Using Charlson Comorbidity Index to Predict Short-Term Clinical Outcomes in Hospitalized Older Adults.

This study examined the prognostic value of the Charlson Comorbidity Index (CCI) in predicting short-term clinical outcomes in hospitalized older adults. We conducted a retrospective cohort study of patients, older than 75 years, admitted to the medicine service at a large tertiary hospital (New York). We used the Enhanced International Classification of Disease, 9th Revision, Clinical Modification adaptation to abstract the CCI from electronic medical records. The CCI scores were compared, using the standard Deyo version and the Schneeweiss version. Outcome measures included in-hospital mortality, length of stay (LOS), and 30-day readmissions. When comparing Charlson/Deyo and Charlson/Deyo/Schneeweiss with and without age, we found similar significant association with regard to in-hospital mortality, with a moderate predictive ability (area under the curve [AUC]: 0.5906-0.6433). However, for 30-day readmissions and LOS, the predictive ability was poor (AUC: 0.5598-0.6106 and ρ: 0.11-0.12, respectively). The CCI is, at most, a moderate predictor of in-hospital mortality and a poor predictor of other important healthcare outcomes relevant to administrative healthcare practices.

Measuring Functional Status in Hospitalized Older Adults Through Electronic Health Record Documentation.

OBJECTIVES: Hospitalization-associated disability affects up to 60% of older adults; however, standardized measures of function are not routinely used and documented. We sought to determine whether nursing documentation in electronic medical records can be used to determine mobility status and associated clinical outcomes. METHODS: A retrospective study of 2383 medical patients aged 75 years and older was conducted at a large academic tertiary hospital in New York. Mobility (low, intermediate, and high) was the primary variable of interest. Short-term clinical outcomes, including length of stay (LOS), discharge disposition, and readmissions, were the primary outcome variables. RESULTS: Average age and Charlson Comorbidity Index were 84.7 (range 74-107) and 6.46, respectively; 84.5% of patients were documented to have been ambulatory before admission. More than half (52.8%) of the subjects with in-hospital mortality were in the low mobility group (27.2 vs 0.27 vs 0, P < 0.0001). Low mobility was associated with increased LOS (7.42 vs 5.69 vs 4.14, P < 0.0001), discharge to a skilled nursing facility (39.36 vs 14.67 vs 1.91, P < 0.0001), and 30-day readmission (24.40 vs 16.67 vs 10.93, P < 0.0001). After controlling for demographics, ambulatory status before admission, and Charlson Comorbidity Index, low mobility was statistically significantly associated with increased LOS, discharge to a skilled nursing facility, and 30-day readmissions. CONCLUSIONS: The use of documented nursing observation may provide a practical way to systematically identify patients at risk for poor outcomes associated with low mobility to ultimately improve outcomes of hospitalized older adults.

The role of geriatrician-hospitalists in the care of older adults: A retrospective cohort study.

INTRODUCTION: Medicare patients account for over 50% of hospital days at a cost of over $1 trillion per year. Yet, hospitalization of older adults often results in poor outcomes. We evaluated the role of geriatrician-hospitalists in the care of older adults. Materials and methods A retrospective cohort study was conducted in a 764-bed tertiary care hospital with patients 65 and older admitted to medicine. Geriatrician-hospitalists care was compared to usual care by non-geriatrician hospitalists (staff and non-staff). Outcome measures included length of stay (LOS) and 30-day readmissions. Process measures included geriatric-focused care practices, such as early mobilization, safety precautions, delirium management, use of potentially inappropriate medications and documentation of advanced directives as well as discharge disposition. RESULTS: Of the 10,529 patients, 2949 (28.0%) were cared for by staff hospitalists, 7181 (68.2%) by non-staff hospitalists and 399 (3.79%) by geriatrician-hospitalists. Patients cared for by geriatrician-hospitalists were significantly older with more comorbidities than those admitted to staff and non-staff hospitalists (average age: 86.3, 79.7, and 80.3, respectively, p < 0.0001; Charlson Comorbidity Index: 7.46, 7.01, and 7.17, respectively, p = 0.0005). Multivariate analysis showed no difference in LOS, 30-day readmissions, and discharge disposition. In terms of care practices, significant differences were found for the following: time to PT (p < 0.0001), duration of indwelling bladder catheters (p = 0.018), documentation of Do-Not-Resuscitate (p < 0.0001), benzodiazepine use (p < 0.0001) and anticholinergics (p = 0.0029), respectively. CONCLUSIONS: As the population continues to age at unprecedented rates and hospitals struggle to meet the demands and expectations, geriatrician-hospitalists may improve care practices important for older adult care management.

Do-Not-Resuscitate Orders in Older Adults During Hospitalization: A Propensity Score-Matched Analysis.

