Geriatric assessment may prevent readmission in frail medical inpatients.

INTRODUCTION: Frailty is common in older adults. Many approaches exist to care of hospitalised older medical inpatients. The objectives of this study were to 1) describe frailty occurrence and 2) explore associations between frailty, type of care, 30-day readmission and 90-day mortality. METHODS: In a cohort of 75+-year-old medical inpatients with daily homecare or moderate comorbidity, frailty was graded as moderate or severe using the record-based Multidimensional Prognostic Index. The emergency department (ED), internal medicine (IM) and geriatric medicine (GM) were compared. Estimates of relative risk (RR) and hazard ratios were calculated in binary regression and Cox regression models. RESULTS: Analyses included 522 patients (61%) with moderate frailty and 333 (39%) with severe frailty. A total of 54% were females, and the median age was 84 years (interquartile range: 79-89). In GM, the distribution of frailty grade differed significantly from that of the ED (p less-than 0.001) and IM (p less-than 0.001). GM had the highest occurrence of severely frail patients and the lowest readmission rate. Compared with GM, the adjusted RR for readmission in ED was 1.58 (1.04-2.41), p = 0.032; and in IM: 1.42 (0.97-2.07), p = 0.069. Between the three specialities, no differences were seen in 90-day mortality hazard. CONCLUSION: In a regional hospital, frail older patients were discharged from all medical specialities. Admission to geriatric medicine was associated with a lower readmission risk and no increase in mortality. Comprehensive Geriatric Assessment may explain the observed differences in readmission risk. FUNDING: None. TRIAL REGISTRATION: Not relevant.

Effects of a new early municipality-based versus a geriatric team-based transitional care intervention on readmission and mortality among frail older patients - a randomised controlled trial.

Purpose Previous studies reported reduced risk of readmission, mortality and shorter length of hospital stay (LOS) among geriatric patients receiving an early (<24h), hospital-based geriatric team intervention after discharge. The objective of this study was to compare a novel, early municipality-based, nurse-led and general practitioner (GP)-supported transitional care intervention (TCI) to an established hospital-based TCI among frail, older, geriatric patients. Material and methods A randomised controlled trial was conducted within a single geriatric department and the adjacent municipality. Inclusion criteria: acutely admitted, frail patients 75+ years old. Eligible patients were randomly allocated (1:1) to the two TCIs. Primary outcome was 30-day unplanned readmission. Secondary outcomes were 90-day all-cause mortality and LOS. Stratified analysis according to type of dwelling was made. Odds ratios (OR) with 95% confidence intervals (CI), and number needed to treat (NNT) were reported. Results 3,103 patients (median age (IQR): 85 (80-90); 57% female) were included. Readmission rates were 22% in the municipality-based intervention (n=332/1,545), and 18% in the hospital-based intervention (n=276/1,558); OR was 1.27, 95% CI (1.06-1.52), p=0.008 and NNT=27. OR for cohabiting patients was 1.47, 95% CI (1.02-2.08); p=0.035. No significant difference was observed in mortality (22% vs. 21%; OR=1.05, 95% CI (0.89-1.25), p=0.577) or LOS (median (IQR): 6 (2-8) vs. 6 (2-8) days, p=0.1787). Conclusions The new municipality-based, nurse-led and GP-supported intervention was inferior to the hospital-based geriatric team intervention in preventing 30-day readmission among frail, geriatric patients. There was no significant difference between the two interventions in regard to 90-day mortality or LOS.

Mortality and readmission risk can be predicted by the record-based Multidimensional Prognostic Index: a cohort study of medical inpatients older than 75 years.

