Chronic Kidney Diseases Among Patients Undergoing Elective Arthroplasty: Risk Groups and the Value of Serum Creatinine.

BACKGROUND: In arthroplasty clinics, we tend to evaluate patient's kidney function looking at serum creatinine (SCr), while estimated glomerular filtration rate (eGFR) is recommended. We reported the prevalence of chronic kidney disease (CKD; eGFR <60 mL/min/1.73 m2) in different patient groups and investigated whether CKD is missed by evaluation based on SCr. METHODS: Preoperative SCr values were used to calculate eGFR in 20,575 consecutive hip or knee arthroplasties. RESULTS: Prevalence of CKD was 9%-12%. It was higher among older women, knee arthroplasty patients, and patients with hypertension, diabetes, or coronary disease. Using SCr instead of eGFR leads to missing CKD in up to 7% of the cases. In older women and older patients with body mass index <25 kg/m2, half of CKD cases were missed. CONCLUSION: Use of eGFR instead of SCr to detect CKD more accurately is recommended.

The Association of Long-Term Opioid Use With Health Care and Home Care Service Use Among Aged Home Care Clients.

OBJECTIVES: To compare health care and home care service utilization, mortality, and long-term care admissions between long-term opioid users and nonusers among aged home care clients. DESIGN: A retrospective cohort study based on the Resident Assessment Instrument-Home Care (RAI-HC) assessments and electronic medical records. SETTING AND PARTICIPANTS: The study sample included all regular home care clients aged ≥65 years (n = 2475), of whom 220 were long-term opioid users, in one city in Finland (population base 222,000 inhabitants). METHODS: Health care utilization, mortality, and long-term care admissions over a 1-year follow-up were recorded from electronic medical records, and home care service use from the RAI-HC. Negative binomial and multivariable logistic regression, adjusted for several socioeconomic and health characteristics, were used to analyze the associations between opioid use and health and home care service use. RESULTS: Compared with nonusers, long-term opioid users had more outpatient consultations (incidence rate ratio 1.26; 95% CI 1.08-1.48), home visits (1.23; 1.01-1.49), phone contacts (1.38; 1.13-1.68), and consultations without a patient attending a practice (1.22; 1.04-1.43) after adjustments. A greater proportion of long-term opioid users than nonusers had at least 1 hospitalization (49% vs 41%) but the number of inpatient days did not differ after adjustments. The home care nurses' median work hours per week were 4.3 (Q1-Q3 1.5-7.7) among opioid users and 2.8 (1.0-6.1) among nonusers. Mortality and long-term care admissions were not associated with opioid use. CONCLUSIONS AND IMPLICATIONS: Long-term opioid use in home care clients is associated with increased health care utilization regardless of the severity of pain and other sociodemographic and health characteristics. This may indicate the inability of health care organizations to produce alternative treatment strategies for pain management when opioids do not meet patients' needs. The exact reasons for opioid users' greater health care utilization should be examined in future.

Classifying home care clients' risk of unplanned hospitalization with the resident assessment instrument.

PURPOSE: To identify predictive case finding tools for classifying the risk of unplanned hospitalization among home care clients utilizing the Resident Assessment Instrument-Home Care (RAI-HC), with special interest in the Detection of Indicators and Vulnerabilities for Emergency Room Trips (DIVERT) Scale. METHODS: A register-based, retrospective study based on the RAI-HC assessments of 3,091 home care clients (mean age 80.9 years) in the City of Tampere, Finland, linked with hospital discharge records. The outcome was an unplanned hospitalization within 180 days after RAI-HC assessment. The Area Under the Curve (AUC) and the sensitivity and specificity were determined for the RAI-HC scales: DIVERT, Activities of Daily Living Hierarchy (ADLh), Cognitive Performance Scale (CPS), Changes in Health, End-Stage Diseases, Signs, and Symptoms Scale (CHESS), and Method for Assigning Priority Levels (MAPLe). RESULTS: Altogether 3091 home care clients had a total of 7744 RAI-HC assessments, of which 1658 (21.4%) were followed by an unplanned hospitalization. The DIVERT Scale had an AUC of 0.62 (95% confidence interval 0.61-0.64) when all assessments were taken into account, but its value was poorer in the older age groups (< 70 years: 0.71 (0.65-0.77), 70-79 years: 0.66 (0.62-0.69), 80-89 years: 0.60 (0.58-0.62), ≥ 90 years: 0.59 (0.56-0.63)). AUCs for the other scales were poorer than those of DIVERT, with CHESS nearest to DIVERT. Time to hospitalization after assessment was shorter in higher DIVERT classes. CONCLUSION: The DIVERT Scale offers an approach to predicting unplanned hospitalization, especially among younger home care clients. Clients scoring high in the DIVERT algorithm were at the greatest risk of unplanned hospitalization and more likely to experience the outcome earlier than others.

