Older Adult Patients in the Emergency Department: Which Patients should be Selected for a Different Approach?

BACKGROUND: While multidimensional and interdisciplinary assessment of older adult patients improves their short-term outcomes after evaluation in the emergency department (ED), this assessment is time-consuming and ill-suited for the busy environment. Thus, identifying patients who will benefit from this strategy is challenging. Therefore, this study aimed to identify older adult patients suitable for a different ED approach as well as independent variables associated with poor short-term clinical outcomes. METHODS: We included all patients ≥65 years attending 52 EDs in Spain over 7 days. Sociodemographic, comorbidity, and baseline functional status data were collected. The outcomes were 30-day mortality, re-presentation, hospital readmission, and the composite of all outcomes. RESULTS: During the study among 96,014 patients evaluated in the ED, we included 23,338 patients ≥65 years-mean age, 78.4±8.1 years; 12,626 (54.1%) women. During follow-up, 5,776 patients (24.75%) had poor outcomes after evaluation in the ED: 1,140 (4.88%) died, 4,640 (20.51) returned to the ED, and 1,739 (7.69%) were readmitted 30 days after discharge following the index visit. A model including male sex, age ≥75 years, arrival by ambulance, Charlson Comorbidity Index ≥3, and functional impairment had a C-index of 0.81 (95% confidence interval, 0.80-0.82) for 30-day mortality. CONCLUSION: Male sex, age ≥75 years, arrival by ambulance, functional impairment, or severe comorbidity are features of patients who could benefit from approaches in the ED different from the common triage to improve the poor short-term outcomes of this population.

Opioid use at the end of life and survival in a Hospital at Home unit.

BACKGROUND AND SIGNIFICANCE: Although opioids are commonly used to treat pain, dyspnea, and other symptoms at the end of life, little information is available on the safety and efficacy of the use of these medications in terminally ill patients in the home care setting. OBJECTIVES: To explore whether high doses of opioids, or increasing doses, influence survival in patients with terminal cancer in a Hospital at Home unit. METHODOLOGY: A retrospective cohort study. Clinical records of 223 oncologic patients admitted to the Hospital at Home unit of Hospital Galdakao-Usansolo from 2003 to 2007 and who died at home were reviewed. Demographic variables (age and gender) as well as clinical variables at the time of admission (Eastern Cooperative Oncology Group Performance Status scale, previous intake of opioids, type of cancer, use of coadjuvant drugs) and daily doses of morphine during the admission were recorded. Main outcomes were the number of days from the maximum dose of opioids administered to death and total length of survival during the admission. RESULTS: Median survival from day of maximum dose to death was longer for patients who received higher doses of opioids (6 days) than those who received lower doses (2 days; p = 0.010). These differences disappeared after adjusting by demographic and clinical variables (HR, 0.86; 95% CI, 0.62-1.18 [p = 0.338]). Patients who received more than twofold increases in their initial doses had longer median survival (22 days) than those who did not (9 days; hazard ratio [HR], 0.45; 95% confidence interval [CI], 0.34-0.60 [p < 0.0001]); these differences persisted after adjustment. CONCLUSIONS: Our results suggest that the use of opioids is safe in for use in Hospital at Home patients with cancer and is not associated with reduced survival.

Validation of priority criteria for cataract extraction.

RATIONALE, AIMS AND OBJECTIVES: Given the increasing prevalence of cataract and demand for cataract extraction surgery, patients must often wait to undergo this procedure. We validated a previously developed priority scoring system in terms of clinical variables, pre-intervention health status, appropriateness of surgery and gain in visual acuity (VA) and health-related quality of life (HRQoL). METHODS: Explicit prioritization criteria for cataract extraction created by a variation of the Research and Development (RAND) and University of California Los Angeles appropriateness methodology were retrospectively applied to a prospective cohort of 5257 patients on waiting lists to undergo cataract by phacoemulsification at 17 hospitals in Spain. Demographic data, clinical data and data related to surgical technique were collected by trained ophthalmologists. Patients were evaluated by their ophthalmologist before the intervention and 6 weeks afterward. They also completed, by mail, the Visual Function Index (VF-14) before the intervention and 3 months afterward. RESULTS: High-priority patients experienced greater improvement in VA and HRQoL than those classified as intermediate or low-priority (P < 0.0001), even after adjusting by VA and the VF-14 score at baseline. The time to intervention was the same for high-priority patients as it was for intermediate and low-priority patients. CONCLUSIONS: The priority score we developed identified patients most likely to experience the greatest improvements from cataract extraction. Use of this tool could provide a fairer and more rational way to prioritize patients for cataract extraction.