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1.  Functional status and quality of life 12 months after discharge from a medical ICU in healthy elderly patients: a prospective observational study 
Critical Care  2011;15(2):R105.
Introduction
Long-term outcomes of elderly patients after medical ICU care are little known. The aim of the study was to evaluate functional status and quality of life of elderly patients 12 months after discharge from a medical ICU.
Methods
We prospectively studied 112/230 healthy elderly patients (≥65 years surviving at least 12 months after ICU discharge) with full functional autonomy without cognitive impairment prior to ICU entry. The main diagnoses at admission using the Acute Physiology and Chronic Health Evaluation III (APACHE III) classification diagnosis and length of ICU stay and ICU scores (APACHE II, Sepsis-related Organ Failure Assessment (SOFA) and OMEGA) at admission and discharge were collected. Comprehensive geriatric assessment included the presence of the main geriatric syndromes and the application of Lawton, Barthel, and Charlson Indexes and Informant Questionnaire on Cognitive Decline to evaluate functionality, comorbidity and cognitive status, respectively. The EuroQol-5D assessed quality of life. Data were collected at baseline, during ICU and ward stay and 3, 6 and 12 months after hospital discharge. Paired or unpaired T-tests compared differences between groups (continuous variables), whereas the chi-square and Fisher exact tests were used for comparing dichotomous variables. For variables significant (P ≤ 0.1) on univariate analysis, a forward multiple regression analysis was performed.
Results
Only 48.9% of patients (mean age: 73.4 ± 5.5 years) were alive 12 months after discharge showing a significant decrease in functional autonomy (Lawton and Barthel Indexes) and quality of life (EuroQol-5D) compared to baseline status (P < 0.001, all). Multivariate analysis showed a higher Barthel Index and EQ-5D vas at hospital discharge to be associated factors of full functional recovery (P < 0.01, both). Thus, in patients with a Barthel Index ≥ 60 or EQ-5D vas ≥40 at discharge the hazard ratio for full functional recovery was 4.04 (95% CI: 1.58 to 10.33; P = 0.005) and 6.1 (95% CI: 1.9 to 19.9; P < 0.01), respectively. Geriatric syndromes increased after ICU stay and remained significantly increased during follow-up (P < 0.001).
Conclusions
The survival rate of elderly medical patients 12 months after discharge from the ICU is low (49%), although functional status and quality of life remained similar to baseline in most of the survivors. However, there was a two-fold increase in the prevalence of geriatric syndromes.
doi:10.1186/cc10121
PMCID: PMC3219378  PMID: 21443796
2.  Development of quality indicators for monitoring outcomes of frail elderly hospitalised in acute care health settings: Study Protocol 
Background
Frail older people admitted to acute care hospitals are at risk of a range of adverse outcomes, including geriatric syndromes, although targeted care strategies can improve health outcomes for these patients. It is therefore important to assess inter-hospital variation in performance in order to plan and resource improvement programs.
Clinical quality outcome indicators provide a mechanism for identifying variation in performance over time and between hospitals, however to date there has been no routine use of such indicators in acute care settings.
A barrier to using quality indicators is lack of access to routinely collected clinical data. The interRAI Acute Care (AC) assessment system supports comprehensive geriatric assessment of older people within routine daily practice in hospital and includes process and outcome data pertaining to geriatric syndromes.
This paper reports the study protocol for the development of aged care quality indicators for acute care hospitals.
Methods/Design
The study will be conducted in three phases:
1. Development of a preliminary inclusive set of quality indicators set based on a literature review and expert panel consultation,
2. A prospective field study including recruitment of 480 patients aged 70 years or older across 9 Australian hospitals. Each patient will be assessed on admission and discharge using the interRAI AC, and will undergo daily monitoring to observe outcomes. Medical records will be independently audited, and
3. Analysis and compilation of a definitive quality indicator set, including two anonymous voting rounds for quality indicator inclusion by the expert panel.
Discussion
The approach to quality indicators proposed in this protocol has four distinct advantages over previous efforts: the quality indicators focus on outcomes; they can be collected as part of a routinely applied clinical information and decision support system; the clinical data will be robust and will contribute to better understanding variations in hospital care of older patients; The quality indicators will have international relevance as they will be built on the interRAI assessment instrument, an internationally recognised clinical system.
doi:10.1186/1472-6963-11-281
PMCID: PMC3212964  PMID: 22014061
3.  Study protocol: follow-up home visits with nutrition: a randomised controlled trial 
BMC Geriatrics  2011;11:90.
Background
Geriatric patients are at high risk of re-admission after discharge. Pre-existing nutritional risk amongst these patients is of primary concern, with former nutritional intervention studies being largely ineffective. None of these studies has included individual dietary counselling by a registered dietician or has considered competing medical conditions in the participants. A former randomised study has shown that comprehensive discharge follow-up in geriatric patients homes by general practitioners and district nurses was effective in reducing the re-admission risk in the intervention group compared to the control group. That study did not include a nutritional intervention. The purpose of this study is to assess the combined benefits of an intervention consisting of discharge follow-up in geriatric patients' home by a general practitioner and a registered dietician.
Methods/design
This single-blind randomised controlled study, will recruit 160 hospitalised geriatric medical patients (65+ y) at nutritional risk. Participants will be randomly allocated to receive in their homes, either 12 weeks individualised nutritional counselling by a registered dietician complemented with follow-up by general practitioners or a 12 weeks follow-up by general practitioners alone.
Discussion
This trial is the first of its kind to provide individual nutritional intervention combined with follow-up by general practitioner as an intervention to reduce risk of re-admission after discharge among geriatric medical patients. The results will hopefully help to guide the development of more effective rehabilitation programs following hospital admissions, which may ultimately lead to reduced health care costs, and improvement in mobility, independence and quality of life for geriatric patients at nutritional risk.
Trial Registration
ClinicalTrials.gov 2010 NCT01249716
doi:10.1186/1471-2318-11-90
PMCID: PMC3306756  PMID: 22204420
4.  Hospital-at-Home Programs for Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD) 
Executive Summary
In July 2010, the Medical Advisory Secretariat (MAS) began work on a Chronic Obstructive Pulmonary Disease (COPD) evidentiary framework, an evidence-based review of the literature surrounding treatment strategies for patients with COPD. This project emerged from a request by the Health System Strategy Division of the Ministry of Health and Long-Term Care that MAS provide them with an evidentiary platform on the effectiveness and cost-effectiveness of COPD interventions.
After an initial review of health technology assessments and systematic reviews of COPD literature, and consultation with experts, MAS identified the following topics for analysis: vaccinations (influenza and pneumococcal), smoking cessation, multidisciplinary care, pulmonary rehabilitation, long-term oxygen therapy, noninvasive positive pressure ventilation for acute and chronic respiratory failure, hospital-at-home for acute exacerbations of COPD, and telehealth (including telemonitoring and telephone support). Evidence-based analyses were prepared for each of these topics. For each technology, an economic analysis was also completed where appropriate. In addition, a review of the qualitative literature on patient, caregiver, and provider perspectives on living and dying with COPD was conducted, as were reviews of the qualitative literature on each of the technologies included in these analyses.
The Chronic Obstructive Pulmonary Disease Mega-Analysis series is made up of the following reports, which can be publicly accessed at the MAS website at: http://www.hqontario.ca/en/mas/mas_ohtas_mn.html.
Chronic Obstructive Pulmonary Disease (COPD) Evidentiary Framework
Influenza and Pneumococcal Vaccinations for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Smoking Cessation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Community-Based Multidisciplinary Care for Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Pulmonary Rehabilitation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Long-term Oxygen Therapy for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Noninvasive Positive Pressure Ventilation for Acute Respiratory Failure Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Noninvasive Positive Pressure Ventilation for Chronic Respiratory Failure Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Hospital-at-Home Programs for Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Home Telehealth for Patients with Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Cost-Effectiveness of Interventions for Chronic Obstructive Pulmonary Disease Using an Ontario Policy Model
Experiences of Living and Dying With COPD: A Systematic Review and Synthesis of the Qualitative Empirical Literature
For more information on the qualitative review, please contact Mita Giacomini at: http://fhs.mcmaster.ca/ceb/faculty_member_giacomini.htm.
For more information on the economic analysis, please visit the PATH website: http://www.path-hta.ca/About-Us/Contact-Us.aspx.
The Toronto Health Economics and Technology Assessment (THETA) collaborative has produced an associated report on patient preference for mechanical ventilation. For more information, please visit the THETA website: http://theta.utoronto.ca/static/contact.
Objective
The objective of this analysis was to compare hospital-at-home care with inpatient hospital care for patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) who present to the emergency department (ED).
