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Normann M, Ekerstad N, Angenete E, Prytz M. Mortality and morbidity after colorectal cancer resection surgery in elderly patients: a retrospective population-based study in Sweden. World J Surg Oncol 2024; 22:23. [PMID: 38254209 PMCID: PMC10802062 DOI: 10.1186/s12957-024-03316-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 01/14/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Colorectal cancer is primarily a condition of older adults, and surgery is the cornerstone of treatment. As life expectancy is increasing and surgical techniques and perioperative care are developing, curative surgery is often conducted even in ageing populations. However, the risk of morbidity, functional decline, and mortality following colorectal cancer resection surgery are known to increase with increasing age. This study aims to describe real-world data about postoperative mortality and morbidity after resection surgery for colorectal cancer in the elderly (≥ 70 years) compared to younger patients (< 70 years), in a Swedish setting. METHODS A cohort study including all patients diagnosed with colorectal cancer in a Swedish region of 1.7 million inhabitants between January 2016 and May 2020. Patients were identified through the Swedish Colorectal Cancer Registry, and all baseline and outcome variables were extracted from the registry. The following outcome measures were compared between the two age groups: 90-day mortality rates, postoperative complications, postoperative intensive care, reoperations, readmissions, and 1-year mortality. To adjust the analyses for baseline confounders in the comparison of the outcome variables, the following methods were used: marginal matching, calliper (ID matching), and logistic regression adjusted for baseline confounders. RESULTS The cohort consisted of 5246 patients, of which 3849 (73%) underwent resection surgery. Patients that underwent resection surgery were significantly younger than those who did not (mean ± SD, 70.9 ± 11.4 years vs 73.7 ± 12.8 years, p < 0.001). Multivariable analyses revealed that both 90-day and 1-year mortality rates were higher in older patients that underwent resection surgery (90-day mortality OR 2.12 [95% CI 1.26-3.59], p < 0.005). However, there were no significant differences in postoperative intensive care, postoperative complications, reoperations, or readmissions. CONCLUSION Elderly patients suffer increased postoperative mortality after resection surgery for colorectal cancer compared to younger individuals. Given the growing elderly population that will continue to require surgery for colorectal cancer, more efficient ways of determining and handling individual risk for older adults need to be implemented in clinical practice.
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Grants
- VGFOUREG-940671 Department of Research and Development, Västra Götalandsregionen, Sweden
- VGFOUREG-940671 Department of Research and Development, Västra Götalandsregionen, Sweden
- VGFOUREG-940671 Department of Research and Development, Västra Götalandsregionen, Sweden
- VGFOUREG-940671 Department of Research and Development, Västra Götalandsregionen, Sweden
- VGFOUFBD-937668 Department of Research and Development, Fyrbodal, Sweden
- VGFOUFBD-937668 Department of Research and Development, Fyrbodal, Sweden
- VGFOUFBD-937668 Department of Research and Development, Fyrbodal, Sweden
- VGFOUFBD-937668 Department of Research and Development, Fyrbodal, Sweden
- University of Gothenburg
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Affiliation(s)
- Maria Normann
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Department of Surgery, Region Västra Götaland, NU-Hospital Group, Trollhättan, Sweden.
| | - Niklas Ekerstad
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Department of Research and Development, Region Västra Götaland, NU-Hospital Group, Trollhättan, Sweden
| | - Eva Angenete
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mattias Prytz
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Region Västra Götaland, NU-Hospital Group, Trollhättan, Sweden
- Department of Research and Development, Region Västra Götaland, NU-Hospital Group, Trollhättan, Sweden
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Timan TJ, Ekerstad N, Karlsson O, Sernert N, Prytz M. One-year mortality rates after standardized management for emergency laparotomy: results from the Swedish SMASH study. BJS Open 2024; 8:zrad133. [PMID: 38284401 PMCID: PMC10823779 DOI: 10.1093/bjsopen/zrad133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/21/2023] [Indexed: 01/30/2024] Open
Abstract
BACKGROUND Patients who require an emergency laparotomy suffer from high mortality and morbidity rates. Studies have shown that the standardization of perioperative management reduces complications in the short term. The aim of the present study was to report long-term mortality rates for the SMASH (Standardized perioperative Management of patients operated with acute Abdominal Surgery in a High-risk and emergency setting) study, as well as short- and long-term outcomes for different age groups within the SMASH study. METHODS A prospective intervention study was introduced in 2018, with the aim of investigating the introduction of a standardized protocol for emergency laparotomy. For 42 months, intervention patients were managed according to the protocol and outcomes were then compared with those of historical controls. RESULTS A total of 1344 unique patients were included (681 in the intervention group and 663 in the control group). The 90-day mortality rate was 14.1 per cent in the intervention group and 20.8 per cent in the control group (P = 0.002) and the 1-year mortality rate in adjusted analyses was 19.7 and 27.8 per cent respectively (P =< 0.001). An age-related subgroup analysis showed that the oldest patients (76 years and older, 260 in the intervention group and 240 in the control group) had a 1-year mortality rate of 29.6 and 43.8 per cent respectively (P = 0.004) and a mean duration of hospital stay of 9.9 and 11.6 days respectively (P = 0.027). Among older adults (61-75 years), the mean duration of hospital stay was 11.7 days in the intervention group compared with 15.1 days in the control group (P = 0.009) and the mean duration of ICU care was reduced to 4.49 days compared with 7.29 days (P = 0.046). CONCLUSION The standardized protocol associated with an emergency laparotomy appears to be beneficial, even in the long term. For elderly patients, it appears to reduce mortality rates and the durations of hospital stay and ICU care.
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Affiliation(s)
- Terje Jansson Timan
- Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Research and Development, NU Hospital Group, Trollhättan, Sweden
- Department of Anaesthesiology and Intensive Care, NU Hospital Group, Trollhättan, Sweden
| | - Niklas Ekerstad
- Department of Research and Development, NU Hospital Group, Trollhättan, Sweden
- Department of Health, Medicine, and Caring Sciences, Unit of Health Care Analysis, Linköping University, Linköping, Sweden
| | - Ove Karlsson
- Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
| | - Ninni Sernert
- Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Research and Development, NU Hospital Group, Trollhättan, Sweden
| | - Mattias Prytz
- Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Research and Development, NU Hospital Group, Trollhättan, Sweden
- Department of Surgery, NU Hospital Group, Trollhättan, Sweden
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Olsson H, Åhlund K, Alfredsson J, Andersson D, Boström AM, Guidetti S, Prytz M, Ekerstad N. Cross-cultural adaption and inter-rater reliability of the Swedish version of the updated clinical frailty scale 2.0. BMC Geriatr 2023; 23:803. [PMID: 38053055 PMCID: PMC10696827 DOI: 10.1186/s12877-023-04525-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 11/28/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Worldwide, there is a large and growing group of older adults. Frailty is known as an important discriminatory factor for poor outcomes. The Clinical Frailty Scale (CFS) has become a frequently used frailty instrument in different clinical settings and health care sectors, and it has shown good predictive validity. The aims of this study were to describe and validate the translation and cultural adaptation of the CFS into Swedish (CFS-SWE), and to test the inter-rater reliability (IRR) for registered nurses using the CFS-SWE. METHODS An observational study design was employed. The ISPOR principles were used for the translation, linguistic validation and cultural adaptation of the scale. To test the IRR, 12 participants were asked to rate 10 clinical case vignettes using the CFS-SWE. The IRR was assessed using intraclass correlation and Krippendorff's alpha agreement coefficient test. RESULTS The Clinical Frailty Scale was translated and culturally adapted into Swedish and is presented in its final form. The IRR for all raters, measured by an intraclass correlation test, resulted in an absolute agreement value among the raters of 0.969 (95% CI: 0.929-0.991) and a consistency value of 0.979 (95% CI: 0.953-0.994), which indicates excellent reliability. Krippendorff's alpha agreement coefficient for all raters was 0.969 (95% CI: 0.917-0.988), indicating near-perfect agreement. The sensitivity of the reliability was examined by separately testing the IRR of the group of specialised registered nurses and non-specialised registered nurses respectively, with consistent and similar results. CONCLUSION The Clinical Frailty Scale was translated, linguistically validated and culturally adapted into Swedish following a well-established standard technique. The IRR was excellent, judged by two established, separately used, reliability tests. The reliability test results did not differ between non-specialised and specialised registered nurses. However, the use of case vignettes might reduce the generalisability of the reliability findings to real-life settings. The CFS has the potential to be a common reference tool, especially when older adults are treated and rehabilitated in different care sectors.
