Geriatric Choosing Wisely choice of recommendations in France: a pragmatic approach based on clinical audits

Background

The international Choosing Wisely campaign seeks to improve the appropriateness of care, notably through large campaigns among physicians and users designed to raise awareness of the risks inherent in overmedication.

Methods

In deploying the Choosing Wisely campaign, the French Society of Geriatrics and Gerontology chose early operationalization via a tool for clinical audit over a limited area before progressive dissemination. This enabled validation of four consensual recommendations concerning the management of urinary tract infections, the prolonged use of anxiolytics, the use of neuroleptics in dementia syndromes, and the use of statins in primary prevention. The fifth recommendation concerns the importance of a dialogue on the level of care. It was written by patient representatives directly involved in the campaign.

Results

The first cross-regional campaign in France involved 5337 chart screenings in 43 health facilities. Analysis of the results showed an important variability in practices between institutions and significant percentage of inappropriate prescriptions, notably of psychotropic medication.

Discussion

The high rate of participation of target institutions shows that geriatrics professionals are interested in the evaluation and optimization of professional practices. Frequent overuse of psychotropic medication highlights the need of campaigns to raise awareness and encourage deprescribing.

[Validation of an ophtalmology tele-expertise protocol in nursing homes]

INTRODUCTION

Assisted living residents are a fragile population with limited access to health care. In recent years, telemedicine has developed in several specialties, including ophthalmology. The main objective of our study is the validation of an ophthalmology telemedicine protocol in assisted living facilities.

MATERIALS AND METHODS

This is a retrospective, multicentric, descriptive study including 4 assisted living facilities in the Rennes area. An ophthalmic technician examined residents for one half-day per week. The examination was performed directly in the patient's room, in bed or in a chair, with portable equipment. An ophthalmologist from our service interpreted the results remotely on a deferred basis within 7 days. Appropriate medical or surgical care was then offered to the patient depending on the diagnosis.

RESULTS

We included 113 residents. A complete, interpretable examination was achieved in 84.1% of cases. One or more ophthalmic conditions were diagnosed in 57.5% of the residents. Of the residents who were then seen at the university medical center, 65% underwent a scheduled surgical procedure or laser. Visual acuity was significantly improved subsequent to the telemedicine encounter.

DISCUSSION

The success rate of a complete, interpretable examination allows us to now validate our nursing home examination procedure. In addition to bringing a large amount of initially unknown information to the medical and paramedical staff of the structure, ophthalmology telemedicine allows for a significant improvement in visual acuity.

CONCLUSION

This project validated the feasibility of ophthalmology telemedicine in an assisted living setting. This protocol may also be applicable to other health care settings (penitentiaries, mental health institutions, etc.).

French Multicenter Evaluation of the Appropriateness of Admission to the Emergency Department of the Over-80s

BACKGROUND

Persons over 80 represents 40% of patients in French emergency services. We assessed the appropriateness of these admissions and sought to identify risk factors for inappropriate hospital stays.

METHODS

The appropriateness of admission was assessed in a prospective, cross-sectional, multicenter study in eight hospitals in France by means of the Appropriateness Evaluation Protocol (French version, AEPf) during two non-consecutive periods of four weeks in 2010. We analyzed admission of patients aged 80 and over who were admitted to the hospital after a stay in the emergency department of the same hospital. Demographics and morbidity factors were recorded as were administrative hospitalization data to identify risk factors associated with inappropriate admissions. We also evaluated the economic impact of inappropriate admissions. For cost analysis, all variables were obtained from anonymized hospital reports of a diagnosis-related group system used for funding of the hospitals by health insurance.

RESULTS

During two different periods, 1577 patients were included. 139 (8.8%) hospital admissions were inappropriate according to explicit criteria of the AEPf, but 18 of these (1.1%) were in fact considered appropriate by the physician responsible for the admission, leading to 121 (7.7%) inappropriate admissions. Multivariate logistic regression showed that patients with heart disease were less often subject to inappropriate admission (odds ratio OR= 0.36 [0.23; 0.56], p < 0.001), as also were patients who usually lived in a nursing home (OR = 0.53 [0.30; 0.87], p = 0.018) and patients with higher Acute Physiology Scores (OR = 0.97 [0.95; 0.99], p < 0.001). Inappropriate admission increased when patients had a syndrome as the main diagnosis (OR = 1.81 [1.81; 2.83], p = 0.010). By contrast, cognitive functions, gait and balance disturbance or falls, behavioral disorders and method of transport to the emergency department did not change the probability of inappropriateness. The median cost of the hospital stay of an older patient was 3 606.5 [2 498.1; 4 994.2] euros for inappropriate admissions.