Clinical Need: Condition and Target Population
Acute Exacerbations of Chronic Obstructive Pulmonary Disease
Chronic obstructive pulmonary disease is a disease state characterized by airflow limitation that is not fully reversible. This airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases. The natural history of COPD involves periods of acute-onset worsening of symptoms, particularly increased breathlessness, cough, and/or sputum, that go beyond normal day-to-day variations; these are known as acute exacerbations.
Two-thirds of COPD exacerbations are caused by an infection of the tracheobronchial tree or by air pollution; the cause in the remaining cases is unknown. On average, patients with moderate to severe COPD experience 2 or 3 exacerbations each year.
Exacerbations have an important impact on patients and on the health care system. For the patient, exacerbations result in decreased quality of life, potentially permanent losses of lung function, and an increased risk of mortality. For the health care system, exacerbations of COPD are a leading cause of ED visits and hospitalizations, particularly in winter.
Technology
Hospital-at-home programs offer an alternative for patients who present to the ED with an exacerbation of COPD and require hospital admission for their treatment. Hospital-at-home programs provide patients with visits in their home by medical professionals (typically specialist nurses) who monitor the patients, alter patients’ treatment plans if needed, and in some programs, provide additional care such as pulmonary rehabilitation, patient and caregiver education, and smoking cessation counselling.
There are 2 types of hospital-at-home programs: admission avoidance and early discharge hospital-at-home. In the former, admission avoidance hospital-at-home, after patients are assessed in the ED, they are prescribed the necessary medications and additional care needed (e.g., oxygen therapy) and then sent home where they receive regular visits from a medical professional. In early discharge hospital-at-home, after being assessed in the ED, patients are admitted to the hospital where they receive the initial phase of their treatment. These patients are discharged into a hospital-at-home program before the exacerbation has resolved. In both cases, once the exacerbation has resolved, the patient is discharged from the hospital-at-home program and no longer receives visits in his/her home.
In the models that exist to date, hospital-at-home programs differ from other home care programs because they deal with higher acuity patients who require higher acuity care, and because hospitals retain the medical and legal responsibility for patients. Furthermore, patients requiring home care services may require such services for long periods of time or indefinitely, whereas patients in hospital-at-home programs require and receive the services for a short period of time only.
Hospital-at-home care is not appropriate for all patients with acute exacerbations of COPD. Ineligible patients include: those with mild exacerbations that can be managed without admission to hospital; those who require admission to hospital; and those who cannot be safely treated in a hospital-at-home program either for medical reasons and/or because of a lack of, or poor, social support at home.
The proposed possible benefits of hospital-at-home for treatment of exacerbations of COPD include: decreased utilization of health care resources by avoiding hospital admission and/or reducing length of stay in hospital; decreased costs; increased health-related quality of life for patients and caregivers when treated at home; and reduced risk of hospital-acquired infections in this susceptible patient population.
Ontario Context
No hospital-at-home programs for the treatment of acute exacerbations of COPD were identified in Ontario. Patients requiring acute care for their exacerbations are treated in hospitals.
Research Question
What is the effectiveness, cost-effectiveness, and safety of hospital-at-home care compared with inpatient hospital care of acute exacerbations of COPD?
Research Methods
Literature Search
Search Strategy
A literature search was performed on August 5, 2010, using OVID MEDLINE, OVID MEDLINE In-Process and Other Non-Indexed Citations, OVID EMBASE, EBSCO Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Wiley Cochrane Library, and the Centre for Reviews and Dissemination database for studies published from January 1, 1990, to August 5, 2010. Abstracts were reviewed by a single reviewer and, for those studies meeting the eligibility criteria, full-text articles were obtained. Reference lists and health technology assessment websites were also examined for any additional relevant studies not identified through the systematic search.
Inclusion Criteria
English language full-text reports;
health technology assessments, systematic reviews, meta-analyses, and randomized controlled trials (RCTs);
studies performed exclusively in patients with a diagnosis of COPD or studies including patients with COPD as well as patients with other conditions, if results are reported for COPD patients separately;
studies performed in patients with acute exacerbations of COPD who present to the ED;
studies published between January 1, 1990, and August 5, 2010;
studies comparing hospital-at-home and inpatient hospital care for patients with acute exacerbations of COPD;
studies that include at least 1 of the outcomes of interest (listed below).
Cochrane Collaboration reviews have defined hospital-at-home programs as those that provide patients with active treatment for their acute exacerbation in their home by medical professionals for a limited period of time (in this case, until the resolution of the exacerbation). If a hospital-at-home program had not been available, these patients would have been admitted to hospital for their treatment.
Exclusion Criteria
< 18 years of age
animal studies
duplicate publications
grey literature
Outcomes of Interest
Patient/clinical outcomes
mortality
lung function (forced expiratory volume in 1 second)
health-related quality of life
patient or caregiver preference
patient or caregiver satisfaction with care
complications
Health system outcomes
hospital readmissions
length of stay in hospital and hospital-at-home
ED visits
transfer to long-term care
days to readmission
eligibility for hospital-at-home
Statistical Methods
When possible, results were pooled using Review Manager 5 Version 5.1; otherwise, results were summarized descriptively. Data from RCTs were analyzed using intention-to-treat protocols. In addition, a sensitivity analysis was done assigning all missing data/withdrawals to the event. P values less than 0.05 were considered significant. A priori subgroup analyses were planned for the acuity of hospital-at-home program, type of hospital-at-home program (early discharge or admission avoidance), and severity of the patients’ COPD. Additional subgroup analyses were conducted as needed based on the identified literature. Post hoc sample size calculations were performed using STATA 10.1.
Quality of Evidence
The quality of each included study was assessed, taking into consideration allocation concealment, randomization, blinding, power/sample size, withdrawals/dropouts, and intention-to-treat analyses.
The quality of the body of evidence was assessed as high, moderate, low, or very low according to the GRADE Working Group criteria. The following definitions of quality were used in grading the quality of the evidence:
Summary of Findings
Fourteen studies met the inclusion criteria and were included in this review: 1 health technology assessment, 5 systematic reviews, and 7 RCTs.
The following conclusions are based on low to very low quality of evidence. The reviewed evidence was based on RCTs that were inadequately powered to observe differences between hospital-at-home and inpatient hospital care for most outcomes, so there is a strong possibility of type II error. Given the low to very low quality of evidence, these conclusions must be considered with caution.
Approximately 21% to 37% of patients with acute exacerbations of COPD who present to the ED may be eligible for hospital-at-home care.
Of the patients who are eligible for care, some may refuse to participate in hospital-at-home care.
Eligibility for hospital-at-home care may be increased depending on the design of the hospital-at-home program, such as the size of the geographical service area for hospital-at-home and the hours of operation for patient assessment and entry into hospital-at-home.
Hospital-at-home care for acute exacerbations of COPD was associated with a nonsignificant reduction in the risk of mortality and hospital readmissions compared with inpatient hospital care during 2- to 6-month follow-up.
Limited, very low quality evidence suggests that hospital readmissions are delayed in patients who received hospital-at-home care compared with those who received inpatient hospital care (mean additional days before readmission comparing hospital-at-home to inpatient hospital care ranged from 4 to 38 days).
There is insufficient evidence to determine whether hospital-at-home care, compared with inpatient hospital care, is associated with improved lung function.
The majority of studies did not find significant differences between hospital-at-home and inpatient hospital care for a variety of health-related quality of life measures at follow-up. However, follow-up may have been too late to observe an impact of hospital-at-home care on quality of life.
A conclusion about the impact of hospital-at-home care on length of stay for the initial exacerbation (defined as days in hospital or days in hospital plus hospital-at-home care for inpatient hospital and hospital-at-home, respectively) could not be determined because of limited and inconsistent evidence.
Patient and caregiver satisfaction with care is high for both hospital-at-home and inpatient hospital care.
PMCID: PMC3384361  PMID: 23074420
5.  Exploration of ICD-9-CM Coding of Chronic Disease within the Elixhauser Comorbidity Measure in Patients with Chronic Heart Failure 
Introduction
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes capture comorbidities that can be used to risk adjust nonrandom patient groups. We explored the accuracy of capturing comorbidities associated with one risk adjustment method, the Elixhauser Comorbidity Measure (ECM), in patients with chronic heart failure (CHF) at one Veterans Affairs (VA) medical center. We explored potential reasons for the differences found between the original codes assigned and conditions found through retrospective review.
Methods
This descriptive, retrospective study used a cohort of patients discharged with a principal diagnosis coded as CHF from one VA medical center in 2003. One admission per patient was used in the study; with multiple admissions, only the first admission was analyzed. We compared the assignment of original codes assigned to conditions found in a retrospective, manual review of the medical record conducted by an investigator with coding expertise as well as by physicians. Members of the team experienced with assigning ICD-9-CM codes and VA coding processes developed themes related to systemic reasons why chronic conditions were not coded in VA records using applied thematic techniques.
