Increased Association With Malnutrition and Malnourishment in Older Adults Admitted With Hip Fractures Who Have Cognitive Impairment and Delirium, as Assessed by 4AT.

BACKGROUND: The Royal College of Physicians recently introduced the 4AT (Alertness, Abbreviated Mental Test-4, Attention, and Acute change or fluctuating course) for screening cognitive impairment and delirium. Here, we examined the association of the 4AT with nutrition status in patients admitted to a hospital with hip fractures between January 1, 2016, and June 6, 2019. METHODS: Nutrition status was assessed using the Malnutrition Universal Screening Tool, and the 4AT was assessed within 1 day after hip surgery. χ2 Tests and logistic regression were conducted to assess the association of nutrition status with 4AT scores, adjusted for age and sex. RESULTS: From 1082 patients aged 60-103 years, categorized into 4AT scores of 0, 1-3, or ≥4, the prevalence of malnutrition risk was 15.5%, 27.3%, and 39.6% and malnourishment was 4.1%, 13.2%, and 11.3%, respectively. Compared with the 4AT = 0 cohort, a 4AT score = 1-3 was associated with an increased malnutrition risk (odds ratio [OR], 2.3; 95% CI, 1.6-3.1) or malnourishment (OR, 3.6; 95% CI, 2.1-6.3). For a 4AT score ≥4, corresponding ORs were 4.0 (95% CI, 2.8-5.9) and 3.6 (95% CI, 1.9-6.8). Overall, there was a significant positive association: as 4AT scores increased, so did malnutrition risk. CONCLUSIONS: Among older adults admitted with hip fractures, high 4AT scores, which are suggestive of cognitive impairment and delirium, identified patients at increased malnutrition risk. These findings lend further support for the use of 4AT to identify patients who are at increased health risk.

Clinical outcomes in patients admitted to hospital with cervical spine fractures or with hip fractures.

Patients admitted with a cervical fracture are twice as likely to die within 30 days of injury than those with a hip fracture. However, guidelines for the management of cervical fractures are less available than for hip fractures. We hypothesise that outcomes may differ between these types of fractures. We analysed 1359 patients (406 men, 953 women) with mean age of 83.8 years (standard deviation = 8.7) admitted to a National Health Service hospital in 2013-2019 with a cervical (7.5%) or hip fracture (92.5%) of similar age. The association of cervical fracture (hip fracture as reference), hospital length of stay (LOS), co-morbidities, age and sex with outcomes (acute delirium, new pressure ulcer, and discharge to residential/nursing care) was assessed by stepwise multivariate logistic regression. Acute delirium without history of dementia was increased with cervical fractures: odds ratio (OR) = 2.4, 95% confidence interval (CI) = 1.3-4.7, age ≥ 80 years: OR = 3.5 (95% CI = 1.9-6.4), history of stroke: OR = 1.8 (95% CI = 1.0-3.1) and ischaemic heart disease: OR = 1.9 (95% CI = 1.1-3.6); pressure ulcers was increased with cervical fractures: OR = 10.9 (95% CI = 5.3-22.7), LOS of 2-3 weeks: OR = 3.0 (95% CI = 1.2-7.5) and LOS of ≥ 3 weeks: OR = 4.9, 95% CI = 2.2-11.0; and discharge to residential/nursing care was increased with cervical fractures: OR = 3.2 (95% CI = 1.4-7.0), LOS of ≥ 3 weeks: OR = 4.4 (95% CI = 2.5-7.6), dementia: OR = 2.7 (95% CI = 1.6-4.7), Parkinson's disease: OR = 3.4 (95% CI = 1.3-8.8), and age ≥ 80 years: OR = 2.7 (95% CI = 1.3-5.6). In conclusion, compared with hip fracture, cervical fracture is more likely to associate with acute delirium and pressure ulcers, and for discharge to residency of high level of care, independent of established risk factors.

Associations of 4AT with mobility, length of stay and mortality in hospital and discharge destination among patients admitted with hip fractures.