Screening of community-dwelling older patients by the emergency medical services: An observational retrospective registry study.

BACKGROUND: Inadequate nutrition, falls, and cognitive impairment are common problems among acutely ill older people and are associated with complicated and prolonged health problems and mortality. OBJECTIVES: To assess if the emergency medical services can identify patients with nutritional risk, falls risk, and cognitive impairment by using simple screening tools and to assess the prevalence of risks and rate they are reported to the emergency department. SETTING: The study was carried out in Espoo, Finland to patients over the age of 70 requiring non-urgent ambulance transfer to the emergency department. OUTCOME MEASURES: A set of validated electronic screening tools was used to identify patients at nutritional risk, risk of falling and having cognitive impairment. MAIN RESULTS: A total of 488 (8%) out of 5792 patients were screened. Of the patients 60%, (n = 292) had at least one risk: 17% (n = 81) had nutritional risk, 43% (n = 209) falls risk, and 28% (n = 137) cognitive impairment. Twenty-two (5%) were screened positive in all three categories. The observed risk was reported to the emergency department staff in 59% (n = 173) of the patients. CONCLUSION: The emergency medical services can be used in preventive health care to identify patients having nutritional risk, falls risk, or cognitive impairment.

Risk factors of readmission after geriatric hospital care: An interRAI-based cohort study in Finland.

PURPOSE: To identify risk factors for readmission after geriatric hospital care. METHODS: A retrospective cohort study of 1,167 community-dwelling patients aged ≥70 years who were hospitalised in two geriatric hospitals and discharged to their homes over a three-year period. We combined the results of the interRAI-post acute care instrument (interRAI-PAC) with hospital discharge records. Factors associated with readmissions within 90 days following discharge were analysed using logistic regression analysis. RESULTS: The patients' mean age was 84.5 (SD 6.2) years, and 71% (n = 827) were women. The 90-day readmission rate was 29.5%. The risk factors associated with readmission in the univariate analysis were as follows: age, admission from home vs. acute care hospital, Alzheimer's disease, unsteady gait, fatigue, unstable conditions, Activities of Daily Living Hierarchy Scale (ADLH) score, Cognitive Performance Scale (CPS) score, body mass index (BMI), frailty index, bowel incontinence, hearing difficulties, and poor self-rated health. In the multivariable analysis, age of ≥90 years, ADLH ≥1, unsteady gait, BMI <25 or ≥30 kg/m 2 , and frailty remained as risk factors for readmission. Surgical operation during the treatment period was associated with a lower readmission risk. CONCLUSIONS AND IMPLICATIONS: InterRAI-PAC performed upon admission to geriatric hospitals revealed patient-related risk factors for readmission. Based on the identified risk factors, we recommend that the patient's functional ability, activities of daily living (ADL) needs, and individual factors underlying ADL disability, as well as nutritional and mobility problems should be carefully addressed and managed during hospitalization to diminish the risk for readmission.

A population-based study of 2347 fall-related injuries among older people in a Finnish emergency department.