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Affiliation(s)
- Henrik Olsson
- Department of Research and Development, NU Hospital Group, Trollhättan, Sweden
- Department of Cardiology, NU Hospital Group, Trollhättan, Sweden
| | - Kristina Åhlund
- Department of Research and Development, NU Hospital Group, Trollhättan, Sweden
- Department of Health Sciences, University West, Trollhättan, Sweden
| | - Joakim Alfredsson
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Unit of Cardiovascular Sciences, Linköping University, Linköping, Sweden
| | - David Andersson
- Department of Management and Engineering, Division of Economics, Linköping University, Linköping, Sweden
| | - Anne-Marie Boström
- Department of Neurobiology, Division of Nursing, Karolinska Institutet, Care Sciences&Society (NVS), Huddinge, Sweden
- Karolinska University Hospital, Theme Inflammation and Aging, Stockholm, Sweden
- Stockholms Sjukhem, Research and Development Unit, Stockholm, Sweden
| | - Susanne Guidetti
- Department of Neurobiology, Division of Occupational Therapy, Karolinska Institutet, Care Sciences&Society (NVS), Huddinge, Sweden
- Women's Health and Allied Health Professionals Theme, Medical Unit Occupational Therapy and Physiotherapy, Karolinska University Hospital, Solna, Sweden
| | - Mattias Prytz
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy,, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, NU-Hospital Group, Region Västra Götaland, Trollhättan, Sweden
| | - Niklas Ekerstad
- Department of Research and Development, NU Hospital Group, Trollhättan, Sweden.
- Department of Health, Medicine, and Caring Sciences, Unit of Health Care Analysis, Linköping University, Linköping, Sweden.
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Falk Erhag H, Guðnadóttir G, Alfredsson J, Cederholm T, Ekerstad N, Religa D, Nellgård B, Wilhelmson K. The Association Between the Clinical Frailty Scale and Adverse Health Outcomes in Older Adults in Acute Clinical Settings - A Systematic Review of the Literature. Clin Interv Aging 2023; 18:249-261. [PMID: 36843633 PMCID: PMC9946013 DOI: 10.2147/cia.s388160] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 12/14/2022] [Indexed: 02/19/2023] Open
Abstract
Background Frail older adults experience higher rates of adverse health outcomes. Therefore, assessing pre-hospital frailty early in the course of care is essential to identify the most vulnerable patients and determine their risk of deterioration. The Clinical Frailty Scale (CFS) is a frailty assessment tool that evaluates pre-hospital mobility, energy, physical activity, and function to generate a score that ranges from very fit to terminally ill. Purpose To synthesize the evidence of the association between the CFS degree and all-cause mortality, all-cause readmission, length of hospital stay, adverse discharge destination, and functional decline in patients >65 years in acute clinical settings. Design Systematic review with narrative synthesis. Methods Electronic databases (PubMed, EMBASE, CINAHL, Scopus) were searched for prospective or retrospective studies reporting a relationship between pre-hospital frailty according to the CFS and the outcomes of interest from database inception to April 2020. Results Our search yielded 756 articles, of which 29 studies were included in this review (15 were at moderate risk and 14 at low risk of bias). The included studies represented 26 cohorts from 25 countries (N = 44166) published between 2011 and 2020. All included studies showed that pre-hospital frailty according to the CFS is an independent predictor of all adverse health outcomes included in the review. Conclusion A primary purpose of the CFS is to grade clinically increased risk (i.e. risk stratification). Our results report the accumulated knowledge on the risk-predictive performance of the CFS and highlight the importance of routinely including frailty assessments, such as the CFS, to estimate biological age, improve risk assessments, and assist clinical decision-making in older adults in acute care. Further research into the potential of the CFS and whether implementing the CFS in routine practice will improve care and patients' quality of life is warranted.
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Affiliation(s)
- Hanna Falk Erhag
- Neuropsychiatric Epidemiology Unit, Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden,Centre for Ageing and Health (Agecap), University of Gothenburg, Gothenburg, Sweden,Region Västra Götaland, Sahlgrenska University Hospital, Department of Acute Medicine and Geriatrics, Gothenburg, Sweden,Correspondence: Hanna Falk Erhag, Neuropsychiatric Epidemiology Unit, Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Wallinsgatan 6, Gothenburg, SE 431 41, Sweden, Tel +46 760 476888, Fax +46 31 786 60 77, Email
| | - Gudny Guðnadóttir
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Acute Medicine and Geriatrics, Gothenburg, Sweden
| | - Joakim Alfredsson
- Department of Cardiology, and Department of Health, Medicine and Caring Sciences, Unit of Cardiovascular Sciences, Linköping University, Linköping, Sweden
| | - Tommy Cederholm
- Clinical Nutrition and Metabolism Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden,Theme Inflammation and Aging, Karolinska University Hospital, Stockholm, Sweden
| | - Niklas Ekerstad
- Department of Health, Medicine, and Caring Sciences, Unit of Health Care Analysis, Linköping University, Linköping, Sweden,The Research and Development Unit, NU Hospital Group, Trollhättan, Sweden
| | - Dorota Religa
- Department of Neurobiology, Care Sciences, and Society, Clinical Geriatrics, Karolinska Institute, Stockholm, Sweden,Division for Clinical Geriatrics, Karolinska University Hospital, Stockholm, Sweden
| | - Bengt Nellgård
- Department of Anesthesiology and Intensive Care, Institute of Clinical Studies, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Katarina Wilhelmson
- Centre for Ageing and Health (Agecap), University of Gothenburg, Gothenburg, Sweden,Region Västra Götaland, Sahlgrenska University Hospital, Department of Acute Medicine and Geriatrics, Gothenburg, Sweden,Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Normann M, Ekerstad N, Angenete E, Prytz M. Effect of comprehensive geriatric assessment for frail elderly patients operated for colorectal cancer—the colorectal cancer frailty study: study protocol for a randomized, controlled, multicentre trial. Trials 2022; 23:948. [PMID: 36397083 PMCID: PMC9670054 DOI: 10.1186/s13063-022-06883-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 10/22/2022] [Indexed: 11/18/2022] Open
Abstract
Background Colorectal cancer (CRC) is the third most common cancer worldwide, with a median age of 72–75 years at diagnosis. Curative treatment usually involves surgery; if left untreated, symptoms may require emergency surgery. Therefore, most patients will be accepted for surgery, despite of high age or comorbidity. It is known that elderly patients suffer higher risks after surgery than younger patients, in terms of complications and mortality. Assessing frailty and offering frail elderly patients individualized treatment according to the comprehensive geriatric assessment (CGA) and care concept has been shown to improve the outcome for frail elderly patients in other clinical contexts. Methods This randomized controlled multicentre trial aims to investigate if CGA and care prior to curatively intended surgery for CRC in frail elderly patients will improve postoperative outcome. All patients ≥ 70 years with surgically curable CRC will be screened for frailty using the Clinical Frailty Scale (CFS-9). Frail patients will be offered inclusion. Randomization is stratified for colon or rectal cancer. Patients in the intervention group are, in addition to standard protocol, treated according to CGA and care. This consists of individualized assessments and interventions, established by a multiprofessional team. Patients in the control group are treated according to best known practice as stipulated by Swedish colorectal cancer treatment guidelines, within an enhanced recovery after surgery (ERAS) setting. The primary outcome is 90-day mortality. Secondary outcomes are the length of hospital stay and total number of hospital days within 3 months, discharge destination, 30-day readmission, ADL, safe medication assessment, CFS-9 score, complications, Health-Related Quality of Life (HRQoL) at 2-month follow-up in comparison to baseline measurements, health economical calculations including cost-effectiveness analysis based on costs of hospital care and primary care, mortality and HRQoL at baseline, 2- and 12-month follow-up and all-cause 1-year mortality. Discussion The trial is the first of its size and extent to investigate intervention with CGA and care prior to surgery for CRC in frail elderly patients. If this addition proves to be favourable, it could have implications on future care of frail elderly patients with CRC. Trial registration ClinicalTrials.gov NCT04358328. Registered on 4 February 2020 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06883-9.
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Affiliation(s)
- Maria Normann
- grid.8761.80000 0000 9919 9582Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden ,grid.459843.70000 0004 0624 0259Department of Surgery, Region Västra Götaland, NU-Hospital Group, Trollhättan, Sweden
| | - Niklas Ekerstad
- grid.5640.70000 0001 2162 9922Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden ,grid.459843.70000 0004 0624 0259Department of Research and Development, Region Västra Götaland, NU-Hospital Group, Trollhättan, Sweden
| | - Eva Angenete
- grid.8761.80000 0000 9919 9582Department of Surgery, SSORG – Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden ,grid.1649.a000000009445082XDepartment of Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mattias Prytz
- grid.8761.80000 0000 9919 9582Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden ,grid.459843.70000 0004 0624 0259Department of Surgery, Region Västra Götaland, NU-Hospital Group, Trollhättan, Sweden ,grid.459843.70000 0004 0624 0259Department of Research and Development, Region Västra Götaland, NU-Hospital Group, Trollhättan, Sweden
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Ekerstad N, Cederholm T, Boström AM, De Geer L, Ekdahl A, Guidetti S, Janzon M, Alfredsson J. [Clinical Frailty Scale - a proxy estimate of biological age]. Lakartidningen 2022; 119:22040. [PMID: 36345801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Abstract
The term frailty denotes a multi-dimensional syndrome characterised by reduced physiological reserves and increased vulnerability. Frailty may be used as a marker of biological age, distinct from chronological age. There are several instruments for frailty assessment. The Clinical Frailty Scale (CFS) is probably the most commonly used in the acute care context. It is a 9-level scale, derived from the accumulated deficit model of frailty, which combines comorbidity, disability, and cognitive impairment. The CFS assessment is fast and easy to implement in daily clinical practice. The CFS is relevant for risk stratification, and may also be used as a screening instrument to identify frail patients suitable for further geriatric evaluation, i.e. a comprehensive geriatric assessment (CGA). By providing information on long-term prognosis, it may improve informed decision-making on an individual basis.