BACKGROUND: the 4AT (Alertness, Abbreviated Mental Test-4, Attention and Acute change or fluctuating course), a tool to screen cognitive impairment and delirium, has recently been recommended by the Scottish Intercollegiate Guidelines Network. We examined its ability to predict health outcomes among patients admitted with hip fractures to a single hospital between January 2018 and June 2019. METHODS: the 4AT was performed within 1 day after hip surgery. A 4AT score of 0 means unlikely delirium or severe cognitive impairment (reference group); a score of 1-3 suggests possible chronic cognitive impairment, without excluding possibility of delirium; a score ≥ 4 suggests delirium with or without chronic cognitive impairment. Logistic regression, adjusted for: age; sex; nutritional status; co-morbidities; polypharmacy; and anticholinergic burden, used the 4AT to predict mobility, length of stay (LOS), mortality and discharge destination, compared with the reference group. RESULTS: from 537 (392 women, 145 men: mean = 83.7 ± standard deviation [SD] = 8.8 years) consecutive patients, 522 completed the 4AT; 132 (25%) had prolonged LOS (>2 weeks) and 36 (6.8%) died in hospital. Risk of failure to mobilise within 1 day of surgery was increased with a 4AT score ≥ 4 (OR = 2.4, 95% confidence interval [CI] = 1.3-4.3). Prolonged LOS was increased with 4AT scores of 1-3 (OR = 2.4, 95%CI = 1.4-4.1) or ≥4 (OR = 3.1, 95%CI = 1.9-6.7). In-patient mortality was increased with a 4AT score ≥ 4 (OR = 3.1, 95%CI = 1.2-8.2) but not with a 4AT score of 1-3. Change of residence on discharge was increased with a 4AT score ≥ 4 (OR = 3.1, 95%CI = 1.4-6.8). These associations persisted after excluding patients with dementia. 4AT score = 1-3 and ≥ 4 associated with increased LOS by 3 and 6 days, respectively. CONCLUSIONS: for older adults with hip fracture, the 4AT independently predicts immobility, prolonged LOS, death in hospital and change in residence on discharge.

Intervention and Public Policy Pathways to Achieve Health Care Equity.

Health care equity reflects an equal opportunity to utilize public health and health care resources in order to maximize one's health potential. Achieving health care equity necessitates the consideration of both quantity and quality of care, as well as vertical (greater health care use by those with greater needs) and horizontal (equal health care use by those with equal needs) equity. In this paper, we summarize the approaches introduced by authors contributing to this Special Issue and how their work is captured by the National Institute of Minority Health and Health Disparities (NIMHD) framework. The paper concludes by pointing out intervention and public policy opportunities for future investigation in order to achieve health care equity.

Affordable Care Act and Disparities in Health Services Utilization among Ethnic Minority Breast Cancer Survivors: Evidence from Longitudinal Medical Expenditure Panel Surveys 2008⁻2015.

Breast cancer is the most prevalent female cancer in the US. Incidence rates are similar for white and black women but mortality rates are higher for black women. This study draws on rich, nationally representative data, the 2008⁻2015 Medical Expenditure Panel Surveys, to estimate effects of the Affordable Care Act (ACA) on reducing disparities in and access to use of diagnostic and medical services for black and Hispanic breast cancer survivors. Random effects multinomial logit, flexible hurdle and Box-Cox estimation techniques are used. The robust estimates indicate that the ACA narrowed the racial/ethnic disparity in health insurance coverage, health care utilization and out-of-pocket prescription drug expenditures among breast cancer survivors. Gaps in uninsurance significantly declined for black and Hispanic survivors. Hispanic women generally and black breast cancer survivors specifically increased use of mammography services post-ACA. The ACA did not significantly impact disparities in physician utilization or out-of-pocket prescription drug expenditures for Hispanic survivors, while there were substantive improvements for black breast cancer survivors. The paper concludes with a discussion of the strengths and limitations of the ACA for reducing disparities and improving health outcomes for a growing population of breast cancer survivors in the US.

Racial and Ethnic Disparities in Patient-Provider Communication With Breast Cancer Patients: Evidence From 2011 MEPS and Experiences With Cancer Supplement.