Results
In the 181-patient cohort, 388 comorbid conditions were identified; 305 of these were chronic conditions, originally coded at the time of discharge with an average of 1.7 comorbidities related to the ECM per patient. The review by an investigator with coding expertise revealed a total of 937 comorbidities resulting in 618 chronic comorbid conditions with an average of 3.4 per patient; physician review found 872 total comorbidities with 562 chronic conditions (average 3.1 per patient). The agreement between the original and the retrospective coding review was 88 percent. The kappa statistic for the original and the retrospective coding review was 0.375 with a 95 percent confidence interval (CI) of 0.352 to 0.398. The kappa statistic for the retrospective coding review and physician review was 0.849 (CI, 0.823–0.875). The kappa statistic for the original coding and the physician review was 0.340 (CI, 0.316–0.364). Several systemic factors were identified, including familiarity with inpatient VA and non-VA guidelines, the quality of documentation, and operational requirements to complete the coding process within short time frames and to identify the reasons for movement within a given facility.
Conclusion
Comorbidities within the ECM representing chronic conditions were significantly underrepresented in the original code assignment. Contributing factors potentially include prioritization of codes related to acute conditions over chronic conditions; coders’ professional training, educational level, and experience; and the limited number of codes allowed in initial coding software. This study highlights the need to evaluate systemic causes of underrepresentation of chronic conditions to improve the accuracy of risk adjustment used for health services research, resource allocation, and performance measurement.
PMCID: PMC3797549  PMID: 24159270
adverse drug events; comorbidity; complications; heart failure; International Classification of Diseases; risk adjustment; veterans
6.  Multiple medication use in older patients in post-acute transitional care: a prospective cohort study 
Background
Older adults with a range of comorbidities are often prescribed multiple medications, which may impact on their function and cognition and increase the potential for drug interactions and adverse events.
Aims
This study investigated the extent of polypharmacy and potentially inappropriate medications in patients receiving post-discharge transitional home care and explored the associations of polypharmacy with patient characteristics, functional outcomes, and frailty.
Methods
A prospective observational study was conducted of 351 patients discharged home from hospital with support from six Transition Care Program (TCP) sites in two states of Australia. A comprehensive geriatric assessment was conducted at TCP admission and discharge using the interRAI Home Care assessment tool, with frailty measured using an index of 57 accumulated deficits. Medications from hospital discharge summaries were coded using the World Health Organization Anatomical Therapeutic Chemical Classification System.
Results
Polypharmacy (5–9 drugs) was observed in 46.7% and hyperpolypharmacy (≥10 drugs) in 39.2% of patients. Increasing numbers of medications were associated with greater number of comorbid conditions, a higher prevalence of diabetes mellitus, coronary heart disease, chronic obstructive pulmonary disease, dizziness, and dyspnea and increased frailty. At discharge from the program, the non-polypharmacy group (<5 drugs) had improved outcomes in Activities of Daily Living, Instrumental Activities of Daily Living and fewer falls, which was mediated because of lower levels of frailty. The commonest drugs were analgesics (56.8%) and antiulcer drugs (52.7%). The commonest potentially inappropriate medications were tertiary tricyclic antidepressants.
Conclusion
Polypharmacy is common in older patients discharged from hospital. It is associated with frailty, falls, and poor functional outcomes. Efforts should be made to encourage regular medication reviews and rationalization of medications as part of discharge planning. Whether careful deprescribing improves outcomes in frail patients should be the focus of randomized trials.
doi:10.2147/CIA.S64105
PMCID: PMC4158998  PMID: 25214773
polypharmacy; older people; post-acute care; functional outcomes
7.  Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials 
Objective To evaluate the effectiveness of comprehensive geriatric assessment in hospital for older adults admitted as an emergency.
Search strategy We searched the EPOC Register, Cochrane’s Controlled Trials Register, the Database of Abstracts of Reviews of Effects (DARE), Medline, Embase, CINAHL, AARP Ageline, and handsearched high yield journals.
Selection criteria Randomised controlled trials of comprehensive geriatric assessment (whether by mobile teams or in designated wards) compared with usual care. Comprehensive geriatric assessment is a multidimensional interdisciplinary diagnostic process used to determine the medical, psychological, and functional capabilities of a frail elderly person to develop a coordinated and integrated plan for treatment and long term follow-up.
Data collection and analysis Three independent reviewers assessed eligibility and trial quality and extracted published data. Two additional reviewers moderated.
Results Twenty two trials evaluating 10 315 participants in six countries were identified. For the primary outcome “living at home,” patients who underwent comprehensive geriatric assessment were more likely to be alive and in their own homes at the end of scheduled follow-up (odds ratio 1.16 (95% confidence interval 1.05 to 1.28; P=0.003; number needed to treat 33) at a median follow-up of 12 months versus 1.25 (1.11 to 1.42; P<0.001; number needed to treat 17) at a median follow-up of six months) compared with patients who received general medical care. In addition, patients were less likely to be living in residential care (0.78, 0.69 to 0.88; P<0.001). Subgroup interaction suggested differences between the subgroups “wards” and “teams” in favour of wards. Patients were also less likely to die or experience deterioration (0.76, 0.64 to 0.90; P=0.001) and were more likely to experience improved cognition (standardised mean difference 0.08, 0.01 to 0.15; P=0.02) in the comprehensive geriatric assessment group.
Conclusions Comprehensive geriatric assessment increases patients’ likelihood of being alive and in their own homes after an emergency admission to hospital. This seems to be especially true for trials of wards designated for comprehensive geriatric assessment and is associated with a potential cost reduction compared with general medical care.
doi:10.1136/bmj.d6553
PMCID: PMC3203013  PMID: 22034146
8.  Left Ventricular Assist Devices 
Executive Summary
Objective
The objective of this health technology policy assessment was to determine the effectiveness and cost-effectiveness of using implantable ventricular assist devices in the treatment of end-stage heart failure.
Heart Failure
Heart failure is a complex syndrome that impairs the ability of the heart to maintain adequate blood circulation, resulting in multiorgan abnormalities and, eventually, death. In the period of 1994 to 1997, 38,702 individuals in Ontario had a first hospital admission for heart failure. Despite reported improvement in survival, the five-year mortality rate for heart failure is about 50%.
For patients with end-stage heart failure that does not respond to medical therapy, surgical treatment or traditional circulatory assist devices, heart transplantation (in appropriate patients) is the only treatment that provides significant patient benefit.
Heart Transplant in Ontario
With a shortage in the supply of donor hearts, patients are waiting longer for a heart transplant and may die before a donor heart is available. From 1999 to 2003, 55 to 74 people received a heart transplant in Ontario each year. Another 12 to 21 people died while waiting for a suitable donor heart. Of these, 1 to 5 deaths occurred in people under 18 years old. The rate-limiting factor in heart transplant is the supply of donor hearts. Without an increase in available donor hearts, attempts at prolonging the life of some patients on the transplant wait list could have a harmful effect on other patients that are being pushed down the waiting list (knock on effect).
LVAD Technology
Ventricular assist devices [VADs] have been developed to provide circulatory assistance to patients with end-stage heart failure. These are small pumps that usually assist the damaged left ventricle [LVADs] and may be situated within the body (intracorporeal] or outside the body [extracorporeal). Some of these devices were designed for use in the right ventricle [RVAD] or both ventricles (bi-ventricular).
LVADs have been mainly used as a “bridge-to-transplant” for patients on a transplant waiting list. As well, they have been used as a “bridge-to-recovery” in acute heart failure, but this experience is limited. There has been an increasing interest in using LVAD as a permanent (destination) therapy.
Review of LVAD by the Medical Advisory Secretariat
The Medical Advisory Secretariat’s review included a descriptive synthesis of findings from five systematic reviews and 60 reports published between January 2000 and December 2003. Additional information was obtained through consultation and by searching the websites of Health Canada, the United Network of Organ Sharing, Organ Donation Ontario, and LVAD manufacturers.
Summary of Findings
Safety and Effectiveness
Previous HTAs and current Level 3 evidence from prospective non-randomized controlled studies showed that when compared to optimal medical therapy, LVAD support significantly improved the pre-transplant survival rates of heart transplant candidates waiting for a suitable donor heart (71% for LVAD and 36% for medical therapy). Pre-transplant survival rates reported ranged from 58% to 90% (median 74%). Improved transplant rates were also reported for people who received pre-transplant LVAD support (e.g. 67% for LVAD vs 33% for medical therapy). Reported transplant rates for LVAD patients ranged from 39% to 90% (median 71%).
Patient’s age greater than 60 years and pre-existing conditions of respiratory failure associated with septicemia, ventilation, and right heart failure were independent risk factors for mortality after the LVAD implantation.
LVAD support was shown to improve the New York Heart Association [NYHA)] functional classification and quality of life of patients waiting for heart transplant. LVAD also enabled approximately 41% - 49% of patients to be discharged from hospitals and wait for a heart transplant at home. However, over 50% of the discharged patients required re-hospitalization due to adverse events.