CONCLUSION

Inappropriate emergency admissions of older patients were infrequent. None of the geriatric syndromes were linked with the phenomenon and principle causes were severity of illness, mention of a cardiac disease, unclear pattern of consultation and institutionalized way of life.

[Refusal of care faced by case manager from elderly persons in complex situation: cross perspectives]

PURPOSE

Case management is a new professional field in France. It is addressed to elderly persons living in community whose situation is regarded as particularly complex. Case managers have to assess needs and coordinate necessary services. One common criteria of complexity is refusal of care. The objective of this study is to compare the words of users with those of case managers about refusal of care, in order to understand its meaning, professionals' attitudes and ethical challenges.

METHODS

Two researchers have cooperated on this qualitative research: the first one, anthropologist, interviewed 19 individuals, and 11 of their caregivers. The second one, geriatrician and researcher in medical ethics, lead four focus groups gathering a total of 18 case managers.

RESULTS

Refusal of care often is the result of the will of preserving one's identity, compromised by illness. Individuals seek control on their life. Facing this behaviour, case managers try to secure the individual, by establishing a personal relationship that respects their choices, even if care has to be delayed. Refusal of care may sometimes disclose a desire to vanish, in front of which professionals meet their own limits.

CONCLUSION

To recognise an elderly person that refuses care as a unique individual who can make choices secure his identity, and allow him to change.

[Factors facilitating and impairing implementation of integrated care]

BACKGROUND

Better integration of healthcare is the focus of many current reforms in Western countries. The goal is to reduce fragmentation of health and social care delivery for patients with chronic diseases. In France, Alzheimer autonomy integration experimentations (Maison Autonomie Intégration Alzheimer [MAIA]) were introduced as part of the 2008-2012 National Alzheimer Plan. To date, implementation of such organizations remains challenging. It is thus paramount to identify factors obstructing, and on the contrary facilitating, implementation of integrated care.

METHODS

After an in-depth literature review of qualitative studies published from January 1995 to December 2010. We selected 10 qualitative studies on health care professionals' perceptions of barriers and facilitators to the implementation of integrated care.

RESULTS

Barriers and facilitating factors linked to the implementation of integrated care were identified at several levels: leadership; collaboration between services and clinicians; and funding and policy making. The operative strategy applied to change care delivery and the role of the leading pilot are key elements during the implementation phase.

CONCLUSION

Strong leadership and active involvement of a broad spectrum of professionals from clinical practitioners to healthcare managers is crucial for a successful implementation of integrated care services.

[Standardized geriatric assessment or comprehensive gerontological assessment: where do we stand?]

The concept of comprehensive gerontological assessment is a foundation of modern geriatrics. Our focus was to try to clarify the underlying concepts, assess the level of evidence and clarify the issues still under debate. The concept implies the definition of an interdisciplinary process for a multidimensional assessment in order to produce a coordinated plan. The central notion is that the systematization of this multidimensionality and interdisciplinarity needs the establishment of dedicated process (meeting tools, clinical information system, etc.). Following dimensions should be covered: health, social, economic, environmental and psychological. Any assessment process that could lead to forgetting one of its dimensions cannot be viewed as a comprehensive gerontological assessment. The level of evidence is higher in hospital acute inpatient unit but it is still low in all other areas of health care but the scattered data in the literature argues for qualitative benefits (improved quality of care or quality of life). The questions that remain are numerous including the choice of strategy for initial evaluation (maximum versus minimum; from the outset by many professionals versus graduated based on the minimum initial evaluation), the choice of tool, the optimal location, the required intensity of monitoring and the ideal target population.

Six-month outcome of elderly people hospitalized via the emergency department: the SAFES cohort

BACKGROUND

The objective of the study was to identify factors predictive of 6-month institutionalization or mortality in frail elderly patients after acute hospitalization.

METHODS

A prospective cohort of elderly subjects 75 years and older was set up in nine French teaching hospitals. Data obtained from a comprehensive geriatric assessment were used in a Cox model to predict 6-month institutionalization or mortality. Institutionalization was defined as incident admission either to a nursing home or other long-term care facility during the follow-up period.

