Nonoperative versus operative management of frail institutionalized older patients with a proximal femoral fracture: a cost-utility analysis alongside a multicenter prospective cohort study.

Hip fractures are associated with significant healthcare costs. In frail institutionalized patients, the costs of nonoperative management are less than operative management with comparable short-term quality of life. Nonoperative management of hip fractures in patients at the end of life should be openly discussed with SDM. PURPOSE: The aim was to describe healthcare use with associated costs and to determine cost-utility of nonoperative management (NOM) versus operative management (OM) of frail institutionalized older patients with a proximal femoral fracture. METHODS: This study included institutionalized patients with a limited life expectancy aged ≥ 70 years who sustained a proximal femoral fracture in the Netherlands. Costs of hospital- and nursing home care were calculated. Quality adjusted life years (QALY) were calculated based on EuroQol-5D-5L utility scores at day 7, 14, and 30 and at 3 and 6 months. The incremental cost-effectiveness ratio (ICER) was calculated from a societal perspective. RESULTS: Of the 172 enrolled patients, 88 (51%) patients opted for NOM and 84 (49%) for OM. NOM was associated with lower healthcare costs at 6 months (NOM; €2425 (SD 1.030), OM; €9325 (SD 4242), p < 0.001). The main cost driver was hospital stay (NOM; €738 (SD 841) and OM; €3140 (SD 2636)). The ICER per QALY gained in the OM versus NOM was €76,912 and exceeded the threshold of €20,000 per QALY. The gained QALY were minimal in the OM group in patients who died within 14- and 30-day post-injury, but OM resulted in more than triple the costs. CONCLUSION: OM results in significant higher healthcare costs, mainly due to the length of hospital stay. For frail patients at the end of life, NOM of proximal femoral fractures should be openly discussed in SDM conversations due to the limited gain in QoL. TRIAL REGISTRATION: Netherlands Trial Register (NTR7245; date 10-06-2018).

Pan-European Study on Functional and Medical Recovery and Geriatric Rehabilitation Services of Post-COVID-19 Patients: Protocol of the EU-COGER Study.

OBJECTIVES: There is insufficient knowledge about the functional and medical recovery of older people infected with SARS-CoV-2. This study aims to gain insight into the course of functional and medical recovery of persons who receive geriatric rehabilitation (GR) following SARS-CoV-2 infection across Europe. Special attention will be paid to the recovery of activities of daily living (ADL) and to the GR services offered to these patients. DESIGN: A multi-center observational cohort study. SETTING AND PARTICIPANTS: This study will include several European countries (EuGMS member states) each providing at least 52 comparable routine datasets (core dataset) of persons recovering from a SARS-CoV-2 infection and receiving geriatric rehabilitation. The routine data will be anonymously collected in an online CASTOR database. The ethical regulations of each participating country will be followed. PRIMARY OUTCOME: ADL functioning. SECONDARY OUTCOMES: length of stay, discharge destination, hospital readmission and mortality. Other variables that will be collected are quality of life, treatment modalities, complications, cognition, frailty, mood/anxiety, BMI, nutrition and pain. All variables will be reported at admission and compared with follow-up scores (discharge, 6 weeks and 6 months follow-up). CONCLUSION: This study will explore the effect of geriatric rehabilitation on post-COVID-19 patients, especially on ADL recovery, and the variety of geriatric rehabilitation services across Europe. Information from this study may help improve recovery of older persons infected with SARS-CoV-2 and improve geriatric rehabilitation services in the ongoing COVID-19 pandemic.

[Geriatric rehabilitation care: Doing the right things right]. / Geriatrische Revalidatiezorg: De juiste dingen goed doen.

BACKGROUND: Geriatric rehabilitation concerns short-term integrated multidisciplinary care aimed at functional recovery and social participation for relatively frail elderly. Given the geriatric clients' complex care issues, nurses should possess sufficient and appropriate competencies in order to identify and assess the relevant symptoms and intervene effectively. Yet, nurses experience a certain apprehensiveness to perform their tasks and express difficulties in multidisciplinary communication and collaboration in a constructive manner. In addition to the client's and informal care giver's perception of their input in the geriatric rehabilitation process, this study provides an in-depth understanding of the way nurses perceive their role in geriatric rehabilitation. METHODS/DESIGN: This descriptive study entails a quantitative and a qualitative component. The quantitative component concerns questionnaires for clients, informal care givers, nurses, and team leaders. The qualitative component aims to obtain in-depth information (i. e. opinions, meanings, and reflections) with regard to the decision making process and the performance of the rehabilitation care by means of open-ended questions (in the questionnaire) and semi-structured interviews. RESULTS: Clients and informal care givers rate specific themes in geriatric rehabilitation in a more negative light than nurses and team leaders do. These themes concern the provision of information in the hospital (prior to admission in the rehabilitation facility), involvement in the draw-up of the treatment plan and rehabilitation goals, geriatric rehabilitation as a 24/7 activity, and taking into account the client's other life events. The latter three findings in particular, are caused by nurses' apprehensiveness to perform their tasks adequately. DISCUSSION: Nurses working in geriatric rehabilitation, experience apprehensiveness to perform their tasks adequately. Uncertainty about the client's reaction or fear of damaging the relationship of trust, results in nurses not involving the clients and informal care givers in the draw-up of the rehabilitation goals. Apprehensiveness also submerges as the lack of experience or specific competences in considering the client's other life events. The recommendations address these aspects in particular.