The current study explores racial/ethnic disparities in the quality of patient-provider communication during treatment, among breast cancer patients. A unique data set, Medical Expenditure Panel Survey and Experiences With Cancer Supplement 2011, is used to examine this topic. Using measures of the quality of patient-provider communication that patients are best qualified to evaluate, we explore the relationship between race/ethnicity and patients' perspectives on whether (1) patient-provider interactions are respectful, (2) providers are listening to patients, (3) providers provide adequate explanations of outcomes and treatment, and (4) providers spend adequate time in interacting with the patients. We also examine the relationship between race/ethnicity and patients' perspectives on whether their (1) doctor ever discussed need for regular follow-up care and monitoring after completing treatment, (2) doctor ever discussed long-term side effects of cancer treatment, (3) doctor ever discussed emotional or social needs related to cancer, and (4) doctor ever discussed lifestyle or health recommendations. Multivariate ordinary least squares and ordered logistic regression models indicate that after controlling for factors such as income and health insurance coverage, the quality of patient-provider communication with breast cancer patients varies by race/ethnicity. Non-Hispanic blacks experience the greatest communication deficit. Our findings can inform the content of future strategies to reduce disparities.

Neck of femur fractures in the elderly: Does every hour to surgery count?

OBJECTIVES: To determine if early surgery before 12h confers a survival or length of stay benefit for patients with neck of femur (NOF) fractures. DESIGN: Retrospective review of prospectively collected data. SETTING: District general hospital. PATIENTS: 1913 patients aged over 60 admitted with a fractured NOF who underwent surgery between 2011 and 2015. Mean age was 83.9 years. 73.7% were female. INTERVENTION: Patients had surgery for fractured NOF with data collected on demographics, mortality and length of stay. MAIN OUTCOME MEASUREMENTS: Data collected included gender, age, ASA grade, fracture anatomy, surgery, time to surgery, days spent in acute hospital and rehabilitation settings and 30-day mortality. Statistical analysis was used to identify independent predictors of mortality and length of stay. RESULTS: 30-day mortality was 6.1% and the mean hospitalisation time was 13±11.3days for the acute hospital and 20.2±17.2days for the trust. Operations were performed at a mean of 23.8±14.8h after presentation. Age, gender, ASA grade and type of fracture were independent predictors of either mortality or length of stay. Timing of surgery had an association with mortality but this only reached statistical significance at 24h. In line with previous studies we analysed time to surgery in 12h blocks. We also used logistic regression, recognizing time as a continuous variable, which revealed that every hour of delay to surgery increased the mortality risk by 1.8%. CONCLUSIONS: While every hour of delay increased mortality risk, the association with mortality only became statistically significant when delaying over 24h. This supports a pragmatic approach, with surgery as soon as medically possible without a race to theatre. LEVEL OF EVIDENCE: Level III retrospective cohort study.

Factors influencing contraceptive use among women in Afghanistan: secondary analysis of Afghanistan Health Survey 2012.

The increase in contraceptive use in Afghanistan has been frustratingly slow from 7.0% in 2003 to 11.3% in 2012. Data on contraceptive use and influencing factors were obtained from Afghanistan Health Survey (AHS) 2012, which had been collected through interview-led questionnaire from 13,654 current married women aged 12-49 years. Odds ratio (OR) and 95% confidence interval (CI) of contraceptive use were estimated by logistic regression analysis. When adjusted for age, residence, region, education, media, and wealth index, significant OR was obtained for parity (OR of 6 or more children relative to 1 child was 3.45, and the 95%CI 2.54-4.69), number of living sons (OR of 5 or more sons relative to no son was 2.48, and the 95%CI 1.86-3.29), wealth index (OR of the richest households relative to the poorest households was 2.14, and the 95%CI 1.72-2.67), antenatal care attendance (OR relative to no attendance was 2.13, and the 95%CI 1.74-2.62), education (OR of secondary education or above relative to no education was 1.62, and the 95%CI 1.26-2.08), media exposure (OR of at least some exposure to electronic media relative to no exposure was 1.15, and the 95%CI 1.01-1.30), and child mortality experience (OR was 0.88, and the 95%CI 0.77-0.99), as well as age, residence (rural/urban), and region. This secondary analysis based on AHS 2012 showed the findings similar to those from the previous studies in other developing countries. Although the unique situation in Afghanistan should be considered to promote contraceptive use, the background may be common among the areas with low contraceptive use.