Post-transplant survival rates for LVAD-bridged patients were similar to or better than the survival rates of patients bridged by medical therapy.
LVAD support has been associated with serious adverse events, including infection (median 53%, range 6%–72%), bleeding (8.6%–48%, median 35%), thromboembolism (5%–37%), neurologic disorders (7%–28%), right ventricular failure (11%–26%), organ dysfunction (5%–50%) and hemolysis (6%–20%). Bleeding tends to occur in the first few post-implant days and is rare thereafter. It is fatal in 2%–7% of patients. Infection and thromboembolism occurred throughout the duration of the implant, though their frequency tended to diminish with time. Device malfunction has been identified as one of the major complications. Fatalities directly attributable to the devices were about 1% in short-term LVAD use. However, mechanical failure was the second most frequent cause of death in patients on prolonged LVAD support. Malfunctions were mainly associated with the external components, and often could be replaced by backed up components.
LVAD has been used as a bridge-to-recovery in patients suffering from acute cardiogenic shock due to cardiomyopathy, myocarditis or cardiotomy. The survival rates were reported to be lower than in bridge-to-transplant (median 26%). Some of the bridge-to-recovery patients (14%–75%) required a heart transplant or remained on prolonged LVAD support. According to an expert in the field, experience with LVAD as a bridge-to-recovery technology has been more favourable in Germany than in North America, where it is not regarded as a major indication since evidence for its effectiveness in this setting is limited.
LVAD has also been explored as a destination therapy. A small, randomized, controlled trial (level 2 evidence) showed that LVAD significantly increased the 1-year survival rate of patients with end-stage heart failure but were not eligible for a heart transplant (51% LVAD vs 25% for medical therapy). However, improved survival was associated with adverse events 2.35 times higher than medically treated patients and a higher hospital re-admission rate. The 2-year survival rate on LVAD decreased to 23%, although it was still significantly better compared to patients on medical therapy (8%). The leading causes of deaths were sepsis (41%) and device failure (17%).
The FDA has given conditional approval for the permanent use of HeartMate SNAP VE LVAS in patients with end-stage heart failure who are not eligible for heart transplantation, although the long-term effect of this application is not known.
In Canada, four LVAD systems have been licensed for bridge-to-transplant only. The use of LVAD support raises ethical issues because of the implications of potential explantation that could be perceived as a withdrawal of life support.
Potential Impact on the Transplant Waiting List
With the shortage of donor hearts for adults, LVAD support probably would not increase the number of patients who receive a heart transplant. If LVAD supported candidates are prioritized for urgent heart transplant, there will be a knock on effect as other transplant candidates without LVAD support would be pushed down, resulting in longer wait, deterioration in health status and die before a suitable donor heart becomes available.
Under the current policy for allocating donor hearts in Ontario, patients on LVAD support would be downgraded to Status 3 with a lower priority to receive a transplant. This would likely result in an expansion of the transplant waiting list with an increasing number of patients on prolonged LVAD support, which is not consistent with the indication of LVAD use approved by Health Canada.
There is indication in the United Kingdom that LVAD support in conjunction with an urgent transplant listing in the pediatric population may decrease the number of deaths on the waiting list without a harmful knock-on effect on other transplant candidates.
Conclusion
LVAD support as a bridge-to-transplant has been shown to improve the survival rate, functional status and quality of life of patients on the heart transplant waiting list. However, due to the shortage of donor hearts and the current heart transplant algorithm, LVAD support for transplant candidates of all age groups would likely result in an expansion of the waiting list and prolonged use of LVAD with significant budget implications but without increasing the number of heart transplants. Limited level 4 evidence showed that LVAD support in children yielded survival rates comparable to those in the adult population. The introduction of LVAD in the pediatric population would be more cost-effective and might not have a negative effect on the transplant waiting list.
PMCID: PMC3387736  PMID: 23074453
9.  Underuse of Indicated Medications Among Physically Frail Older US Veterans at the Time of Hospital Discharge: Results of a Cross-Sectional Analysis of Data From the Geriatric Evaluation and Management Drug Study 
Background
Medication underutilization, or the omission of a potentially beneficial medication indicated for disease management, is common among older adults but poorly understood.
Objectives
The aims of this work were to assess the prevalence of medication underuse and to determine whether polypharmacy or comorbidity was associated with medication underuse among physically frail older veterans transitioning from the hospital to the community.
Methods
This was a cross-sectional analysis of patients who were discharged from 11 US veterans’ hospitals to outpatient care, based on data from the Geriatric Evaluation and Management Drug Study, a substudy of the Veterans Affairs Cooperative Study of geriatric evaluation and management. Patients were enrolled between August 31, 1995, and January 31, 1999. To qualify for the study, patients had to be aged ≥65 years, hospitalized in a medical or surgical ward for >48 hours, and meet ≥2 of the following criteria: moderate functional disability; recent cerebrovascular accident with residual neurological deficit; history of ≥1 fall in the previous 3 months; documented difficulty with walking (ie, requiring personal assistance or equipment), not including preadmission use of a wheelchair with ability to transfer to and from chair independently; malnutrition (admission serum albumin of 3.5 g/dL, <80% of ideal body weight, or recent ≥15-lb weight loss reported in admission history); dementia; depression; documented diagnosis of new fracture or revision needed of older fracture; unplanned admission within 3 months of previous admission; and prolonged bed rest. Clinical pharmacist/physician pairs reviewed medical records and medication lists and independently applied the Assessment of Underutilization (AOU) index to determine omissions of indicated medications. Discordances in index ratings were resolved during clinical consensus conferences. The primary outcome measure was the percentage of patients with ≥1 medication omission detected by the AOU. Multivariable logistic regression analyses identified factors associated with underuse.
Results
A total of 384 patients were included in the study. The majority (53.6%) were between the ages of 65 and 74 years, and the mean (SD) Charlson comorbidity index was 2.44 (1.93). Overall, 374 patients (97.4%) were men and 274 (71.4%) were white. Medication undertreatment occurred in 238 participants (62.0%). Diseases of the circulatory, endocrine/nutritional, musculoskeletal, and respiratory systems were the most commonly undertreated conditions. The indicated medications most likely to be omitted were nitrates for those with a history of myocardial infarction, multivitamins in those with malnutrition, and inhaled anticholinergics for chronic obstructive airways disease. Statistically significant factors associated with medication underuse included limitations in activities of daily living (adjusted odds ratio [AOR], 2.17 [95% CI, 1.27–3.71]; P = 0.01), being white (AOR, 1.70 [95% CI, 1.06–2.71]; P = 0.03), and Charlson comorbidity index (AOR, 1.13 for each 1-point increase [95% CI, 1.00–1.27]; P = 0.04). Discharge from a general medicine service as opposed to a surgical service was associated with lower risk of medication underuse (AOR, 0.61 [95% CI, 0.38–0.98]; P = 0.04).
Conclusions
Medication underuse was relatively common in this study. Patients with greater comorbidity, but not polypharmacy, had increased odds of undertreatment.
doi:10.1016/j.amjopharm.2009.11.002
PMCID: PMC2929122  PMID: 19948303
medication use; underutilization; comorbidity; transition of care; frail elderly
10.  Features and outcomes of unplanned hospital admissions of older people due to ill-defined (R-coded) conditions: Retrospective analysis of hospital admissions data in England 
BMC Geriatrics  2011;11:62.
Background
Rising rates of unplanned admissions among older people are placing unprecedented demand on health services internationally. Unplanned hospital admissions for ill-defined conditions (coded with an R prefix within Chapter XVIII of the International Classification of Diseases-10) have been targeted for admission avoidance strategies, but little is known about these admissions. The aim of this study was to determine the incidence and factors predicting ill-defined (R-coded) hospital admissions of older people and their association with health outcomes.
Methods
Retrospective analysis of unplanned hospital admissions to general internal and geriatric medicine wards in one hospital over 12 months (2002) with follow-up for 36 months. The study was carried out in an acute teaching hospital in England. The participants were all people aged 65 and over with unplanned hospital admissions to general internal and geriatric medicine. Independent variables included time of admission, residence at admission, route of admission to hospital, age, gender, comorbidity measured by count of diagnoses. Main outcome measures were primary diagnosis (ill-defined versus other diagnostic code), death during the hospital stay, deaths to 36 months, readmissions within 36 months, discharge destination and length of hospital stay.