RESULTS

Crude institutionalization and death rates after 6 months of follow-up were 18% and 24%, respectively. Independent predictors of institutionalization were: living alone (HR=1.83; 95% CI=1.27-2.62) or a higher number of children (HR=0.86; 95% CI=0.78-0.96), balance problems (HR=1.72; 95% CI=1.19-2.47), malnutrition or risk thereof (HR=1.93; 95% CI=1.24-3.01), and dementia syndrome (HR=1.88; 95% CI=1.32-2.67). Factors found to be independently related to 6-month mortality were exclusively medical factors: malnutrition or risk thereof (HR=1.92; 95% CI=1.17-3.16), delirium (HR=1.80; 95% CI=1.24-2.62), and a high level of comorbidity (HR=1.62; 95% CI=1.09-2.40). Institutionalization (HR=1.92; 95% CI=1.37-2.71) and unplanned readmission (HR=4.47; 95% CI=3.16-2.71) within the follow-up period were also found as independent predictors.

CONCLUSION

The main factors predictive of 6-month outcome identified in this study are modifiable by global and multidisciplinary interventions. Their early identification and management would make it possible to modify frail elderly subjects' prognosis favorably.

Rapid cognitive decline, one-year institutional admission and one-year mortality: analysis of the ability to predict and inter-tool agreement of four validated clinical frailty indexes in the SAFEs cohort

OBJECTIVES

To evaluate the predictive ability of four clinical frailty indexes as regards one-year rapid cognitive decline (RCD - defined as the loss of at least 3 points on the MMSE score), and one-year institutional admission (IA) and mortality respectively; and to measure their agreement for identifying groups at risk of these severe outcomes.

DESIGN

One-year follow-up and multicentre study of old patients participating in the SAFEs cohort study.

SETTING

Nine university hospitals in France.

PARTICIPANTS

1,306 patients aged 75 or older (mean age 85±6 years; 65% female) hospitalized in medical divisions through an Emergency department.

MEASUREMENTS

Four frailty indexes (Winograd; Rockwood; Donini; and Schoevaerdts) reflecting the multidimensionality of the frailty concept, using an ordinal scoring system able to discriminate different grades of frailty, and constructed based on the accumulation of identified deficits after comprehensive geriatric assessment conducted during the first week of hospital stay, were used to categorize participants into three different grades of frailty: G1 - not frail; G2 - moderately frail; and G3 - severely frail. Comparisons between groups were performed using Fisher's exact test. Agreement between indexes was evaluated using Cohen's Kappa coefficient.

RESULTS

All patients were classified as frail by at least one of the four indexes. The Winograd and Rockwood indexes mainly classified subjects as G2 (85% and 96%), and the Donini and Schoevaerdts indexes mainly as G3 (71% and 67%). Among the SAFEs cohort population, 250, 1047 and 1,306 subjects were eligible for analyses of predictability for RCD, 1-year IA and 1-year mortality respectively. At 1 year, 84 subjects (34%) experienced RCD, 377 (36%) were admitted into an institutional setting, and 445 (34%) had died. With the Rockwood index, all subjects who experienced RCD were classified in G2; and in G2 and G3 when the Donini and Schoevaerdts indexes were used. No significant difference was found between frailty grade and RCD, whereas frailty grade was significantly associated with an increased risk of IA and death, whatever the frailty index considered. Agreement between the different indexes of frailty was poor with Kappa coefficients ranging from -0.02 to 0.15.

CONCLUSION

These findings confirm the poor clinimetric properties of these current indexes to measure frailty, underlining the fact that further work is needed to develop a better and more widely-accepted definition of frailty and therefore a better understanding of its pathophysiology.

Predictors of institution admission in the year following acute hospitalisation of elderly people

OBJECTIVES

The aim of the study was to identify factors related to institutionalisation within one-year follow up of subjects aged 75 or over, hospitalised via the emergency department (ED).

DESIGN

Prospective multicentre cohort.

SETTING

Nine French university teaching hospitals.

PARTICIPANTS

One thousand and forty seven (1 047) non institutionalised subjects aged 75 or over, hospitalised via ED. A sub-group analysis was performed on the 894 subjects with a caregiver.

MEASUREMENTS

Patients were assessed using Comprehensive Geriatric Assessment (CGA) tools. Cox survival analysis was performed to identify predictors of institutionalisation at one year.

RESULTS

Within one year after hospital admission, 210 (20.1%) subjects were institutionalised. For the overall study population, age >85 years (HR 1.6; 95%CI 1.1-2.1; p=0.005), inability to use the toilet (HR 1.6; 95%CI 1.1-2.4; p=0.007), balance disorders (HR 1.6; 95%CI 1.1-2.1; p=0.005) and presence of dementia syndrome (HR 1.9; 95%CI 1.4-2.6; p<0.001) proved to be independent predictors of institutionalisation; while a greater number of children was inversely linked to institutionalisation (HR 0.8; 95%CI 0.7-0.9; p<0.001). Bathing was of borderline significance (p=.09). For subjects with a caregiver, initial caregiver burden was significantly linked to institutionalisation within one year, in addition to the predictors observed in the overall study population.