OBJECTIVES: To explore the effect of the presence and timing of a do-not-resuscitate (DNR) order on short-term clinical outcomes, including mortality. DESIGN: Retrospective cohort study with propensity score matching to enable direct comparison of DNR and no-DNR groups. SETTING: Large, academic tertiary-care center. PARTICIPANTS: Hospitalized medical patients aged 65 and older. MEASUREMENTS: Primary outcome was in-hospital mortality. Secondary outcomes included discharge disposition, length of stay, 30-day readmission, restraints, bladder catheters, and bedrest order. RESULTS: Before propensity score matching, the DNR group (n=1,347) was significantly older (85.8 vs 79.6, p<.001) and had more comorbidities (3.0 vs 2.5, p<.001) than the no-DNR group (n=9,182). After propensity score matching, the DNR group had significantly longer stays (9.7 vs 6.0 days, p<.001), were more likely to be discharged to hospice (6.5% vs 0.7%, p<.001), and to die (12.2% vs 0.8%, p<.001). There was a significant difference in length of stay between those who had a DNR order written within 24 hours of admission (early DNR) and those who had a DNR order written more than 24 hours after admission (late DNR) (median 6 vs 10 days, p<.001). Individuals with early DNR were less likely to spend time in intensive care (10.6% vs 17.3%, p=.004), receive a palliative care consultation (8.2% vs 12.0%, p=.02), be restrained (5.8% vs 11.6%, p<.001), have an order for nothing by mouth (50.1% vs 56.0%, p=.03), have a bladder catheter (31.7% vs 40.9%, p<.001), or die in the hospital (10.2% vs 15.47%, p=.004) and more likely to be discharged home (65.5% vs 58.2%, p=.01). CONCLUSION: Our study underscores the strong association between presence of a DNR order and mortality. Further studies are necessary to better understand the presence and timing of DNR orders in hospitalized older adults.

Opiate Prescribing in Hospitalized Older Adults: Patterns and Outcomes.

BACKGROUND/OBJECTIVES: Whereas opiate prescribing patterns have been well described in outpatient and emergency department settings, they have been less defined in hospitalized older adults. The objective was to describe patterns of opiate prescribing and associated outcomes in hospitalized older adults. DESIGN: Retrospective cohort study. SETTING: Tertiary care facility. PARTICIPANTS: Hospitalized medical patients aged 65 and older (N = 9,245; mean age 80.3, 55.2% female, 72.3% white, 90.8% non-Hispanic). MEASUREMENTS: Opiate exposure and duration of action, concurrent use of potentially inappropriate medications (PIMs), adverse events, discharge disposition, length of stay (LOS), and 30-day readmissions. RESULTS: There was no difference in sex, race, ethnicity, or Charlson Comorbidity Index between opiate exposure groups. Participants who had never received opiates had a significantly shorter mean LOS than prior and new opiate users (5.2, 6.8, 7.7 days; P < .001) and were more likely to be discharged home (88.6%, 82.8%, 82.5%; P < .001) and significantly less likely to be readmitted within 30-days (19.6%, 25.0%, 22.3%; P < .001). Participant who had never been exposed to opiates had a significantly shorter mean LOS than those receiving short- and long-acting opiates (5.2, 7.3, 8.6 days; P < .001) and were more likely to be discharged home (88.6%, 82.6%, 82.4%; P < .001) and significantly less likely to be readmitted within 30-days (19.6%, 27.7%, 28.9%; P < .001). CONCLUSION: Opiate use is widespread during hospitalization and is associated with significant negative clinical outcomes and quality metrics. There is an urgent need to develop innovative pain management alternatives to opiate use.

Implementing ACOVE Quality Indicators as an Intervention Checklist to Improve Care for Hospitalized Older Adults.

BACKGROUND: Medicare patients account for approximately 50% of hospital days. Hospitalization in older adults often results in poor outcomes. OBJECTIVE: To test the feasibility and impact of using Assessing Care of Vulnerable Elders (ACOVE) quality indicators (QIs) as a therapeutic intervention to improve care of hospitalized older adults. DESIGN: >Post-test only prospective intervention with a nonequivalent retrospective control group. SETTING: Large tertiary hospital in the greater New York Metropolitan area. PATIENTS: Hospitalized patients, 75 years and over, admitted to medical units. INTERVENTION: A checklist, comprised of four ACOVE QIs, administered during daily interdisciplinary rounds: venous thrombosis prophylaxis (VTE) (QI 1), indwelling bladder catheters (QI 2), mobilization (QI 3), and delirium evaluation (QI 4). MEASUREMENTS: Variables were extracted from electronic medical records with QI compliance as primary outcome, and length of stay (LOS), discharge disposition, and readmissions as secondary outcomes. Generalized linear mixed models for binary clustered data were used to estimate compliance rates for each group (intervention group or control group) in the postintervention period, along with their corresponding 95% confidence intervals. RESULTS: Of the 2,396 patients, 530 were on an intervention unit. In those patients not already compliant with VTE, compliance rate was 57% in intervention vs 39% in control (𝑃 < .0056). For indwelling catheters, mobilization, and delirium evaluation, overall compliance was significantly higher in the intervention group 72.2% vs 54.4% (𝑃 = .1061), 62.9% vs 48.2% (𝑃 < .0001), and 27.9% vs 21.7% (𝑃 = .0027), respectively. CONCLUSION: The study demonstrates the feasibility and effectiveness of integrating ACOVE QIs to improve the quality of care in hospitalized older adults.