Results
Incidence of R-codes at discharge was 21.6%, but was higher in general internal than geriatric medicine (25.6% v 14.1% respectively). Age, gender and co-morbidity were not significant predictors of R-code diagnoses. Admission via the emergency department (ED), out of normal general practitioner (GP) hours, under the care of general medicine and from non-residential care settings increased the risk of receiving R-codes. R-coded patients had a significantly shorter length of stay (5.91 days difference, 95% CI 4.47, 7.35), were less likely to die (hazard ratio 0.71, 95%CI 0.59, 0.85) at any point, but were as likely to be readmitted as other patients (hazard ratio 0.96 (95% CI 0.88, 1.05).
Conclusions
R-coded diagnoses accounted for 1/5 of emergency admission episodes, higher than anticipated from total English hospital admissions, but comparable with rates reported in similar settings in other countries. Unexpectedly, age did not predict R-coded diagnosis at discharge. Lower mortality and length of stay support the view that these are avoidable admissions, but readmission rates particularly for further R-coded admissions indicate on-going health care needs. Patient characteristics did not predict R-coding, but organisational features, particularly admission via the ED, out of normal GP hours and via general internal medicine, were important and may offer opportunity for admission reduction strategies.
doi:10.1186/1471-2318-11-62
PMCID: PMC3209437  PMID: 22011327
11.  Coaching Older Adults and Carers to have their preferences Heard (COACH): A randomised controlled trial in an intermediate care setting (study protocol) 
The Australasian Medical Journal  2012;5(8):444-454.
Background
Frail older people who are considering movement into residential aged care or returning home following a hospital admission often face complex and difficult decisions.Despite research interest in this area, a recent Cochrane review was unable to identify any studies of interventions to support decision-making in this group that met the experimental or quasi-experimental study design criteria.
Aims
This study tests the impact of a multi-component coaching intervention on the quality of preparation for care transitions, targeted to older adults and informal carers. In addition, the study assesses the impact of investing specialist geriatric resources into consultations with families in an intermediate care setting where decisions about future care needs are being made.
Method
This study was a randomised controlled trial of 230 older adults admitted to intermediate care in Australia. Masked assessment at 3 and 12 months examined physical functioning, health–related quality of life and utilisation of health and aged care resources. A geriatrician and specialist nurse delivered a coaching intervention to both the older person and their carer/family. Components of the intervention included provision of a Question Prompt List prior to meeting with a geriatrician (to clarify medical conditions and treatments, medications, ‘red flags’, end of life decisions and options for future health care) and a follow-up meeting with a nurse who remained in telephone contact. Participants received a printed summary and an audio recording of the meeting with the geriatrician.
Conclusion
The costs and outcomes of the intervention are compared with usual care. Trial registration: Australian New Zealand Clinical Trials Registry (ACTRN12607000638437).
doi:10.4066/AMJ.2012.1366.
PMCID: PMC3442189  PMID: 23024719
Caregivers; continuity of patient care; cost-benefit analysis; health care costs; intermediate care facilities; patient-centred care; quality of life; randomised controlled trial
12.  Inpatient rehabilitation specifically designed for geriatric patients: systematic review and meta-analysis of randomised controlled trials 
Objective To assess the effects of inpatient rehabilitation specifically designed for geriatric patients compared with usual care on functional status, admissions to nursing homes, and mortality.
Design Systematic review and meta-analysis.
Data sources Medline, Embase, Cochrane database, and reference lists from published literature.
Review methods Only randomised controlled trials were included. Trials had to report on inpatient rehabilitation and report at least one of functional improvement, admission to nursing homes, or mortality. Trials of consultation or outpatient services, trials including patients aged <55, trials of non-multidisciplinary rehabilitation, and trials without a control group receiving usual care were excluded. Data were double extracted. Odds ratios and relative risks with 95% confidence intervals were calculated.
Results 17 trials with 4780 people comparing the effects of general or orthopaedic geriatric rehabilitation programmes with usual care were included. Meta-analyses of effects indicated an overall benefit in outcomes at discharge (odds ratio 1.75 (95% confidence interval 1.31 to 2.35) for function, relative risk 0.64 (0.51 to 0.81) for nursing home admission, relative risk 0.72 (0.55 to 0.95) for mortality) and at end of follow-up (1.36 (1.07 to 1.71), 0.84 (0.72 to 0.99), 0.87 (0.77 to 0.97), respectively). Limited data were available on impact on health care or cost. Compared with those in control groups, weighted mean length of hospital stay after randomisation was longer in patients allocated to general geriatric rehabilitation (24.5 v 15.1 days) and shorter in patients allocated to orthopaedic rehabilitation (24.6 v 28.9 days).
Conclusion Inpatient rehabilitation specifically designed for geriatric patients has the potential to improve outcomes related to function, admission to nursing homes, and mortality. Insufficient data are available for defining characteristics and cost effectiveness of successful programmes.
doi:10.1136/bmj.c1718
PMCID: PMC2857746  PMID: 20406866
13.  Audit and feedback: an intervention to improve discharge summary completion 
Discharge summaries (DS) communicate important clinical information from inpatient to outpatient settings. Previous studies noted increased adverse events and rehospitalization due to poor DS quality. We postulated that an audit and feedback intervention of DS completed by geriatric medicine fellows would improve the completeness of their summaries. We conducted a preintervention post intervention study. In phase 1 (AUDIT #1 and FEEDBACK) we scored all DS (n ¼ 89) completed by first year fellows between July 2006 to December 2006 using a 21-item checklist. Individual performance scores were reviewed with each fellow in 30-minute feedback sessions. In phase 2 (AUDIT #2) we scored all DS (n ¼ 79) completed after the first phase between February 2007 to July 2007 using the same checklist. Data were analyzed using generalized estimating equations. Fellows were more likely to complete all required DS data after feedback when compared with prior to feedback (91% vs. 71%, P < 0.001). Feedback was also associated with improved admission (93% vs. 70%, P < 0.001), duration of hospitalization (93% vs 78%, P < 0.001), discharge planning (93% vs. 18%, P < 0.02) and postdischarge care (83% vs. 57%., P < 0.001) section-specific information. In conclusion, audit and feedback sessions were associated with better DS completeness in areas of particular importance to geriatric care.
doi:10.1002/jhm.831
PMCID: PMC3102562  PMID: 21241038
14.  Moving from Data on Deaths to Public Health Policy in Agincourt, South Africa: Approaches to Analysing and Understanding Verbal Autopsy Findings 
PLoS Medicine  2010;7(8):e1000325.
Peter Byass and colleagues compared two methods of assessing data from verbal autopsies, review by physicians or probabilistic modeling, and show that probabilistic modeling is the most efficient means of analyzing these data
Background
Cause of death data are an essential source for public health planning, but their availability and quality are lacking in many parts of the world. Interviewing family and friends after a death has occurred (a procedure known as verbal autopsy) provides a source of data where deaths otherwise go unregistered; but sound methods for interpreting and analysing the ensuing data are essential. Two main approaches are commonly used: either physicians review individual interview material to arrive at probable cause of death, or probabilistic models process the data into likely cause(s). Here we compare and contrast these approaches as applied to a series of 6,153 deaths which occurred in a rural South African population from 1992 to 2005. We do not attempt to validate either approach in absolute terms.
Methods and Findings
The InterVA probabilistic model was applied to a series of 6,153 deaths which had previously been reviewed by physicians. Physicians used a total of 250 cause-of-death codes, many of which occurred very rarely, while the model used 33. Cause-specific mortality fractions, overall and for population subgroups, were derived from the model's output, and the physician causes coded into comparable categories. The ten highest-ranking causes accounted for 83% and 88% of all deaths by physician interpretation and probabilistic modelling respectively, and eight of the highest ten causes were common to both approaches. Top-ranking causes of death were classified by population subgroup and period, as done previously for the physician-interpreted material. Uncertainty around the cause(s) of individual deaths was recognised as an important concept that should be reflected in overall analyses. One notably discrepant group involved pulmonary tuberculosis as a cause of death in adults aged over 65, and these cases are discussed in more detail, but the group only accounted for 3.5% of overall deaths.
Conclusions
There were no differences between physician interpretation and probabilistic modelling that might have led to substantially different public health policy conclusions at the population level. Physician interpretation was more nuanced than the model, for example in identifying cancers at particular sites, but did not capture the uncertainty associated with individual cases. Probabilistic modelling was substantially cheaper and faster, and completely internally consistent. Both approaches characterised the rise of HIV-related mortality in this population during the period observed, and reached similar findings on other major causes of mortality. For many purposes probabilistic modelling appears to be the best available means of moving from data on deaths to public health actions.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Whenever someone dies in a developed country, the cause of death is determined by a doctor and entered into a “vital registration system,” a record of all the births and deaths in that country. Public-health officials and medical professionals use this detailed and complete information about causes of death to develop public-health programs and to monitor how these programs affect the nation's health. Unfortunately, in many developing countries dying people are not attended by doctors and vital registration systems are incomplete. In most African countries, for example, less than one-quarter of deaths are recorded in vital registration systems. One increasingly important way to improve knowledge about the patterns of death in developing countries is “verbal autopsy” (VA). Using a standard form, trained personnel ask relatives and caregivers about the symptoms that the deceased had before his/her death and about the circumstances surrounding the death. Physicians then review these forms and assign a specific cause of death from a shortened version of the International Classification of Diseases, a list of codes for hundreds of diseases.