PURPOSE: Fall-related injuries are a significant cause of morbidity, mortality and functional decline among older people. The aim of this study is to analyze the incidence of fall-related emergency department (ED) visits and compare the characteristics of single and recurrent fallers in a population-based sample. METHODS: Consecutive patients aged ≥ 80 years and living in the Tampere city region who visited collaborative emergency department within a two-year study period (1 January 2015 to 31 December 2016) due to fall-related injury were included. The incidence of fall-related injuries and recurrent falls was calculated using population statistics. RESULTS: A total of 6915 ≥ 80-year-old patients visited our ED 17,769 times during the study period. Thirteen percent of these visits (n = 2347, median 87 years, 80-103 years; 74% female) were fall-related. The incidence of fall-related ED visits increased from 94/1000 person-years to 171/1000 among those aged 80-89 years and ≥ 90 years, respectively. Twenty-four percent of patients had recurrent falls (range 2-5) during the observational period. Twenty-five percent of those discharged home had a subsequent fall-related injury within one month after the index visit. The distribution of diagnoses was similar among those with single and recurrent falls. CONCLUSION: Fall-related injuries are a significant health issue. Almost one in eight of all ED visits were fall-related, and 24% of patients had recurrent fall-related injuries. The risk of subsequent injury was high during the first month after the first injury, emphasizing the need to intervene with the fall risk promptly.

Reasons for home care clients' unplanned Hospital admissions and their associations with patient characteristics.

BACKGROUND: Unplanned hospitalizations and emergency room visits occur frequently among home care clients The aim of this study was to identify typical discharge diagnoses and their associations with patient characteristics among a total of 6812 Finnish home care clients aged ≥63 years who were hospitalized within one year of their first home care assessment. METHODS: A register-based study based on Resident Assessment Instrument-Home Care (RAI-HC) assessments and nationwide hospital discharge records. The RAI-HC assessments were linked to the hospital discharge records of the participants' first unplanned hospitalization. Univariate and multivariable regression analyses were used to evaluate the association of RAI-HC determinants with discharge diagnoses. RESULTS: The most common reason for the first hospitalization was an infectious disease (21%; n = 1446). When hospitalizations were classified according to the main diagnosis, chronic skin ulcers, functional impairment and daily urinary incontinence were associated with hospitalization due to infectious diseases; impaired cognitive capacity, Alzheimer's disease or other dementia and polypharmacy (protective effect) were associated with hospitalizations due to dementia; age of ≥90 years, congestive heart failure, coronary artery disease and using ≥10 drugs with hospitalizations due to heart diseases; and moderate or strong pain with hospitalization due to musculoskeletal disorders. Previous falls, female sex and an earlier hip fracture were associated with injury-related hospitalizations. Feelings of loneliness increased the odds of hospitalization due to geriatric symptoms without a specific diagnosis. CONCLUSION: Patient characteristics and geriatric syndromes identified using RAI-HC predict the reasons for future hospitalizations among new home care clients.

Predictors for Unplanned Hospitalization of New Home Care Clients.

OBJECTIVES: To identify factors predicting unplanned hospitalization of new home care clients using the Resident Assessment Instrument for Home Care (RAI-HC). DESIGN: A register-based study based on RAI-HC assessments and nationwide hospital discharge records. SETTING: Municipal home care services in Finland. PARTICIPANTS: New Finnish home care clients aged 63 and older (N = 15,700). MEASUREMENTS: Information from home care clients' first RAI-HC assessment was connected to information regarding their first hospitalization over 1 year of follow-up. Multivariate regression analyses were used to evaluate the independent risk factors for hospitalization. RESULTS: Forty-three percent (n = 6,812) of participants were hospitalized at least once. The strongest independent risk factors were hospitalization during the year preceding the RAI-HC assessment (odds ratio (OR) = 2.01, 95% confidence interval (CI) = 1.87-2.16), aged 90 and older (OR = 1.69, 95% CI = 1.48-1.92), renal insufficiency (OR = 1.44, 95% CI = 1.22-1.69) and using 10 or more drugs (OR = 1.41, 95% CI = 1.26-1.58). Other independent risk factors were male sex, previous emergency department visits or other acute outpatient care use, daily urinary incontinence, fecal incontinence, history of falls, cognitive impairment, chronic skin ulcer, pain, unstable health status, housing-related problems, and poor self-rated health. Parkinson's disease, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, and cancer were independent prognostic indicators. A body mass index of 24 kg/m2 or greater and the client's own belief that functional capacity could improve had a protective role. CONCLUSION: Assessing new home care clients using the RAI-HC reveals modifiable risk factors for unplanned hospitalization. Systematic assessment by a multidisciplinary team at the beginning of the service and targeting modifiable risk factors could reduce the risk of unplanned hospitalization.