CONCLUSIONS

CGA performed at the beginning of hospitalisation in acute medical wards is useful to predict institutionalisation. Most of the predictors identified can lead to targeted therapeutic options with a view to preventing or delaying institution admission.

Predicting early mortality among elderly patients hospitalised in medical wards via emergency department: the SAFES cohort study

OBJECTIVES

The aim of the study was, by early identification of deleterious prognostic factors that are open to remediation, to be in a position to assign elderly patients to different mortality risk groups to improve management.

DESIGN

Prospective multicentre cohort.

SETTING

Nine French teaching hospitals.

PARTICIPANTS

One thousand three hundred and six (1 306) patients aged 75 and over, hospitalised after having passed through Emergency Department (ED).

MEASUREMENTS

Patients were assessed using Comprehensive Geriatric Assessment (CGA) tools. A Cox survival analysis was performed to identify prognostic variables for six-week mortality. Receiver Operating Characteristics analysis was used to study the discriminant power of the model. A mortality risk score is proposed to define three risk groups for six-week mortality.

RESULTS

Crude mortality rate after a six week follow-up was 10.6% (n=135). Prognostic factors identified were: malnutrition risk (HR=2.1; 95% CI: 1.1-3.8; p=.02), delirium (HR=1.7; 95% CI: 1.2-2.5; p=.006), and dependency: moderate dependency (HR=4.9; 95% CI: 1.5-16.5; p=.01) or severe dependency (HR=10.3; 95% CI: 3.2-33.1; p < .001). The discriminant power of the model was good: the c-statistic representing the area under the curve was 0.71 (95% IC: 0.67 - 0.75; p < .001). The six-week mortality rate increased significantly (p < .001) across the three risk groups: 1.1% (n=269; 95% CI=0.5-1.7) in the lowest risk group, 11.1% (n=854; 95% CI=9.4-12.9) in the intermediate risk group, and 22.4% (n=125; 95% CI=20.1-24.7) in the highest risk group.

CONCLUSIONS

A simple score has been calculated (using only three variables from the CGA) and a practical schedule proposed to characterise patients according to the degree of mortality risk. Each of these three variables (malnutrition risk, delirium, and dependency) identified as independent prognostic factors can lead to a targeted therapeutic option to prevent early mortality.

Prior conceptions of integration and coordination as modulators of an innovation's adoption: the case of a pilot project targeting the implementation of a services' integration device in France

Purpose

Context

Data sources

Case description

Conclusion

Discussion

Implementing an evidence-based integration model in France to maintain independence: Project and Research on Integration of Services to Maintain the Autonomy (PRISMA)

Introduction

The fragmentation of the French health and services system has a negative impact on the quality of the services offered because dependant community-dwelling older persons receive services from a mean of three interveners, and 25% of the most dependent ones perceive assistance from at least 6 interveners. In 2006, the Ministry of Health funded an experimentation of implantation of an evidence-based model of integration based on case management: PRISMA.

Aims and objective

An implementation evaluative research was associated with the experimentation undertaken by an international (France, Quebec) and multidisciplinary (medical doctors, sociologists, economists) group of research.

Methods

This evaluation is carried out continuously all along the implementation process. It is essentially based on research-action framework. A multi-case qualitative analysis is performed on three sites contrasted in regard of the health and services local organisation: rural, urban and megalopolitan.

Results

Initial implementation seems to be low during the first 18 months. First objective signs of integration after 12 months were the emergence of a coordination process on a strategic level, the adoption of a unique assessment tools by all the partners and the project of constituting a multi-professional team of case managers. Sociological and political identified barriers will be discussed.

Is there a way to measure implementation of integration in different countries? The case of the PRISMA implementation qualitative methodology

Introduction

The PRISMA implementation research has used an innovative tool: the penetration rate of integrated model in the system. The experimentation in France of the PRISMA adopts and adapts this methodology.

Aims and objective

This measurement relates to the functions of the 6 tools and mechanisms of the model: coordination boards, single entry point, case-management, single assessment instrument, individualised services plan and information system. In contrast with Quebec, no public policy in France incites to move towards this model of integration. In addition, in the French system the construction of coordination boards is complex because there is as much as ten supervision authorities and about fifteen organisation managers involved in each experimental site.