Why Was This Study Done?
Physician review of VA forms is time-consuming and expensive. Consequently, computer-based, “probabilistic” models have been developed that process the VA data and provide a likely cause of death. These models are faster and cheaper than physician review of VAs and, because they do not rely on the views of local doctors about the likely causes of death, they are more internally consistent. But are physician review and probabilistic models equally sound ways of interpreting VA data? In this study, the researchers compare and contrast the interpretation of VA data by physician review and by a probabilistic model called the InterVA model by applying these two approaches to the deaths that occurred in Agincourt, a rural region of northeast South Africa, between 1992 and 2005. The Agincourt health and sociodemographic surveillance system is a member of the INDEPTH Network, a global network that is evaluating the health and demographic characteristics (for example, age, gender, and education) of populations in low- and middle-income countries over several years.
What Did the Researchers Do and Find?
The researchers applied the InterVA probabilistic model to 6,153 deaths that had been previously reviewed by physicians. They grouped the 250 cause-of-death codes used by the physicians into categories comparable with the 33 cause-of-death codes used by the InterVA model and derived cause-specific mortality fractions (the proportions of the population dying from specific causes) for the whole population and for subgroups (for example, deaths in different age groups and deaths occurring over specific periods of time) from the output of both approaches. The ten highest-ranking causes of death accounted for 83% and 88% of all deaths by physician interpretation and by probabilistic modelling, respectively. Eight of the most frequent causes of death—HIV, tuberculosis, chronic heart conditions, diarrhea, pneumonia/sepsis, transport-related accidents, homicides, and indeterminate—were common to both interpretation methods. Both methods coded about a third of all deaths as indeterminate, often because of incomplete VA data. Generally, there was close agreement between the methods for the five principal causes of death for each age group and for each period of time, although one notable discrepancy was pulmonary (lung) tuberculosis, which accounted for 6.4% and 21.3% of deaths in this age group, respectively, according to the physicians and to the model. However, these deaths accounted for only 3.5% of all the deaths.
What Do These Findings Mean?
These findings reveal no differences between the cause-specific mortality fractions determined from VA data by physician interpretation and by probabilistic modelling that might have led to substantially different public-health policy programmes being initiated in this population. Importantly, both approaches clearly chart the rise of HIV-related mortality in this South African population between 1992 and 2005 and reach similar findings on other major causes of mortality. The researchers note that, although preparing the amount of VA data considered here for entry into the probabilistic model took several days, the model itself runs very quickly and always gives consistent answers. Given these findings, the researchers conclude that in many settings probabilistic modeling represents the best means of moving from VA data to public-health actions.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000325.
The importance of accurate data on death is further discussed in a perspective previously published in PLoS Medicine Perspective by Colin Mathers and Ties Boerma
The World Health Organization (WHO) provides information on the vital registration of deaths and on the International Classification of Diseases; the WHO Health Metrics Network is a global collaboration focused on improving sources of vital statistics; and the WHO Global Health Observatory brings together core health statistics for WHO member states
The INDEPTH Network is a global collaboration that is collecting health statistics from developing countries; it provides more information about the Agincourt health and socio-demographic surveillance system and access to standard VA forms
Information on the Agincourt health and sociodemographic surveillance system is available on the University of Witwatersrand Web site
The InterVA Web site provides resources for interpreting verbal autopsy data and the Umeå Centre for Global Health Reseach, where the InterVA model was developed, is found at http://www.globalhealthresearch.net
A recent PLoS Medicine Essay by Peter Byass, lead author of this study, discusses The Unequal World of Health Data
doi:10.1371/journal.pmed.1000325
PMCID: PMC2923087  PMID: 20808956
15.  Preoperative assessment of the older surgical patient: honing in on geriatric syndromes 
Nearly 50% of Americans will have an operation after the age of 65 years. Traditional preoperative anesthesia consultations capture only some of the information needed to identify older patients (defined as ≥65 years of age) undergoing elective surgery who are at increased risk for postoperative complications, prolonged hospital stays, and delayed or hampered functional recovery. As a catalyst to this review, we compared traditional risk scores (eg, cardiac-focused) to geriatric-specific risk measures from two older female patients seen in our preoperative clinic who were scheduled for elective, robotic-assisted hysterectomies. Despite having a lower cardiac risk index and Charlson comorbidity score, the younger of the two patients presented with more subtle negative geriatric-specific risk predictors – including intermediate or pre-frail status, borderline malnutrition, and reduced functional/mobility – which may have contributed to her 1-day-longer length of stay and need for readmission. Adequate screening of physiologic and cognitive reserves in older patients scheduled for surgery could identify at-risk, vulnerable elders and enable proactive perioperative management strategies (eg, strength, balance, and mobility prehabilitation) to reduce adverse postoperative outcomes and readmissions. Here, we describe our initial two cases and review the stress response to surgery and the impact of advanced age on this response as well as preoperative geriatric assessments, including frailty, nutrition, physical function, cognition, and mood state tests that may better predict postoperative outcomes in older adults. A brief overview of the literature on anesthetic techniques that may influence geriatric-related syndromes is also presented.
doi:10.2147/CIA.S75285
PMCID: PMC4279607  PMID: 25565783
frailty; mobility-disability; postoperative delirium; preoperative evaluation; stress response
16.  A randomised clinical trial on a comprehensive geriatric assessment and intensive home follow-up after hospital discharge: the Transitional Care Bridge 
Background
Older patients are at high risk for poor outcomes after acute hospital admission. The mortality rate in these patients is approximately 20%, whereas 30% of the survivors decline in their level of activities of daily living (ADL) functioning three months after hospital discharge. Most diseases and geriatric conditions that contribute to poor outcomes could be subject to pro-active intervention; not only during hospitalization, but also after discharge. This paper presents the design of a randomised controlled clinical trial concerning the effect of a pro-active, multi-component, nurse-led transitional care program following patients for six months after hospital admission.
Methods/Design
Three hospitals in the Netherlands will participate in the multi-centre, double-blind, randomised clinical trial comparing a pro-active multi-component nurse-led transitional care program to usual care after discharge. All patients acutely admitted to the Department of Internal Medicine who are 65 years and older, hospitalised for at least 48 hours and are at risk for functional decline are invited to participate in the study. All patients will receive integrated geriatric care by a geriatric consultation team during hospital admission. Randomization, which will be stratified by study site and cognitive impairment, will be conducted during admission. The intervention group will receive the transitional care bridge program, consisting of a handover moment with a community care Care Nurse (CN) during hospital admission and five home visits after discharge. The control group will receive 'care as usual' after discharge. The main outcome is the level of ADL functioning six months after discharge compared to premorbid functioning measured with the Katz ADL index. Secondary outcomes include; survival, cognitive functioning, quality of life, and health care utilization, satisfaction of the patient and primary care giver with the transitional care bridge program. All outcomes will be measured at three, six and twelve months after discharge. Approximately 674 patients will be enrolled to either the intervention or control group.
Discussion
The study will provide new knowledge on a combined intervention of integrated care during hospital admission, a proactive handover moment before discharge and intensive home visits after discharge.
Trial registration
Trial registration number: NTR 2384
doi:10.1186/1472-6963-10-296
PMCID: PMC2984496  PMID: 21034479
17.  Detecting Changes in Chief Complaint Word Count: Effects on Syndromic Surveillance 
Objective
To identify changes in emergency department (ED) syndromic surveillance data by analyzing trends in chief complaint (CC) word count; to compare these changes to coding changes reported by EDs; and to examine how these changes might affect the ability of syndromic surveillance systems to identify syndromes in a consistent manner.
Introduction
The New York City (NYC) Department of Health and Mental Hygiene (DOHMH) receives daily ED data from 49 of NYC’s 52 hospitals, representing approximately 95% of ED visits citywide. Chief complaint (CC) is categorized into syndrome groupings using text recognition of symptom key-words and phrases. Hospitals are not required to notify the DOHMH of any changes to procedures or health information systems (HIS). Previous work noticed that CC word count varied over time within and among EDs. The variations seen in CC word count may affect the quality and type of data received by the DOHMH, thereby affecting the ability to detect syndrome visits consistently.
Methods
The daily mean number of words in the chief complaint field were examined by hospital from 2008–2011. Spectral analyses were performed on daily CC word count by hospital to explore temporal trends. Change Point Analysis (CPA) using Taylor’s Method with a maximum change level of four was conducted on the CC field by hospital using 1,000 bootstrap samples. According to Taylor, a level one change is the most important change detected on the program’s first pass through the data. For this analysis, a change point was considered significant if it was level 1, detected an average change of more than 0.50 words per day, and was sustained for at least 6 months before a level 2 change of at least 0.50 words occurred. Results of the CPA were compared to reported changes identified by a survey conducted by DOHMH staff of 49 hospitals that collected information about their HIS and coding practices, including any recent system changes.