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Affiliation(s)
- Niklas Ekerstad
- docent, läkare, institutionen för hälsa, medicin och vård, Linköpings universitet; FoU-enheten, NU-sjukvården
| | - Tommy Cederholm
- professor, läkare, institutionen för folkhälso- och vårdvetenskap, Uppsala universitet; Tema inflammation och åldrande, Karolinska universitetssjukhuset
| | - Anne-Marie Boström
- docent, sjuksköterska, institutionen för neurobiologi, vårdvetenskap och samhälle, Karolins-ka institutet; Tema Inflammation och åldrande, Karolinska universitetssjukhuset, Huddinge; Karolinska Institutet, Institutionen NVS, sektionen för omvårdnad, Huddinge
| | - Lina De Geer
- med dr, läkare, verksamhetschef, verksamhetschef, ANOPIVA, Universitetssjukhuset i Linköping; institutionen för biomedicinska och kliniska vetenskaper, Linköpings universitet
| | - Anne Ekdahl
- docent, läkare, sektionen för geriatrik, Helsingborgs lasarett; institutionen för kliniska vetenskaper Helsingborg, Lunds universitet
| | - Susanne Guidetti
- professor, arbetsterapeut, institutionen för neurobiologi, vårdvetenskap och samhälle, arbetsterapi, Karolinska institutet; Tema kvinnohälsa och hälsoprofessioner, Karolinska universitetssjukhuset
| | - Magnus Janzon
- docent, läkare, centrumchef, Hjärtcentrum, Universitetssjukhuset i Linköping; institutionen för hälsa, medicin och vård, Linköpings universitet
| | - Joakim Alfredsson
- docent, kardiologiska kliniken, Universitetssjukhuset i Linköping; institutionen för hälsa, medi-cin och vård, Linköpings universitet
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Drees C, Krevers B, Ekerstad N, Rogge A, Borzikowsky C, McLennan S, Buyx AM. Clinical Priority Setting and Decision-Making in Sweden: A Cross-sectional Survey Among Physicians. Int J Health Policy Manag 2022; 11:1148-1157. [PMID: 33904696 PMCID: PMC9808196 DOI: 10.34172/ijhpm.2021.16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 02/20/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Priority setting in healthcare that aims to achieve a fair and efficient allocation of limited resources is a worldwide challenge. Sweden has developed a sophisticated approach. Still, there is a need for a more detailed insight on how measures permeate clinical life. This study aimed to assess physicians' views regarding (1) impact of scarce resources on patient care, (2) clinical decision-making, and (3) the ethical platform and national guidelines for healthcare by the National Board of Health and Welfare (NBHW). METHODS An online cross-sectional questionnaire was sent to two groups in Sweden, 2016 and 2017. Group 1 represented 331 physicians from different departments at one University hospital and group 2 consisted of 923 members of the Society of Cardiology. RESULTS Overall, a 26% (328/1254) response rate was achieved, 49% in group 1 (162/331), 18% in group 2 (166/923). Scarcity of resources was perceived by 59% more often than 'at least once per month,' whilst 60% felt less than 'well-prepared' to address this issue. Guidelines in general had a lot of influence and 19% perceived them as limiting decision-making. 86% professed to be mostly independent in decision-making. 36% knew the ethical platform 'well' and 'very well' and 64% NBHW's national guidelines. 57% expressed a wish for further knowledge and training regarding the ethical platform and 51% for support in applying NBHW's national guidelines. CONCLUSION There was a need for more support to deal with scarcity of resources and for increased knowledge about the ethical platform and NBHW's national guidelines. Independence in clinical decision-making was perceived as high and guidelines in general as important. Priority setting as one potential pathway to fair and transparent decision-making should be highlighted more in Swedish clinical settings, with special emphasis on the ethical platform.
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Affiliation(s)
- Catharina Drees
- Division of Biomedical Ethics, Institute of Experimental Medicine, ChristianAlbrechts-University of Kiel, Kiel, Germany
| | - Barbro Krevers
- Department of Health, Medicine and Caring Sciences, Unit of Health Care Analysis, Linköping University, Linköping, Sweden
- National Centre for Priorities in Health, Linköping University, Linköping, Sweden
| | - Niklas Ekerstad
- Department of Health, Medicine and Caring Sciences, Unit of Health Care Analysis, Linköping University, Linköping, Sweden
- National Centre for Priorities in Health, Linköping University, Linköping, Sweden
- NU Hospital Group, The Research and Development Unit, Trollhättan, Sweden
| | - Annette Rogge
- Division of Biomedical Ethics, Institute of Experimental Medicine, ChristianAlbrechts-University of Kiel, Kiel, Germany
| | - Christoph Borzikowsky
- Institute of Medical Informatics and Statistics, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Stuart McLennan
- Institute of History and Ethics in Medicine, Technical University of Munich, Munich, Germany
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Alena M. Buyx
- Institute of History and Ethics in Medicine, Technical University of Munich, Munich, Germany
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Ekerstad N, Javadzadeh D, Alexander KP, Bergström O, Eurenius L, Fredrikson M, Gudnadottir G, Held C, Ängerud KH, Jahjah R, Jernberg T, Mattsson E, Melander K, Mellbin L, Ohlsson M, Ravn-Fischer A, Svennberg L, Yndigegn T, Alfredsson J. Clinical Frailty Scale classes are independently associated with 6-month mortality for patients after acute myocardial infarction. Eur Heart J Acute Cardiovasc Care 2022; 11:89-98. [PMID: 34905049 PMCID: PMC8826894 DOI: 10.1093/ehjacc/zuab114] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/09/2021] [Accepted: 11/19/2021] [Indexed: 12/22/2022]
Abstract
Aims Data on the prognostic value of frailty to guide clinical decision-making for patients with myocardial infarction (MI) are scarce. To analyse the association between frailty classification, treatment patterns, in-hospital outcomes, and 6-month mortality in a large population of patients with MI. Methods and results An observational, multicentre study with a retrospective analysis of prospectively collected data using the SWEDEHEART registry. In total, 3381 MI patients with a level of frailty assessed using the Clinical Frailty Scale (CFS-9) were included. Of these patients, 2509 (74.2%) were classified as non-vulnerable non-frail (CFS 1–3), 446 (13.2%) were vulnerable non-frail (CFS 4), and 426 (12.6%) were frail (CFS 5–9). Frailty and non-frail vulnerability were associated with worse in-hospital outcomes compared with non-frailty, i.e. higher rates of mortality (13.4% vs. 4.0% vs. 1.8%), cardiogenic shock (4.7% vs. 2.5% vs. 1.9%), and major bleeding (4.5% vs. 2.7% vs. 1.1%) (all P < 0.001), and less frequent use of evidence-based therapies. In Cox regression analyses, frailty was strongly and independently associated with 6-month mortality compared with non-frailty, after adjustment for age, sex, the GRACE risk score components, and other potential risk factors [hazard ratio (HR) 3.32, 95% confidence interval (CI) 2.30–4.79]. A similar pattern was seen for vulnerable non-frail patients (fully adjusted HR 2.07, 95% CI 1.41–3.02). Conclusion Frailty assessed with the CFS was independently and strongly associated with all-cause 6-month mortality, also after comprehensive adjustment for baseline differences in other risk factors. Similarly, non-frail vulnerability was independently associated with higher mortality compared with those with preserved functional ability.