PURPOSE: To examine the predictive value of the record-based Multidimensional Prognostic Index (MPI) on mortality, readmission and length of hospital stay (LOS) among older medical inpatients. METHODS: A cohort of medical inpatients aged ≥ 75 years was rated using the record-based MPI to assess frailty retrospectively. 90-day and 1-year mortality hazard ratios (HRs) were calculated in a sex- and age-adjusted Cox proportional hazards model. 30-day readmission relative risk (RR) estimates were calculated in a binary regression model with mortality as a competing risk. Discrimination was expressed by the area under the receiver operating characteristic (ROC) curve. Median LOS was calculated using the non-parametric Kruskal-Wallis one-way ANOVA. RESULTS: In total, 1190 patients with a median age of 83 years were included. 50% were male. 335 patients (28%) were categorized as non-frail (MPI score 0.0-0.33), 522 (44%) moderately frail (MPI score 0.34-0.66) and 333 (28%) severely frail (MPI score 0.67-1.0). 90-day mortality HR was 7.4 (95% confidence interval (CI) 2.9-18.6, p < 0.001) for the moderately frail and 18.5 (95% CI 7.5-46.1, p < 0.001) for the severely frail compared with the non-frail. ROC area was 0.76 (95% CI 0.72-0.80). Similarly, 1-year mortality HR was 3.3 (95% CI 2.2-5.0, p < 0.001) for the moderately frail and 7.1 (95% CI 4.7-10.6, p < 0.001) for the severely frail. 30-day readmission RR was 2.1 (95% CI 1.5-2.9, p < 0.001) for the moderately frail and 1.8 (95% CI 1.3-2.6, p = 0.001) for the severely frail. LOS was significantly longer with increasing MPI score (p < 0.001). CONCLUSION: The record-based MPI assessed at discharge predicts dose-dependent post-discharge mortality and readmission risk and is associated with LOS in older medical inpatients.

A reliable and record-based frailty assessment method for older medical inpatients.

PURPOSE: The comprehensive geriatric assessment (CGA) including frailty assessment is considered the gold standard of assessment in geriatric patients. The Multidimensional Prognostic Index (MPI) is a CGA-based bedside assessment tool. Older medical inpatients' medical records comprehensively describe the MPI-featured components. Consequently, MPI-based frailty assessment may be accomplished retrospectively. We found no previous studies concerning record-based MPI. We studied the reproducibility and diagnostic accuracy of a record-based MPI. METHODS: The study was designed as a fully crossed, prospective, and cross-sectional study. A total of 50 inpatients aged ≥ 75 years were included from two medical wards. Record-based MPI was assessed by two independent raters in patients who required personal assistance on a daily basis or had a Charlson Comorbidity Index (CCI) ≥ 1. In the same patients, a bedside MPI rating was performed. Inter-rater and inter-method reproducibility and diagnostic accuracy measures were calculated. RESULTS: Evaluating the inter-rater reproducibility; the mean difference was -0.02 points [95% confidence interval (CI) - 0.06 to 0.01, p = 0.20]. Intraclass correlation coefficient (ICC) was 0.71. Evaluating inter-method reproducibility; the mean difference was -0.02 (95% CI - 0.04 to 0.01, p = 0.18); ICC = 0.83. Sensitivity was 100% and specificity 80%. The areas under the receiver operating curves (ROC) was 0.92 (95% CI 0.75-1.00) and 0.77 (95% CI 0.52-1.00). CONCLUSION: The record-based MPI rating method has an acceptable inter-rater reliability, good inter-method reliability, and high agreement as compared to the bedside-rated MPI. The diagnostic accuracy seems considerable. The record-based MPI seems useful in retrospective frailty assessment among older medical inpatients.

Early supported discharge following mild stroke: a qualitative study of patients' and their partners' experiences of rehabilitation at home.

BACKGROUND: Early supported discharge (ESD) allows mild-to-moderate stroke patients to return home as soon as possible and continue rehabilitation at their own pace in familiar surroundings. Thus, the main responsibility for continued rehabilitation is in the hands of patients and their partners, who must collaborate to adjust to poststroke everyday life. However, couples' joint experiences of stroke, early discharge and rehabilitation at home remain minimally investigated. AIM: To investigate how mild stroke patients' and their partners' experience and manage everyday life in a context of ESD. METHODS: We conducted qualitative interviews with a purposive sample of 22 ESD patients and 18 partners. Interviews were conducted 3-6 weeks after stroke, and we used thematic analysis to analyse the data. FINDINGS: The analysis identified three themes. First, 'Home as a healing place' involved the couples' experiences of a well-informed discharge from hospital. They trusted the health professionals' assessment that the patient was ready to go home. They described home as a comforting and calm place, where recovery could meaningfully take place. The second theme, 'Flow of everyday life', comprised the experiences of adapting to and continuing everyday life. Most of the interviewees had relatively minor physical and cognitive impairments, and the patients and their partners were hopeful for a full recovery in the foreseeable future. Finally, 'Professional safety net' involved the much appreciated stroke team. Although most of the participants only had one visit from the team, knowing that they were an accessible resource was very important to the couples. CONCLUSION: ESD was experienced as a meaningful and adequate rehabilitation service that allowed patients and partners to collaboratively reinvent and rebuild their flow of everyday life by jointly adjusting routines, activities and their relationship.