When a significant level one change was identified, time series graphs for six months before and after the change were created for five syndromes (cold, diarrhea, fever-flu, influenza-like-illness, and respiratory) and the syndrome’s constituent symptom categories (e.g. cough fever, etc.). Changes in syndrome count and composition at the level one change in word count were noted.
Results
The mean chief complaint word count across all hospitals from 2008 – 2011 in NYC was 3.14, with a range of 0 to 18 words. CPA detected a significant level 1 change in 21 hospitals, with a mean change of 0.60 words, with 9 increases (mean= 0.71 words) and 12 decreases (mean= 0.53 words). According to the results of a survey of 49 NYC EDs, 19 have changed coding practices or Health Information Systems since 2008. CPA identified a coincident and significant shift in word count for 8 of these hospitals. CPA also detected significant shifts in word count for 13 hospitals that did not report any changes. Figure 1 shows the results of CPA from one ED in NYC
We observed immediate changes in daily syndrome count after the detected change in CC word count. For example, respiratory syndrome count increased with increased word count and decreased with decreased word count for 10 of the 21 EDs with a significant change in word count. Only 2 EDs saw an opposite effect on respiratory syndrome count. Meanwhile, 9 EDs saw no obvious change in respiratory syndrome count. Furthermore, these changes in daily CC word count coincided with subsequent changes in syndrome composition, the breakdown of syndromes into constituent symptoms.
Conclusions
Change Point Analysis may be a useful method for prospectively detecting shifts in CC word count, which might represent a change in ED practices. In some instances changes to CC word count had an apparent effect on both syndrome capture and syndrome composition. Further studies are required to determine how often these changes happen and how they may affect the quality of syndromic surveillance.
PMCID: PMC3692864
Chief Complaint; Word Count; Change Point Analysis
18.  Quality of care assessment in geriatric evaluation and management units: construction of a chart review tool for a tracer condition 
BMC Geriatrics  2009;9:34.
Background
The number of elderly people requiring hospital care is growing, so, quality and assessment of care for elders are emerging and complex areas of research. Very few validated and reliable instruments exist for the assessment of quality of acute care in this field. This study's objective was to create such a tool for Geriatric Evaluation and Management Units (GEMUs).
Methods
The methodology involved a reliability and feasibility study of a retrospective chart review on 934 older inpatients admitted in 49 GEMUs during the year 2002–2003 for fall-related trauma as a tracer condition. Pertinent indicators for a chart abstraction tool, the Geriatric Care Tool (GCT), were developed and validated according to five dimensions: access to care, comprehensiveness, continuity of care, patient-centred care and appropriateness. Consensus methods were used to develop the content. Participants were experts representing eight main health care professions involved in GEMUs from 19 different sites. Items associated with high quality of care at each step of the multidisciplinary management of patients admitted due to falls were identified. The GCT was tested for intra- and inter-rater reliability using 30 medical charts reviewed by each of three independent and blinded trained nurses. Kappa and agreement measures between pairs of chart reviewers were computed on an item-by-item basis.
Results
Three quarters of 169 items identifying the process of care, from the case history to discharge planning, demonstrated good agreement (kappa greater than 0.40 and agreement over 70%). Indicators for the appropriateness of care showed less reliability.
Conclusion
Content validity and reliability results, as well as the feasibility of the process, suggest that the chart abstraction tool can gather standardized and pertinent clinical information for further evaluating quality of care in GEMU using admission due to falls as a tracer condition. However, the GCT should be evaluated in other models of acute geriatric units and new strategies should be developed to improve reliability of peer assessments in characterizing the quality of care for elderly patients with complex conditions.
doi:10.1186/1471-2318-9-34
PMCID: PMC2724372  PMID: 19640294
19.  Experience with dedicated geriatric surgical consult services: Meeting the need for surgery in the frail elderly 
Background:
Surgeons are increasingly faced with consultation for intervention in residents of geriatric centers or in patients who suffer from end stage medical disease. We review our experience with consult services dedicated to the needs of these frail patients.
Study design:
Patients were prospectively followed after being evaluated by three different geriatric surgical consult services: Group 1 was based at a geriatric center associated with a tertiary medical center, Group 2 was based at a community geriatric center, and Group 3 was based with an hospital-based service for ambulatory patients with end stage congestive heart failure.
Results:
A total of 256 frail elderly patients underwent of 311 general surgical procedures ranging from major abdominal and vascular procedures to minor procedures such as debridement of decubitus ulcers, long-term intravenous access, enterostomy and enteral tube placement. Almost half of the surgical volume in Group 1 and 3 were ‘maintenance’ (decubitus debridement, long term intravenous or stomal or tube care); all of Group 2 were for treatment of decubiti. There was minimal morbidity and mortality from surgery itself, and overall one year survival for Groups 1, 2, and 3 was 46%, 60%, and 79%, respectively. Multivariate analysis showed that each group had its own unique indicators of decreased survival: Group 1 dementia and coronary artery disease, in Group 2 gender and coronary artery disease, and Group 3, gender alone. Age, number of comorbid illnesses, and type of surgery (major vs minor) were not significant indicators.
Conclusions:
This is the first review of the role of dedicated surgical consult services which focused on residents of geriatric centers and frail elderly. Conditions routinely encountered in this population such as dementia, end stage disease, multiple comorbidities, polypharmacy, decreased functional and nutritional status are not frequently encountered by general surgeons. But the surgery is safe, and survival data is comparable to those in geriatric centers who did not undergo surgery. A multidisciplinary team approach gives the most effective care, with a primary goal of palliation.
PMCID: PMC2685228  PMID: 19503769
surgery in the elderly; geriatrics; surgical consultations; nursing home residents; congestive heart failure; frailty; palliative care; dementia; coronary artery disease; survival
20.  Health-related Quality of Life (HRQOL) Decreases Independently of Chronic Conditions and Geriatric Syndromes in Older Adults With Diabetes: The Fujiwara-kyo Study 
Journal of Epidemiology  2014;24(4):259-266.
Background
Very few studies have investigated the association between diabetes and impaired health-related quality of life (HRQOL) in older adults, independent of chronic conditions and geriatric syndromes.
Methods
We conducted a self-administered questionnaire survey and structured interviews with 3946 people aged 65 years or older to obtain medical histories of diabetes, chronic conditions, and geriatric syndromes. Blood tests were performed to measure glycated hemoglobin (HbA1c) and plasma glucose levels. HRQOL was evaluated using the Medical Outcomes Study 36-Item Short-Form General Health Survey (SF-36), and multiple logistic regression analysis was used to calculate adjusted odds ratios and 95% CIs for low HRQOL.
Results
A total of 3521 participants had not received a physician diagnosis of diabetes. Of these, 2345 participants with an HbA1c less than 5.7% were defined as the referent group. As compared with the referent group, 1029 participants with an HbA1c of at least 5.7% but less than 6.5% showed no significant decrease in QOL on the SF-36 physical, mental, and role component summaries, after adjustment for chronic conditions, geriatric syndromes, and other potential confounders. However, 572 patients who had received a physician diagnosis of diabetes and/or had an HbA1c of 6.5% or higher had a significantly higher adjusted odds ratio (1.48; 95% CI, 1.18–1.84) for the low physical component summary. No significant differences in relation to glycemic control, treatment regimen, or diabetes duration were found in any of the 3 component summaries among the 425 participants who were undergoing diabetes treatment.
Conclusions
Older Japanese adults with diabetes had decreased physical QOL, independent of chronic conditions and geriatric syndromes.
doi:10.2188/jea.JE20130131
PMCID: PMC4074629  PMID: 24814506
diabetes; older adults; geriatric syndromes; chronic conditions; SF-36
21.  Effectiveness of Acute Geriatric Unit Care Using Acute Care for Elders Components: A Systematic Review and Meta-Analysis 
Objectives
To compare the effectiveness of acute geriatric unit care, based on all or part of the Acute Care for Elders (ACE) model and introduced in the acute phase of illness or injury, with that of usual care.
Design
Systematic review and meta-analysis of 13 randomized controlled and quasi-experimental trials with parallel comparison groups retrieved from multiple sources.
Setting
Acute care geriatric and nongeriatric hospital units.
Participants
Acutely ill or injured adults (N = 6,839) with an average age of 81.
Interventions
Acute geriatric unit care characterized by one or more ACE components: patient-centered care, frequent medical review, early rehabilitation, early discharge planning, prepared environment.