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Affiliation(s)
- Niklas Ekerstad
- Department of Health, Medicine and Caring Sciences, Unit of Health Care Analysis and National Centre for Priorities in Health, Linköping University, Sandbäcksgatan 7, 58183 Linköping, Sweden.,The Research and Development Unit, NU Hospital Group, Trollhättan, Sweden
| | | | | | - Olle Bergström
- Department of Medicine, Växjö County Hospital, Växjö, Sweden
| | - Lars Eurenius
- Department of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Fredrikson
- Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health, Linköping University, Linköping, Sweden
| | - Gudny Gudnadottir
- Section of Geriatrics, Department of Acute Medicine and Geriatrics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Claes Held
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | | | - Radwan Jahjah
- Department of Cardiology, Unit of Cardiovascular Sciences, Linköping University, Linköping, Sweden.,Department of Health, Medicine and Caring Sciences, Unit of Cardiovascular Sciences, Linköping University, Linköping, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Ewa Mattsson
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | | | - Linda Mellbin
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Monica Ohlsson
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Annica Ravn-Fischer
- Department of Cardiology, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lars Svennberg
- Department of Cardiology, County Hospital of Gävle, Region Gävleborg, Sweden
| | | | - Joakim Alfredsson
- Department of Cardiology, Unit of Cardiovascular Sciences, Linköping University, Linköping, Sweden.,Department of Health, Medicine and Caring Sciences, Unit of Cardiovascular Sciences, Linköping University, Linköping, Sweden
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9
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Olsson H, Karlson BW, Herlitz J, Karlsson T, Hellberg J, Prytz M, Sernert N, Ekerstad N. Predictors of short- and long-term mortality in critically ill, older adults admitted to the emergency department: an observational study. BMC Emerg Med 2022; 22:15. [PMID: 35086496 PMCID: PMC8793240 DOI: 10.1186/s12873-022-00571-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 01/03/2022] [Indexed: 11/30/2022] Open
Abstract
Background In the future, we can expect an increase in older patients in emergency departments (ED) and acute wards. The main purpose of this study was to identify predictors of short- and long-term mortality in the ED and at hospital discharge. Methods This is a retrospective, observational, single-center, cohort study, involving critically ill older adults, recruited consecutively in an ED. The primary outcome was mortality. All patients were followed for 6.5–7.5 years. The Cox proportional hazards model was used. Results Regarding all critically ill patients aged ≥ 70 years and identified in the ED (n = 402), there was a significant association between mortality at 30 days after ED admission and unconsciousness on admission (HR 3.14, 95% CI 2.09–4.74), hypoxia on admission (HR 2.51, 95% CI 1.69–3.74) and age (HR 1.06 per year, 95% CI 1.03–1.09), (all p < 0.001). Of 402 critically ill patients aged ≥ 70 years and identified in the ED, 303 were discharged alive from hospital. There was a significant association between long-term mortality and the Charlson Comorbidity Index (CCI) > 2 (HR 1.90, 95% CI 1.46–2.48), length of stay (LOS) > 7 days (HR 1.72, 95% CI 1.32–2.23), discharge diagnosis of pneumonia (HR 1.65, 95% CI 1.24–2.21) and age (HR 1.08 per year, 95% CI 1.05–1.10), (all p < 0.001). The only symptom or vital sign associated with long-term mortality was hypoxia on admission (HR 1.70, 05% CI 1.30–2.22). Conclusions Among critically ill older adults admitted to an ED and discharged alive the following factors were predictive of long-term mortality: CCI > 2, LOS > 7 days, hypoxia on admission, discharge diagnosis of pneumonia and age. The following factors were predictive of mortality at 30 days after ED admission: unconsciousness on admission, hypoxia and age. These data might be clinically relevant when it comes to individualized care planning, which should take account of risk prediction and estimated prognosis.
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Affiliation(s)
- Henrik Olsson
- Department of Cardiology, NU Hospital Group, Trollhättan, Sweden
| | - Björn W Karlson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,AstraZeneca Gothenburg, Mölndal, Sweden
| | - Johan Herlitz
- Center for Prehospital Research, Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
| | - Thomas Karlsson
- Biostatistics, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jenny Hellberg
- Department of Cardiology, NU Hospital Group, Trollhättan, Sweden
| | - Mattias Prytz
- Department of Surgery, NU-Hospital Group, Region Västra Götaland, Trollhättan, Sweden
| | - Ninni Sernert
- Department of Orthopaedics Sahlgrenska Academy, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Niklas Ekerstad
- Department of Gothenburg Health, Medicine and Caring Sciences, Unit of Health Care Analysis, Linköping University, Linköping, Sweden.
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10
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Åhlund K, Öberg B, Ekerstad N, Bäck M. A balance between meaningfulness and risk of harm - frail elderly patients' perceptions of physical activity and exercise - an interview study. BMC Geriatr 2020; 20:490. [PMID: 33228542 PMCID: PMC7685538 DOI: 10.1186/s12877-020-01868-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 11/03/2020] [Indexed: 12/22/2022] Open
Abstract
Background There is growing evidence of the benefits of physical activity and exercise for frail elderly patients with comorbidity. In order to improve participation in physical activity and exercise interventions, there is a need to increase our understanding of the patient’s perspective. Aim The aim of this study is to explore the perceptions of physical activity and exercise among frail elderly patients with a severe comorbidity burden. Method Face-to-face, in-depth interviews were conducted with eighteen frail elderly patients with a severe comorbidity burden, median age 85.5 years (min-max 75–94). The interviews were transcribed verbatim and analyzed according to content analysis inspired by Krippendorf. Results An overall theme, defined as “Meaningfulness and risk of harm in an aging body” was identified, followed by three main categories, labeled physical activity in daily life, goals of physical activity and exercise and prerequisites for physical activity and exercise, and eight sub-categories. Conclusion This study suggests that, in frail elderly patients with severe multimorbidity, physical activity and exercise is a balance between what is perceived as meaningful and the risk of harm. Patients perceived aging as an inevitable process that they needed to accept and gradually adapt their physical activities in daily life to match. As patients said they were unclear about the benefits and risks of exercise and referred to their previous life and experiences when describing physical activity and exercise, it is likely that the communication relating to this within the healthcare system needs to be further developed To promote physical activity and exercise to maintain or improve physical fitness in this frail population, healthcare providers need to use extended, personalized information to tailor the type of physical activities, goals and prerequisites for each patient. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-020-01868-2.
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Affiliation(s)
- Kristina Åhlund
- Department of Physiotherapy, NU Hospital Group, Trollhättan, Sweden. .,Department of Health, Medicine and Caring Sciences, Division of Prevention, Rehabilitation and Community Medicine, Unit of Physiotherapy, Linköping University, Linköping, Sweden.
| | - Birgitta Öberg
- Department of Health, Medicine and Caring Sciences, Division of Prevention, Rehabilitation and Community Medicine, Unit of Physiotherapy, Linköping University, Linköping, Sweden
| | - Niklas Ekerstad
- Department of Research and Development, NU Hospital Group, Trollhättan, Sweden.,Department of Health, Medicine and Caring Sciences, Division of Society and Health, Linköping University, Linköping, Sweden
| | - Maria Bäck
- Department of Health, Medicine and Caring Sciences, Division of Prevention, Rehabilitation and Community Medicine, Unit of Physiotherapy, Linköping University, Linköping, Sweden.,Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Gothenburg, Sweden
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11
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W Ekdahl A, Ekerstad N, Alfredsson J, Johanzon M, Metzner C, Wilhelmson K, Strandberg T, Cederholm T. [Frailty]. Lakartidningen 2020; 117:F3HE. [PMID: 32396209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Frailty is a concept that is better than multimorbidity at identifying older people in need of special multidimensional care. Frailty denotes a state of accelerated biological aging in which the body gradually loses the ability to handle physical, mental and social stress. It is a dynamic condition which can be partly prevented and treated with physical exercise, nutrition and appropriate medication. They are many validated and simple screening tools for frailty. Some of these screening tools can assess the degree of frailty and thereby provide a risk stratification in for example a medical emergency. This can be used to support decisions to offer relevant medical intervention to chronologically old but biologically young people as well as to refrain from treatment in chronologically young but biologically older people.
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Affiliation(s)
| | | | - Joakim Alfredsson
- docent, kardiologiska kliniken, Universitetssjukhuset i Linköping; institutionen för medi-cin och hälsa, Linköpings universitet
| | - Madelene Johanzon
- Silvialäkare, ordförande Nationella programområdet äldres hälsa; medicinkliniken, Centralsjukhuset Karlstad
| | - Carina Metzner
- verksamhetschef multisjuka äldre, ordförande Svensk geriatrisk förening, Karolinska universitetssjukhuset
| | | | - Timo Strandberg
- professor, institutionen för folkhälso- och vårdvetenskap, Uppsala universitet; Tema åldrande, Karolinska universitetssjukhuset
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12
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Abstract
Aims: The aims of this study are to describe informal care activities and to estimate the societal cost of informal care of community-dwelling frail elderly people in Sweden. Methods: This study was performed within the frame of the TREEE project that included 408 frail elderly patients. At index hospitalisation (baseline), primary informal caregivers of the patients were provided with a questionnaire on informal care during a period of three months. Questions concerning other (secondary) informal caregivers were also included. A rough estimate of the total cost of informal care of frail elderly people in Sweden was obtained by combining data from this study with published data and official statistics. Results: In total, 176 informal caregivers responded, and 89% had provided informal care. The informal caregivers (primary and secondary) provided care for an average of 245 hours over three months. Taking care of the home was the dominating activity. In total, the mean cost of informal care was estimated to approximately 18,000 SEK (€1878) over three months, corresponding to an annual cost of approximately 72,000 SEK (€7477) per frail elderly person. The total annual societal costs of informal care of community dwelling frail elderly people aged 75 years and older in Sweden was estimated to be approximately 11,000 million SEK (€1150 million). Conclusions: The care of frail elderly people provided by informal caregivers is extensive and represents a great economic value. Although our calculations are associated with uncertainty, the size indicates that supporting informal caregivers should be a priority for society.
