardiovascular disorder was the most frequent diagnosis. Nineteen (63.3%) needed help for personal care. Several of the participants were lonely and depressed. The homecare teams struggled to give proper care. The health authorities encouraged the population to reduce their outside physical activities to a minimum. The restrictions due to COVID-19 affected daily life and several respondents expressed uncertainties about the future.

CONCLUSIONS

It is important to describe the patients' experiences in a homecare setting at the initiation of lockdowns due to COVID-19. The isolation protected them from the virus, but they struggled with loneliness and the lack of physical contact with their loved ones. In the future, we need to understand and address the unmet needs of elderly homecare patients in lockdown.

Risk factors for unfavorable clinical outcomes in patients with brain abscess in South Korea

Background

Brain abscess can be life-threatening and manifest various neurological findings, although the mortality rate has decreased recently. We investigated the risk factors for unfavorable outcomes of patients with brain abscess.

Methods

A retrospective cohort study examined patients with brain abscess seen from May 2005 to December 2018 in a tertiary care hospital in Seoul, South Korea. We reviewed the medical records for clinical findings, therapeutic modalities, and prognostic factors of brain abscess. Unfavorable clinical outcomes were defined as death, moderate to severe disability with neurological deficits, or vegetative state at 1 year or at the time of discharge from outpatient follow-up.

Results

The study enrolled 135 patients: 65.2% were males; the mean age was 56 years. 35.6% had unfavorable outcomes. In multivariate analysis, higher Sequential Organ Failure Assessment (SOFA) (p < 0.001), pre-existing hemiplegia (p = 0.049), and higher Charlson comorbidity index (CCI) (p = 0.028) were independently associated with unfavorable outcomes.

Conclusions

Higher SOFA, pre-existing hemiplegia and higher Charlson comorbidity index were significant risk factors for unfavorable clinical outcomes in patients with brain abscess.

Prognostic association of frailty with post-arrest outcomes following cardiac arrest: A systematic review and meta-analysis

OBJECTIVE

To synthesize the current evidence examining the association between frailty and a series of post-arrest outcomes following the provision of cardiopulmonary resuscitation (CPR).

DATA SOURCES

We searched MEDLINE, PubMed (exclusive of MEDLINE), EMBASE, CINAHL, and Web of Science from inception to August 2020 for observational studies that examined an association between frailty and post-arrest health outcomes, including in-hospital and post-discharge mortality. We conducted citation tracking for all eligible studies.

STUDY SELECTION

Our search yielded 20,480 citations after removing duplicate records. We screened titles, abstracts and full-texts independently and in duplicate.

DATA EXTRACTION

The prognosis research strategy group (PROGRESS) and the critical appraisal and data extraction for systematic review of prediction modelling studies (CHARMS) guidelines were followed. Study and outcome-specific risk of bias were assessed using the Quality in Prognosis Studies (QUIPS) instrument. We rated the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) recommendations for prognostic factor research.

DATA SYNTHESIS

Four studies were included in this review and three were eligible for statistical pooling. Our sample comprised 1,134 persons who experienced in-hospital cardiac arrest (IHCA). The mean age of the sample was 71 years. The study results were pooled according to the specific frailty instrument. Three studies used the Clinical Frailty Scale (CFS) and adjusted age (our minimum confounder); the presence of frailty was associated with an approximate three-fold increase in the odds of dying in-hospital after IHCA (aOR = 2.93; 95% CI = 2.43-3.53, high certainty). Frailty was also associated with decreased incidence of ROSC (return of spontaneous circulation) and discharge home following IHCA. One study with high risk of bias used the Hospital Frailty Risk Score and reported a 43% decrease in the odds of discharge home for patients with frailty following IHCA.

CONCLUSION

High certainty evidence was found for an association between frailty and in-hospital mortality following IHCA. Frailty is a robust prognostic factor that contributes valuable information and can inform shared-decision making and policies surrounding advance care directives. Registration: PROSPERO Registration # CRD42020212922.