Measurements
Falls, pressure ulcers, delirium, functional decline at discharge from baseline 2-week prehospital and hospital admission statuses, length of hospital stay, discharge destination (home or nursing home), mortality, costs, and hospital readmissions.
Results
Acute geriatric unit care was associated with fewer falls (risk ratio (RR) = 0.51, 95% confidence interval (CI) = 0.29–0.88), less delirium (RR = 0.73, 95% CI = 0.61–0.88), less functional decline at discharge from baseline 2-week prehospital admission status (RR = 0.87, 95% CI = 0.78–0.97), shorter length of hospital stay (weighted mean difference (WMD) = −0.61, 95% CI = −1.16 to −0.05), fewer discharges to a nursing home (RR = 0.82, 95% CI = 0.68–0.99), lower costs (WMD = −$245.80, 95% CI = −$446.23 to −$45.38), and more discharges to home (RR = 1.05, 95% CI = 1.01–1.10). A nonsignificant trend toward fewer pressure ulcers was observed. No differences were found in functional decline between baseline hospital admission status and discharge, mortality, or hospital readmissions.
Conclusion
Acute geriatric unit care, based on all or part of the ACE model and introduced during the acute phase of older adults' illness or injury, improves patient- and system-level outcomes.
doi:10.1111/jgs.12028
PMCID: PMC3557720  PMID: 23176020
ACE model; elderly; meta-analysis; function-focused interventions; acute geriatric unit
22.  A DBase III Clinical Application in Use on a Geriatric Evaluation Unit 
A clinical information management system using dBASE III on a micro computer has been developed for a Geriatric Evaluation Unit (GEU). This application provides clinicians with information and computing access not available on the hospital's computers. Two major functions are routinely performed: 1) longitudinal archival of in-patient and out-patient data, providing supportive clinical documentation for clinic visits, pre-admission review, discharge notes and summaries, and 2) education and research support services to GEU team members including management of research datasets, statistical analysis, literature searching, word processing, drug interactions, and intra-ward mail. The system is menu driven and takes minutes to learn. Higher levels of capability are available to experienced dBASE users. The demonstration will cover program/data file arrangement and logistics of integrating the application into the Geriatrics program. Programming techniques will be discussed and source code will be available.
PMCID: PMC2578055
23.  Year in Review: Medication Mishaps in the Elderly 
Objective
This paper reviews articles from the past year that examined medication mishaps (i.e., medication errors and adverse drug events [ADEs]) in the elderly.
Methods
The MEDLINE and EMBASE databases were searched for English-language articles published in 2010 using a combination of search terms including: medication errors, medication adherence, medication compliance, suboptimal prescribing, monitoring, adverse drug events, adverse drug withdrawal events, therapeutic failures, and aged. A manual search of the reference lists of the identified articles and the authors’ article files, book chapters and recent reviews was conducted to identify additional publications. Five studies of note were selected for annotation and critique. From this literature search, this paper also provides a selected bibliography of manuscripts published in 2010 (excluding those previously published in the American Journal of Geriatric Pharmacotherapy or by one of the authors) that address various types of medication errors and ADEs in the elderly.
RESULTS
Three studies addressed types of medication errors. One study examined underuse (due to prescribing) as a type of medication error. This was a before-and-after study from the Netherlands reported that those who received comprehensive geriatric assessments had a reduction in the rate of under-treatment of chronic conditions over a third (from 32.9% to 22.3%, p < 0.05). A second study focused on reducing medication errors due to the prescribing of potentially inappropriate medications. This quasi-experimental study found that a computerized provider order entry clinical decision support system decreased the number of potentially inappropriate medications ordered for patient’s ≥ 65 years of age who were hospitalized (11.56 before to 9.94 orders per day after, p < 0.001). The third medication error study was a cross-sectional phone survey of managed-care elders. This study found that more blacks than whites had low antihypertensive medication adherence as per a self-reported measure (18.4% vs. 12.3% respectively; p < 0.001). Moreover, blacks compared to whites used more complementary and alternative medicine (CAM) for the treatment of hypertension (30.5% vs. 24.7%, respectively; p = 0.005). In multivariable analyses stratified by race, among blacks, those that used CAM were more likely than those that did not to have low antihypertensive medication adherence (prevalence rate ratio 1.56, 95% confidence interval 1.14–2.15, p= 0.006).
The remaining two articles each addressed some form of medication adverse events. A case-control study of Medicare Advantage patients revealed for the first time that skeletal muscle relaxant use was significantly associated with an increased fracture risk (adjusted odds ratio 1.40, 95% confidence interval 1.15–1.72; p < 0.001). This increased risk was even more pronounced with the concomitant use of benzodiazepines. Finally, a randomized controlled trial across 16 centers in France used a one-week educational intervention about high-risk medications and ADEs directed at rehabilitation health care teams. They found that the rate of ADEs in the intervention group was lower than that in the usual care group (22% vs. 36%, respectively, p = 0.004).
CONCLUSION
Information from these studies may be used to advance health professionals’ understanding of medication errors and ADEs and may help guide research and clinical practices in years to come.
doi:10.1016/j.amjopharm.2011.01.003
PMCID: PMC3457784  PMID: 21459304
medication errors; suboptimal prescribing; medication adherence; drug monitoring; adverse drug events; aged
24.  Comparative hospital databases: value for management and quality. 
Quality in Health Care  1994;3(1):3-10.
OBJECTIVES--To establish an accurate and reliable comparative database of discharge abstracts and to appraise its value for assessments of quality of care. DESIGN--Retrospective review of case notes by trained research abstractors and comparison with matched information as routinely collected by the hospitals' own information systems. SETTING--Three district general hospitals and two major London teaching hospitals. PATIENTS--The database included 3905 medical and surgical cases and 2082 obstetric cases from 1990 and 1991. MAIN MEASURES--Accessibility of case notes; measures of reliability between reviewers and of validity of case note content; application of high level quality indicators. RESULTS--The existing hospital systems extracted insufficient detail from case notes to conduct clinical comparative analyses for medical and surgical cases. The research abstractors at least doubled the diagnostic codes extracted. Interabstractor agreement of about 70% was obtained for primary diagnosis and assignment to diagnosis related group. These data were sufficient to create a comparative database and apply high level quality indicators designed to flag topics for further study. For obstetric-specific indicators the rates were comparable for abstractors and the hospital information systems, which in each case was a departmentally based system (SMMIS) producing more detailed and accessible data. CONCLUSIONS--Current methods of extracting and coding diagnostic and procedural data from case notes in this sample of hospitals is unsatisfactory: notes were difficult to access and recording is unacceptably incomplete. IMPLICATIONS--Improvements as piloted in this project, are readily available should the NHS, hospital managers, and clinicians see the value of these data in their clinical and managerial activities.
PMCID: PMC1055175  PMID: 10136257
25.  Geriatric intervention in elderly patients with hip fracture in an orthopedic ward 
Abstract:
Background:
Hip fracture is a common cause of long hospital stay in the elderly. Approximately one third of these patients die within the first year. As a consequence geriatric and orthopedic collaboration (orthogeriatrics) has been organized in different ways. The aim of this study is to evaluate the efficiency of a multidisciplinary geriatric in-hospital intervention on patient outcome.
Methods:
A total of 495 elderly hip fracture patients consecutively admitted to orthopedic surgery, were followed. Data were based on medical records. The intervention group (n=233) was compared to a historical cohort group (n=262) receiving traditional orthopedic treatment. Intervention program was based on initial physical and mental screening and evaluation, geriatric-focused care, and early discharge planning. The intervention was provided by a multidisciplinary geriatric team. After discharge, follow-up home-visits by a physiotherapist were performed, except for patients discharged to nursing homes, due to a 24-hour staff and easy access to the GP.
Results:
Median length of stay was reduced from 15 to 13 days. More patients began treatment with calcium/vitamin-D and bisphosphonate (p=sig). There was no difference in hemoglobin variation between the time of admission and three to six months post admission, and no difference in three-month readmissions (odds ratio (OR) = 1.09 [95%CI: 0.71;1.67]). Discharge destination was unchanged (OR=0.93 [95%CI: 0.52; 1.65]). In-hospital mortality was 8% in the intervention group vs. 6% (p=0.48), in the control group. Three-month mortality was 16% in the intervention group vs. 15% (p=0.39), in the control group. In the intervention group, residents from nursing homes had a higher three-month mortality (OR=2.37 [95% CI: 0.99; 5.67]), and the risk of new fractures within two years decreased from 9.5% to 7.7%, though not statistically significant.
Conclusion:
Our study indicates that co-management of hip fracture patients by orthopedic surgeons and geriatricians may be associated with a reduction in length of hospital stay without negatively affecting major patient outcomes. The concept should be further developed particularly among the frail elderly.
doi:10.5249/jivr.v4i2.96
PMCID: PMC3426900  PMID: 21502786

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