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Affiliation(s)
- Jenny Alwin
- Department of Medical and Health Sciences, Division of Health Care Analysis, Linköping University, Sweden
| | - Björn W Karlson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden.,Department of Acute and Internal Medicine, NU (NÄL-Uddevalla) Hospital Group, Sweden
| | - Magnus Husberg
- Department of Medical and Health Sciences, Division of Health Care Analysis, Linköping University, Sweden
| | - Per Carlsson
- Department of Medical and Health Sciences, Division of Health Care Analysis, Linköping University, Sweden
| | - Niklas Ekerstad
- Department of Cardiology, NU (NÄL-Uddevalla) Hospital Group, Sweden
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13
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Åhlund K, Ekerstad N, Bäck M, Karlson BW, Öberg B. Preserved physical fitness is associated with lower 1-year mortality in frail elderly patients with a severe comorbidity burden. Clin Interv Aging 2019; 14:577-586. [PMID: 30936688 PMCID: PMC6429995 DOI: 10.2147/cia.s198591] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Introduction Physical deterioration in connection with a care episode is common. The aim of this study was, in frail elderly patients with a severe comorbidity burden, to analyze 1) the association between physical fitness measurements and 1-year mortality and 2) the association between preserved physical fitness during the first three months after discharge from emergency hospital care and 1-year prognosis. Methods Frail elderly patients (≥75 years) in need of inpatient emergency medical care were included. Aerobic capacity (six-minute walk test, 6MWT) and muscle strength (handgrip strength test, HS) were assessed during the hospital stay and at a three-month follow-up. The results were analyzed using multivariate Cox regression; 1) 0–12-month analysis and 2) 0–3-month change in physical fitness in relation to 1-year mortality. The analyses were adjusted for age, gender, comorbidity and frailty. Results This study comprised 408 frail elderly hospitalized patients of whom 390 were evaluable (mean age 85.7 years, Charlson’s index mean 6.8). The three-month mortality was 11.5% and the 1-year mortality was 37.9%. After adjustments, the Cox-regression analysis showed that both 6MWT and HS were associated with 1-year mortality, HR6MWT 3.31 (95% CI 1.89–5.78, p>0.001) and HRHS 2.39 (95% CI 1.33–4.27, p=0.003). The 0–3-month change in the 6MWT and the HS were associated with 1-year mortality, where patients who deteriorated had a poorer prognosis than those with improved fitness, HR6MWT 3.80 (95% CI 1.42–10.06, p=0.007) and HRHS 2.21 (95% CI 1.07–4.58, p=0.032). Conclusion In frail elderly patients with a severe comorbidity burden, physical fitness in connection with emergency hospital care was independently associated with 1-year mortality. Moreover, a change in physical fitness during the first months after hospital care was important for the long-term prognosis. These results emphasize the importance of providing hospital care designed to prevent physical deterioration in frail elderly patients.
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Affiliation(s)
- Kristina Åhlund
- Department of Physiotherapy, NU Hospital Group, Trollhättan, Sweden, .,Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Linköping, Sweden,
| | - Niklas Ekerstad
- Department of Research and Development, NU Hospital Group, Trollhättan, Sweden.,Department of Medical and Health Sciences, Division of Health Care Analysis, Linköping University, Linköping, Sweden
| | - Maria Bäck
- Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Linköping, Sweden, .,Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Björn W Karlson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Internal and Acute Medicine, NU Hospital Group, Trollhättan-Uddevalla, Sweden
| | - Birgitta Öberg
- Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Linköping, Sweden,
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14
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Ekerstad N, Pettersson S, Alexander K, Andersson D, Eriksson S, Janzon M, Lindenberger M, Swahn E, Alfredsson J. Frailty as an instrument for evaluation of elderly patients with non-ST-segment elevation myocardial infarction: A follow-up after more than 5 years. Eur J Prev Cardiol 2018; 25:1813-1821. [DOI: 10.1177/2047487318799438] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background There is a growing body of evidence on the relevance of using frailty measures also in a cardiovascular context. The estimated time to death is crucial in clinical decision-making in cardiology. However, data on the importance of frailty in long-term mortality are very scarce. The aim of the study was to assess the prognostic value of frailty on mortality at long-term follow-up of more than 5 years in patients 75 years or older hospitalised for non-ST-segment elevation myocardial infarction. We hypothesised that frailty is independently associated with long-term mortality. Design This was a prospective, observational study conducted at three centres. Methods and results Frailty was assessed according to the Canadian Study of Health and Aging clinical frailty scale (CFS). Of 307 patients, 149 (48.5%) were considered frail according to the study instrument (degree 5–7 on the scale). The long-term all-cause mortality of more than 5 years (median 6.7 years) was significantly higher among frail patients (128, 85.9%) than non-frail patients (85, 53.8%), ( P < 0.001). In Cox regression analysis, frailty was independently associated with mortality from the index hospital admission to the end of follow-up (hazard ratio 2.06, 95% confidence interval 1.51–2.81; P < 0.001) together with age ( P < 0.001), ejection fraction ( P = 0.012) and Charlson comorbidity index ( P = 0.018). Conclusions In elderly non-ST-segment elevation myocardial infarction patients, frailty was independently associated with all-cause mortality at long-term follow-up of more than 6 years. The combined use of frailty and comorbidity may be the ultimate risk prediction concept in the context of cardiovascular patients with complex needs.
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Affiliation(s)
- Niklas Ekerstad
- Department of Medical and Health Sciences, Linköping University, Sweden
- Department of Cardiology, NU (NÄL-Uddevalla) Hospital Group, Sweden
| | - Staffan Pettersson
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Sweden
| | - Karen Alexander
- Department of Medicine, Duke Clinical Research Institute, USA
| | - David Andersson
- Department of Management and Engineering, Linköping University, Sweden
| | - Sofia Eriksson
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Sweden
| | - Magnus Janzon
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Sweden
| | - Marcus Lindenberger
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Sweden
| | - Eva Swahn
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Sweden
| | - Joakim Alfredsson
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Sweden
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15
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Ekerstad N, Karlson BW, Andersson D, Husberg M, Carlsson P, Heintz E, Alwin J. Short-term Resource Utilization and Cost-Effectiveness of Comprehensive Geriatric Assessment in Acute Hospital Care for Severely Frail Elderly Patients. J Am Med Dir Assoc 2018; 19:871-878.e2. [PMID: 29784592 DOI: 10.1016/j.jamda.2018.04.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 03/23/2018] [Accepted: 04/02/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The objective of this study was to estimate the 3-month within-trial cost-effectiveness of comprehensive geriatric assessment (CGA) in acute medical care for frail elderly patients compared to usual medical care, by estimating health-related quality of life and costs from a societal perspective. DESIGN Clinical, prospective, controlled, 1-center intervention trial with 2 parallel groups. INTERVENTION Structured, systematic interdisciplinary CGA-based care in an acute elderly care unit. If the patient fulfilled the inclusion criteria, and there was a bed available at the CGA unit, the patient was included in the intervention group. If no bed was available at the CGA unit, the patient was included in the control group and admitted to a conventional acute medical care unit. SETTING AND PARTICIPANTS A large county hospital in western Sweden. The trial included 408 frail elderly patients, 75 years or older, in need of acute in-hospital treatment. The patients were allocated to the intervention group (n = 206) or control group (n = 202). Mean age of the patients was 85.7 years, and 56% were female. MEASURES The primary outcome was the adjusted incremental cost-effectiveness ratio associated with the intervention compared to the control at the 3-month follow-up. RESULTS We undertook cost-effectiveness analysis, adjusted by regression analyses, including hospital, primary, and municipal care costs and effects. The difference in the mean adjusted quality-adjusted life years gained between groups at 3 months was 0.0252 [95% confidence interval (CI): 0.0082-0.0422]. The incremental cost, that is, the difference between the groups, was -3226 US dollars (95% CI: -6167 to -285). CONCLUSION The results indicate that the care in a CGA unit for acutely ill frail elderly patients is likely to be cost-effective compared to conventional care after 3 months.