Methods of adaptation of the tool in France

The measurement was not only the absence, partial existence or existence of the 6 components but takes into account the appropriation process for each one, the administrative time and the new definition of thresholds to reach as compared to the model.

Results

This research tool presents two advantages. The measurement scale enables also the partners to appropriate the function of each model component and more precisely the global model of the integration. Actors do not feel evaluated but accompanied.

[Inappropriateness of hospital use in two acute geriatrics department: description of the phenomenon and analysis of risk factors]

BACKGROUND

Inappropriateness of hospital use occurs when a gap between the patient's needs and the level of care delivered exists. Taking into account the improvement of number of acute geriatric care, it appears relevant to study the rate and causes of inappropriate hospital use in this context.

METHODS

All patients in two services of acute geriatrics were included: medical and socioeconomic data were collected, the appropriateness of each day of their hospitalization was evaluated using the French version of the Appropriateness Evaluation Protocol and the inappropriate days' Causes Analysis Protocol. Risk factors of having at least one inappropriate day occurring during the stay were searched using relevant statistical tests. A logistic regression model assessed influence of independent variables on the risk of inappropriateness.

RESULTS

Only the existence of cognitive impairment and the department where the hospitalization takes place were found to be risk factors of inappropriateness. The ranking of inappropriateness according to the causes is the same in the two services, yet with statistically different rates, in particular for causes related to waiting for admission in subacute or long-term care institutional network and for a service provided outside the hospital where the patient was admitted. In the two departments, over 25% of the inappropriate days were related to a patient's or his family's choice.

CONCLUSION

Access to subacute or long-term care institution is the first cause of inappropriate hospital use in the two departments. The importance of the rate of inappropriate days related to a choice of the patient or his family was probably a Geriatric specificity. Furthermore, in view of reducing the inappropriate hospital use, attention should be particularly paid on patients with cognitive impairment.

Fulminant invasive pulmonary aspergillosis in immunocompetent patients--a two-case report

Two cases of invasive aspergillosis (IA) in immunocompetent patients with a fulminant fatal outcome are reported. Both patients were elderly and had a history of chronic lung disease treated with prolonged inhaled corticosteroids and a short course of systemic corticosteroids. They presented with dyspnea and fever, their respiratory function deteriorated rapidly, and they died 7 days after admission. Aspergillus fumigatus was cultured from respiratory samples. IA was confirmed in one case by necropsy that showed diffuse bilateral necrotizing pneumonitis and myocarditis. In the other case, IA diagnosis was established by thoracic CT scan plus detection of Aspergillus antigen in two blood samples. These two cases demonstrate that short-term corticosteroid therapy in immunocompetent patients with underlying chronic lung conditions is a risk factor for IA, and that its evolution can be fulminant.

[Diabetic foot ulcers: anti-infectious strategies]

Infection is a common problem in diabetic patients with foot ulcers. The diagnosis of infection is not always easy to establish, but must be made for proper therapeutic decision making. In addition to local care, search for arteriopathy and strict control of blood glucose, treatment of infected foot ulcers requires an appropriate anti-infectious strategy. We developed diagnostic and therapeutic decisional algorithms from data available in the literature in order to establish a management strategy for different clinical situations. The fundamental role of clinical assessment is underlined and the different causal microorganisms are recalled, together with the anti-microbial activity and bone concentrations of the main antibiotics used. An optimal anti-infection work-up can undoubtedly significantly reduce the number of amputations in diabetic patients.

[CREST syndrome presenting as pulmonary hypertension]

The authors report the case of a 62-year-old patient complaining of recent onset of disabling breathlessness on exertion, and presenting clinical signs of previously undiagnosed scleroderma. Echocardiography revealed a diagnosis of precapillary pulmonary hypertension (74/14 mmHg) (PHT), with no pulmonary cause revealed by pulmonary ventilation-perfusion scintigraphy or by thoracic fine section computed tomography. The diagnosis of PHT in the context of circumscribed scleroderma was confirmed by x-rays of the hands, capillaroscopy, oesophageal investigations and positive anticentromere antinuclear antibodies. The clinical course was marked by rapid deterioration of the symptoms, requiring treatment with prostacyclin by continuous intravenous infusion. The appearance of PHT in a context of circumscribed scleroderma, usually a relatively benign disease, is a rare, late event, exceptionally revealing the disease, as in this case, and indicating a very unfavourable prognosis.