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Affiliation(s)
- Niklas Ekerstad
- Department of Cardiology, NU (NÄL-Uddevalla) Hospital Group, Trollhättan-Uddevalla-Vänersborg, Sweden; Department of Medical and Health Sciences, Division of Health Care Analysis, Linköping University, Sweden.
| | - Björn W Karlson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - David Andersson
- Department of Management and Engineering, Division of Economics, Linköping University, Sweden
| | - Magnus Husberg
- Department of Medical and Health Sciences, Division of Health Care Analysis, Linköping University, Sweden
| | - Per Carlsson
- Department of Medical and Health Sciences, Division of Health Care Analysis, Linköping University, Sweden
| | - Emelie Heintz
- Department of Learning, Informatics, Management and Ethics (LIME), QRC Research Unit, Karolinska Institutet, Stockholm, Sweden
| | - Jenny Alwin
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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16
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Ekerstad N, Karlsson T, Söderqvist S, Karlson BW. Hospitalized frail elderly patients - atrial fibrillation, anticoagulation and 12 months' outcomes. Clin Interv Aging 2018; 13:749-756. [PMID: 29731616 PMCID: PMC5927348 DOI: 10.2147/cia.s159373] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background and objective Multiple chronic conditions and recurring acute illness are frequent among elderly people. One such condition is atrial fibrillation (AF), which increases the risk of stroke up to fivefold. The aim of this study was to investigate the prevalence of AF among hospitalized frail elderly patients, their use of anticoagulation and their 12-month outcomes. Patients and methods This was a clinical observational study of acutely hospitalized frail patients over the age of 75 years. The CHA2DS2-VASc Score was used to evaluate ischemic stroke risk in patients with AF. Clinically relevant outcomes were the composite of ischemic stroke and/or bleeding within 12 months, which was considered as primary in the analysis, ischemic stroke/transient ischemic attack (TIA), mortality, bleeding and hospital care consumption. Student’s t-test, Fisher’s exact test, Mann–Whitney U test and a Cox proportional hazards model were used for the analyses. Results The prevalence of AF was 47%, and 63% of them were prescribed an anticoagulant. AF patients without anticoagulation were older, more often females, more often in residential care, and they had worse Mini Nutritional Assessment and activities of daily living scores. Of the patients without anticoagulation, 56% had a documented contraindication. In univariate analysis, there were significantly more events among AF patients without anticoagulation regarding the composite outcome of ischemic stroke and/or bleeding (hazard ratio [HR] 3.65, 95% CI = 1.70–7.86; p < 0.001). When adjusting for potential confounders in Cox regression analysis, the difference remained significant (HR 4.54, 95% CI = 1.83–11.25; p = 0.001). Conclusion The prevalence of AF in a hospitalized frail elderly population was 47%. Of these, 63% were prescribed anticoagulation therapy. Almost half of the patients without stroke prophylaxis had no documented contraindication. At 1 year, there were significantly more events in terms of ischemic stroke and/or bleeding among AF patients without anticoagulation therapy than among those with.
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Affiliation(s)
- Niklas Ekerstad
- Department of Cardiology, NU (NÄL-Uddevalla) Hospital Group, Trollhättan-Uddevalla-Vänersborg, Sweden.,Department of Medical and Health Sciences, Division of Health Care Analysis, Linköping University, Linköping, Sweden
| | - Thomas Karlsson
- Health Metrics Unit, Institution of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Sara Söderqvist
- Department of Acute and Internal Medicine, NU (NÄL-Uddevalla) Hospital Group, Trollhättan-Uddevalla-Vänersborg, Sweden
| | - Björn W Karlson
- Department of Acute and Internal Medicine, NU (NÄL-Uddevalla) Hospital Group, Trollhättan-Uddevalla-Vänersborg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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17
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Ekerstad N, Östberg G, Johansson M, Karlson BW. Are frail elderly patients treated in a CGA unit more satisfied with their hospital care than those treated in conventional acute medical care? Patient Prefer Adherence 2018; 12:233-240. [PMID: 29445266 PMCID: PMC5808689 DOI: 10.2147/ppa.s154658] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Our aim was to study whether the acute care of frail elderly patients directly admitted to a comprehensive geriatric assessment (CGA) unit is superior to the care in a conventional acute medical care unit in terms of patient satisfaction. DESIGN TREEE (Is the TReatment of frail Elderly patients Effective in an Elderly care unit?) is a clinical, prospective, controlled, one-center intervention trial comparing acute treatment in CGA units and in conventional wards. SETTING This study was conducted in the NÄL-Uddevalla county hospital in western Sweden. PARTICIPANTS In this follow-up to the TREEE study, 229 frail patients, aged ≥75 years, in need of acute in-hospital treatment, were eligible. Of these patients, 139 patients were included in the analysis, 72 allocated to the CGA unit group and 67 to the conventional care group. Mean age was 85 years and 65% were female. INTERVENTION Direct admittance to an acute elderly care unit with structured, systematic interdisciplinary CGA-based care, compared to conventional acute medical care via the emergency room. MEASUREMENTS The primary outcome was the satisfaction reported by the patients shortly after discharge from hospital. A four-item confidential questionnaire was used. Responses were given on a 4-graded scale. RESULTS The response rate was 61%. In unadjusted analyses, significantly more patients in the intervention group responded positively to the following three questions about the hospitalization: "Did you get the nursing from the ward staff that you needed?" (p=0.003), "Are you satisfied with the information you received on your diseases and medication?" (p=0.016), and "Are you satisfied with the planning before discharge from the hospital?" (p=0.032). After adjusted analyses by multiple regression, a significant difference in favor of the intervention remained for the first question (p=0.027). CONCLUSION Acute care in a CGA unit with direct admission was associated with higher levels of patient satisfaction compared with conventional acute care via the emergency room.
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Affiliation(s)
- Niklas Ekerstad
- Department of Cardiology, NU (NÄL-Uddevalla) Hospital Group, Trollhättan-Uddevalla-Vänersborg
- Department of Medical and Health Sciences, Division of Health Care Analysis, Linköping University, Linköping
- Correspondence: Niklas Ekerstad, Department of Cardiology, NU (NAL-Uddevalla) Hospital Group, Lärketorpsvägen, 46100 Trollhättan, Sweden, Tel +46 736 249 652, Fax +46 104 357 129, Email
| | - Göran Östberg
- Division of Internal and Acute Medicine, NU Hospital Group, Trollhättan-Uddevalla-Vänersborg
| | - Maria Johansson
- Division of Internal and Acute Medicine, NU Hospital Group, Trollhättan-Uddevalla-Vänersborg
| | - Björn W Karlson
- Division of Internal and Acute Medicine, NU Hospital Group, Trollhättan-Uddevalla-Vänersborg
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Åhlund K, Bäck M, Öberg B, Ekerstad N. Effects of comprehensive geriatric assessment on physical fitness in an acute medical setting for frail elderly patients. Clin Interv Aging 2017; 12:1929-1939. [PMID: 29180856 PMCID: PMC5691905 DOI: 10.2147/cia.s149665] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Introduction Frail elderly people often use emergency care. During hospitalization, physical decline is common, implying an increased risk of adverse health outcomes. Comprehensive Geriatric Assessment (CGA) has been shown to be beneficial for these patients in hospital care. However, there is very limited evidence about the effects on physical fitness. The aim was to compare effects on physical fitness in the acute care of frail elderly patients at a CGA unit versus conventional care, 3 months after discharge. Patients and methods A clinical, prospective, controlled trial with two parallel groups was conducted. Patients aged ≥75 years, assessed as frail and in need of inpatient care, were assigned to a CGA unit or conventional care. Measurements of physical fitness, including handgrip strength (HS), timed up-and-go (TUG), and the 6-minute walk test (6-MWT) were made twice, at the hospital index care period and at the 3-month follow-up. Data were analyzed as the mean change from index to the 3-month follow-up, and dichotomized as decline versus stability/improvement in physical fitness. Results In all, 408 participants, aged 85.7±5.4 years, were included. The intervention group improved significantly in all components of physical fitness. The controls improved in TUG and declined in HS and 6-MWT. When the changes were dichotomized the intervention group declined to a lesser extent; HS p<0.001, 6-MWT p<0.001, TUG p<0.003. The regression analysis showed the following odds ratios (ORs) for how these outcomes were influenced by the intervention; HS OR 4.4 (confidence interval [CI] 95% 2.2–9.1), 6-MWT OR 13.9 (CI 95% 4.2–46.2), and TUG OR 2.5 (CI 95% 1.1–5.4). Conclusion This study indicates that the acute care of frail elderly patients at a CGA unit is superior to conventional care in terms of preserving physical fitness at 3 months follow-up. CGA management may positively influence outcomes of great importance for these patients, such as mobility, strength, and endurance.
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Affiliation(s)
- Kristina Åhlund
- Department of Physiotherapy, NU Hospital Group, Trollhättan.,Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Linköping
| | - Maria Bäck
- Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Linköping.,Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Gothenburg
| | - Birgitta Öberg
- Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Linköping
| | - Niklas Ekerstad
- Department of Cardiology, NU Hospital Group, Trollhättan.,Department of Medical and Health Sciences, Division of Health Care Analysis, Linköping University, Linköping, Sweden
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Ekerstad N, Bylin K, Karlson BW. Early rehospitalizations of frail elderly patients - the role of medications: a clinical, prospective, observational trial. Drug Healthc Patient Saf 2017; 9:77-88. [PMID: 28860862 PMCID: PMC5571818 DOI: 10.2147/dhps.s139237] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Early readmissions of frail elderly patients after an episode of hospital care are common and constitute a crucial patient safety outcome. Our purpose was to study the impact of medications on such early rehospitalizations. PATIENTS AND METHODS This is a clinical, prospective, observational study on rehospitalizations within 30 days after an acute hospital episode for frail patients over the age of 75 years. To identify adverse drug reactions (ADRs), underuse of evidence-based treatment and avoidability of rehospitalizations, the Naranjo score, the Hallas criteria and clinical judgment were used. RESULTS Of 390 evaluable patients, 96 (24.6%) were rehospitalized. The most frequent symptoms and conditions were dyspnea (n = 25) and worsened general condition (n = 18). The most frequent diagnoses were heart failure (n = 17) and pneumonia/acute bronchitis (n = 13). By logistic regression analysis, independent risk predictors for rehospitalization were heart failure (odds ratio [OR] = 1.8; 95% CI = 1.1-3.1) and anemia (OR = 2.3; 95% CI = 1.3-4.0). The number of rehospitalizations due to probable ADRs was 13, of which two were assessed as avoidable. The number of rehospitalizations probably due to underuse of evidence-based drug treatment was 19, all of which were assessed as avoidable. The number of rehospitalizations not due to ADRs or underuse of evidence-based drug treatment was 64, of which none was assessed as avoidable. CONCLUSION One out of four frail elderly patients discharged from hospital was rehospitalized within 1 month. Although ADRs constituted an important cause of rehospitalization, underuse of evidence-based drug treatment might be an even more frequent cause. Potentially avoidable rehospitalizations were more frequently associated with underuse of evidence-based drug treatment than with ADRs. Efforts to avoid ADRs in frail elderly patients must be balanced and combined with evidence-based drug therapy, which can benefit these patients.
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Affiliation(s)
- Niklas Ekerstad
- Department of Cardiology, NU (NÄL-Uddevalla) Hospital Group, Trollhättan
- Department of Medical and Health Sciences, Division of Health Care Analysis, Linköping University, Linköping
| | - Kristoffer Bylin
- Department of Acute and Internal Medicine, NU (NÄL-Uddevalla) Hospital Group, Trollhättan
| | - Björn W Karlson
- Department of Acute and Internal Medicine, NU (NÄL-Uddevalla) Hospital Group, Trollhättan
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Ekerstad N, Dahlin Ivanoff S, Landahl S, Östberg G, Johansson M, Andersson D, Husberg M, Alwin J, Karlson BW. Acute care of severely frail elderly patients in a CGA-unit is associated with less functional decline than conventional acute care. Clin Interv Aging 2017; 12:1239-1249. [PMID: 28848332 PMCID: PMC5557103 DOI: 10.2147/cia.s139230] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background A high percentage of individuals treated in specialized acute care wards are frail and elderly. Our aim was to study whether the acute care of such patients in a comprehensive geriatric assessment (CGA) unit is superior to care in a conventional acute medical care unit when it comes to activities of daily living (ADLs), frailty, and use of municipal help services. Patients and methods A clinical, prospective, controlled trial with two parallel groups was conducted in a large county hospital in West Sweden and included 408 frail elderly patients, age 75 or older (mean age 85.7 years; 56% female). Patients were assigned to the intervention group (n=206) or control group (n=202). Primary outcome was decline in functional activity ADLs assessed by the ADL Staircase 3 months after discharge from hospital. Secondary outcomes were degree of frailty and use of municipal help services. Results After adjustment by regression analyses, treatment in a CGA unit was independently associated with lower risk of decline in ADLs [odds ratio (OR) 0.093; 95% confidence interval (CI) 0.052–0.164; P<0.0001], and with a less prevalent increase in the degree of frailty (OR 0.229; 95% CI 0.131–0.400; P<0.0001). When ADLs were classified into three strata (independence, instrumental ADL-dependence, and personal ADL-dependence), changes to a more dependence-associated stratum were less prevalent in the intervention group (OR 0.194; 95% CI 0.085–0.444; P=0.0001). There was no significant difference between the groups in increased use of municipal help services (OR 0.682; 95% CI 0.395–1.178; P=0.170). Conclusion Acute care of frail elderly patients in a CGA unit was independently associated with lesser loss of functional ability and lesser increase in frailty after 3 months.
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Affiliation(s)
- Niklas Ekerstad
- Department of Cardiology, NU (NÄL-Uddevalla) Hospital Group, Trollhättan-Uddevalla-Vänersborg.,Department of Medical and Health Sciences, Division of Health Care Analysis, Linköping University
| | | | - Sten Landahl
- Department of Geriatrics, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg
| | - Göran Östberg
- Division of Internal and Acute Medicine, NU Hospital Group, Trollhättan-Uddevalla-Vänersborg
| | - Maria Johansson
- Division of Internal and Acute Medicine, NU Hospital Group, Trollhättan-Uddevalla-Vänersborg
| | - David Andersson
- Department of Management and Engineering, Division of Economics
| | - Magnus Husberg
- Department of Medical and Health Sciences, Division of Health Care Analysis, Linköping University
| | - Jenny Alwin
- Department of Medical and Health Sciences, Division of Health Care Analysis, Linköping University
| | - Björn W Karlson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Abstract
BACKGROUND AND PURPOSE Early rehabilitation is important for frail older adults due to reduced reserve capacity and physical fitness. To facilitate individualized rehabilitation programs, we need tools to make it possible to assess physical fitness in relation to frailty, instead of chronological age. The purpose of this study was, in a Swedish context, to describe measures of physical fitness in hospitalized frail older adults in relation to their degree of frailty. METHODS This was a cross-sectional study. A total of 408 frail older adults, mean age 86.6 years (75-99 years), in need of emergency medical inpatient care, were included in the NÄL-Uddevalla (NU) hospital group in Sweden. During the hospital stay, physical fitness was assessed using 4 different tests: hand-grip strength, the Timed Up and Go Test, 5-time sit-to-stand test, and 6-minute walk test. In the analyses, the physical fitness outcomes were related to the degree of frailty using the FRail Elderly Support ResearcH group screening instrument and previously used cutoffs or age-related reference values for older adults. RESULTS AND DISCUSSION This study showed that most hospitalized frail older adults perform far lower than previously described age-related reference values relating to physical fitness. An increased degree of frailty contributes to reduced physical fitness in tests assessing strength and endurance. CONCLUSIONS A frail-related screening instrument may be useful in the evaluation of physical fitness in hospitalized frail older adults and may facilitate the development of realistic, individualized rehabilitation programs beneficial to an early start on the emergency medical ward.
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Affiliation(s)
- Kristina Åhlund
- Department of Physiotherapy, NU Hospital Group, Trollhättan, Sweden.,Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Linköping, Sweden
| | - Niklas Ekerstad
- Department of Cardiology, NU Hospital Group, Trollhättan, Sweden.,Department of Medical and Health Sciences, Division of Health Care Analysis, Linköping University, Linköping, Sweden
| | - Birgitta Öberg
- Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Linköping, Sweden
| | - Maria Bäck
- Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Linköping, Sweden.,Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Gothenburg, Sweden
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Ekerstad N, Karlson BW, Dahlin Ivanoff S, Landahl S, Andersson D, Heintz E, Husberg M, Alwin J. Is the acute care of frail elderly patients in a comprehensive geriatric assessment unit superior to conventional acute medical care? Clin Interv Aging 2016; 12:1-9. [PMID: 28031704 PMCID: PMC5179210 DOI: 10.2147/cia.s124003] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE The aim of this study was to investigate whether the acute care of frail elderly patients in a comprehensive geriatric assessment (CGA) unit is superior to the care in a conventional acute medical care unit. DESIGN This is a clinical, prospective, randomized, controlled, one-center intervention study. SETTING This study was conducted in a large county hospital in western Sweden. PARTICIPANTS The study included 408 frail elderly patients, aged ≥75 years, in need of acute in-hospital treatment. The patients were allocated to the intervention group (n=206) or control group (n=202). Mean age of the patients was 85.7 years, and 56% were female. INTERVENTION This organizational form of care is characterized by a structured, systematic interdisciplinary CGA-based care at an acute elderly care unit. MEASUREMENTS The primary outcome was the change in health-related quality of life (HRQoL) 3 months after discharge from hospital, measured by the Health Utilities Index-3 (HUI-3). Secondary outcomes were all-cause mortality, rehospitalizations, and hospital care costs. RESULTS After adjustment by regression analysis, patients in the intervention group were less likely to present with decline in HRQoL after 3 months for the following dimensions: vision (odds ratio [OR] =0.33, 95% confidence interval [CI] =0.14-0.79), ambulation (OR =0.19, 95% CI =0.1-0.37), dexterity (OR =0.38, 95% CI =0.19-0.75), emotion (OR =0.43, 95% CI =0.22-0.84), cognition (OR = 0.076, 95% CI =0.033-0.18) and pain (OR =0.28, 95% CI =0.15-0.50). Treatment in a CGA unit was independently associated with lower 3-month mortality adjusted by Cox regression analysis (hazard ratio [HR] =0.55, 95% CI =0.32-0.96), and the two groups did not differ significantly in terms of hospital care costs (P>0.05). CONCLUSION Patients in an acute CGA unit were less likely to present with decline in HRQoL after 3 months, and the care in a CGA unit was also independently associated with lower mortality, at no higher cost.
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Affiliation(s)
- Niklas Ekerstad
- Department of Cardiology, NU (NÄL-Uddevalla) Hospital Group, Trollhattan; Division of Health Care Analysis, Department of Medical and Health Sciences, Linköping University, Linköping
| | - Björn W Karlson
- Department of Molecular and Clinical Medicine, Institute of Medicine
| | | | - Sten Landahl
- Department of Geriatrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg
| | - David Andersson
- Division of Economics, Department of Management and Engineering, Linköping University, Linköping
| | - Emelie Heintz
- Health Outcomes and Economic Evaluation Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Husberg
- Division of Health Care Analysis, Department of Medical and Health Sciences, Linköping University, Linköping
| | - Jenny Alwin
- Division of Health Care Analysis, Department of Medical and Health Sciences, Linköping University, Linköping
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Ekerstad N, Swahn E, Janzon M, Alfredsson J, Löfmark R, Lindenberger M, Andersson D, Carlsson P. Frailty is independently associated with 1-year mortality for elderly patients with non-ST-segment elevation myocardial infarction. Eur J Prev Cardiol 2013; 21:1216-24. [PMID: 23644488 DOI: 10.1177/2047487313490257] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND For the large population of elderly patients with cardiovascular disease, it is crucial to identify clinically relevant measures of biological age and their contribution to risk. Frailty is denoting decreased physiological reserves and increased vulnerability. We analysed the manner in which the variable frailty is associated with 1-year outcomes for elderly non-ST-segment elevation myocardial infarction (NSTEMI) patients. METHODS AND RESULTS Patients aged 75 years or older, with diagnosed NSTEMI were included at three centres, and clinical data including judgment of frailty were collected prospectively. Frailty was defined according to the Canadian Study of Health and Aging Clinical Frailty Scale. Of 307 patients, 149 (48.5%) were considered frail. By Cox regression analyses, frailty was found to be independently associated with 1-year mortality after adjusting for cardiovascular risk and comorbid conditions (hazard ratio 4.3, 95% CI 2.4-7.8). The time to the first event was significantly shorter for frail patients than for nonfrail (34 days, 95% CI 10-58, p = 0.005). CONCLUSIONS Frailty is strongly and independently associated with 1-year mortality. The combined use of frailty and comorbidity may constitute an important risk prediction concept in regard to cardiovascular patients with complex needs.
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Affiliation(s)
- Niklas Ekerstad
- Linköping University, Linköping, Sweden NU County Hospital, Trollhättan-Vänersborg-Uddevalla, Sweden
| | - Eva Swahn
- Linköping University, Linköping, Sweden
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Ekerstad N, Swahn E, Janzon M, Alfredsson J, Löfmark R, Lindenberger M, Carlsson P. Frailty is independently associated with short-term outcomes for elderly patients with non-ST-segment elevation myocardial infarction. Circulation 2011; 124:2397-404. [PMID: 22064593 DOI: 10.1161/circulationaha.111.025452] [Citation(s) in RCA: 242] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND For the large and growing population of elderly patients with cardiovascular disease, it is important to identify clinically relevant measures of biological age and their contribution to risk. Frailty is an emerging concept in medicine denoting increased vulnerability and decreased physiological reserves. We analyzed the manner in which the variable frailty predicts short-term outcomes for elderly non-ST-segment elevation myocardial infarction patients. METHODS AND RESULTS Patients aged ≥ 75 years, with diagnosed non-ST-segment elevation myocardial infarction were included at 3 centers, and clinical data including judgment of frailty were collected prospectively. Frailty was defined according to the Canadian Study of Health and Aging Clinical Frailty Scale. The impact of the comorbid conditions on risk was quantified by the coronary artery disease-specific index. Of 307 patients, 149 (48.5%) were considered frail. By multiple logistic regression, frailty was found to be strongly and independently associated with risk for the primary composite outcome (death from any cause, myocardial reinfarction, revascularization due to ischemia, hospitalization for any cause, major bleeding, stroke/transient ischemic attack, and need for dialysis up to 1 month after inclusion) (odds ratio, 2.2; 95% confidence interval, 1.3-3.7), in-hospital mortality (odds ratio, 4.6; 95% confidence interval, 1.3-16.8), and 1-month mortality (odds ratio, 4.7; 95% confidence interval, 1.7-13.0). CONCLUSIONS Frailty is strongly and independently associated with in-hospital mortality, 1-month mortality, prolonged hospital care, and the primary composite outcome. The combined use of frailty and comorbidity may constitute an ultimate risk prediction concept in regard to cardiovascular patients with complex needs.
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Affiliation(s)
- Niklas Ekerstad
- Center for Medical Technology Assessment/IMH, Linköping University, Sandbäcksgatan 7, 58183 Linköping, Sweden.
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Ekerstad N. [Ethical approval should be given for research concerning severely ill elderly]. Lakartidningen 2011; 108:2072-2073. [PMID: 22165531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Ekerstad N, Löfmark R, Andersson D, Carlsson P. A tentative consensus-based model for priority setting: an example from elderly patients with myocardial infarction and multi-morbidity. Scand J Public Health 2011; 39:345-53. [PMID: 21511875 DOI: 10.1177/1403494811405092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND In most Western countries the growing gap between available resources and greater potential for medical treatment has brought evidence-based guidelines into focus. However, such guidelines are difficult to use when the evidence base is weak. Priority setting for frail elderly patients with heart disease illustrates this problem. We have outlined a tentative model for priority setting regarding frail elderly heart patients. The model takes cardiovascular risk, frailty, and comorbidity into account. OBJECTIVE Our aim is to validate the model's components. We want to evaluate the inter-rater reliability of the study experts' rankings regarding each of the model's categories. METHODS A confidential questionnaire study consisting of 15 authentic and validated cases was conducted to assess the views of purposefully selected cardiology experts (n = 58). They were asked to rank the cases regarding the need for coronary angiography using their individual clinical experience. The response rate was 71%. Responses were analysed with frequencies and descriptive statistics. The inter-rater reliability regarding the experts' rankings of the cases was estimated via an intra-class correlation test (ICC). RESULTS The cardiologists considered the clinical cases to be realistic. The intra-class correlation (two-way random, consistency, average measure) was 0.978 (95% CI 0.958-0.991), which denotes a very good inter-rater reliability on the group level. The model's components were considered relevant regarding complex cases of non-ST elevation myocardial infarction. Comorbidity was considered to be the most relevant component, frailty the second most relevant, followed by cardiovascular risk. CONCLUSIONS A framework taking comorbidity, frailty, and cardiovascular risk into account could constitute a foundation for consensus-based guidelines for frail elderly heart patients. From a priority setting perspective, it is reasonable to believe that the framework is applicable to other groups of elderly patients with acute disease and complex needs.
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Affiliation(s)
- Niklas Ekerstad
- The Center for Medical Technology Assessment/IMH, Linköping University, Sandbäcksgatan 7, 58183 Linköping, Sweden.
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Ekerstad N, Löfmark R, Carlsson P. Elderly people with multi-morbidity and acute coronary syndrome: doctors' views on decision-making. Scand J Public Health 2009; 38:325-31. [PMID: 19948651 DOI: 10.1177/1403494809354359] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND In most Western countries the growing gap between available resources and greater potential for medical treatment has brought evidence-based guidelines into focus. However, problems exist in areas where the evidence base is weak, e.g. elderly patients with heart disease and multiple co-morbidities. OBJECTIVE Our aim is to evaluate the views of Swedish cardiologists on decision-making for elderly people with multiple co-morbidities and acute coronary syndrome without ST-elevation (NSTE ACS), and to generate some hypotheses for testing. METHODS A confidential questionnaire study was conducted to assess the views of cardiologists/internists (n = 370). The response rate was 69%. Responses were analyzed with frequencies and descriptive statistics. When appropriate, differences in proportions were assessed by a chi-square test. A content analysis was used to process the answers to the open-ended questions. RESULTS 81% of the respondents reported extensive use of national guidelines for care of heart disease in their clinical decision-making. However, when making decisions for multiple-diseased elderly patients, the individual physician's own clinical experience and the patient's views on treatment choice were used to an evidently greater extent than national guidelines. Approximately 50% estimated that they treated multiple-diseased elderly patients with NSTE ACS every day. Preferred measures for improving decision-making were: (a) carrying out treatment studies including elderly patients with multiple co-morbidities, and (b) preparing specific national guidelines for multiple-diseased elderly patients. CONCLUSIONS In the future, national guidelines for heart disease should be adapted in order to be applicable for elderly patients with multiple co-morbidities.
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Affiliation(s)
- Niklas Ekerstad
- The Center for Medical Technology Assessment/IMH, Linköping University, Linköping, Sweden.
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Ekerstad N. [New ethical platform for health care--exit Hippocrates?]. Lakartidningen 2007; 104:2936-2937. [PMID: 17977299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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Ekerstad N. [Constructive proposal on improvement of emergency medical training is wanted]. Lakartidningen 1997; 94:2259. [PMID: 9213697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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