Structured scoring of supporting nursing tasks to enhance early discharge in geriatric rehabilitation: The BACK-HOME quasi-experimental study.

INTRODUCTION: In geriatric rehabilitation it is important to have timely discharge of patients, especially if they have low nursing support needs. However, no instruments are available to identify early discharge potential. OBJECTIVE: To evaluate if weekly scoring of a nursing support scorecard in the evenings/nights and discussing the results in the multidisciplinary team meeting, leads to potential differences in discharge of geriatric rehabilitation patients. DESIGN: Quasi-experimental study with a reference cohort (n=200) and a Back-Home implementation cohort (n=283). SETTING/PARTICIPANTS: Patients in geriatric rehabilitation in the four participating skilled nursing facilities in the Netherlands. METHODS: Implementation of the nursing support scorecard during one year consisted of (1) weekly scoring of the scorecard to identify the supporting nursing tasks during the evenings/nights by trained nurses, and (2) discussion of the results in a multidisciplinary team meeting to establish if discharge home planning was feasible. Data on patients' characteristics and setting before admission were collected at admission; at discharge, the length of stay, discharge destination and barriers for discharge were collected by the nursing staff. RESULTS: Both cohorts were comparable with regard to median age, gender [reference cohort: 81 (IQR 75-88) years; 66% females vs. Back-Home cohort 82 (IQR 76-87) years; 71% females] and reasons for admission: stroke (23% vs. 23%), joint replacement (12% vs. 13%), traumatic injuries (31% vs. 34%), and other (35% vs. 30%). Overall, the median length of stay for the participants discharged home in the reference cohort was 56 (IQR 29-81) days compared to 46 (IQR 30-96) days in the Back-Home cohort (p=0.08). When no home adjustments were needed, participants were discharged home after 50 (IQR 29.5-97) days in the reference cohort, and after 42.5 (IQR 26-64.8) days in the Back-Home cohort (p=0.03). Reasons for discharge delay were environmental factors (36.7%) and patient-related factors, such as mental (21.5%) and physical capacity (33.9%). CONCLUSION: Structured scoring of supporting nursing tasks for geriatric rehabilitation patients may lead to earlier discharge from a skilled nursing facility to home, if no home adjustments are needed.

Medical services for older people in nursing homes--comparing services in England and the Netherlands.

As Europe faces an ageing population with increasing pressure on long term care, it is important for different systems to be compared and contrasted for the benefit of all. We compare long term care in the Netherlands to England, by examining the different care models, in terms of patient outcomes, quality of care, continuity of care and funding.

[There is no natural death without suffering, even in a nursing home]. / Geen natuurlijk overlijden zonder lijden, ook in het verpleeghuis.

During the past 30 years, the legal and moral framework for terminal care and hospice provision has changed, both nationally and internationally, but the situation is still not completely clear. The nursing homes in the Netherlands have also developed, described and implemented palliative care. In most regional systems for palliative care, a supportive and sometimes an active therapeutic role is played by medical, nursing, paramedical and pastoral nursing home professionals. In view of the strong relationship between a poor or worsening nutritional state and fluid balance and death, particularly of psychogeriatric nursing-home patients, a multiprofessional guideline has been drawn up for the responsible provision of food and fluids in nursing homes. It is likely, although not certain, that this guideline will contribute to the limitation of the suffering of the dying patient. The guideline will in any case make the compassion of the family and the sympathy of care-givers discussible and almost always manageable. In many nursing homes, meanwhile, it has become accepted practice, soon after admission, to discuss the future suffering of the patient during the process of dying and to record this conversation.

Hip fracture in elderly patients: outcomes for function, quality of life, and type of residence.

A prospective study was done to investigate functional outcome, quality of life, and type of residence after hip fracture in patients 65 years of age and older. One hundred two patients admitted consecutively to a university and a general hospital were followed up as long as 4 months after admission. The mean age of the participants was 83 years; 58% of patients came from their own home, and 42 % of patients came from institutions. Nearly 70% of patients had two or more diagnoses other than the hip fracture. Cumulative mortality was 20% at 4 months after fracture. Of surviving patients, 57% were back in their original situation for accommodation, 43% reached the same level of walking ability, and 17% achieved the same level of activities of daily living as before fracture. Patients experienced on average three complications, 26% of which were severe. Quality of life improved in the followup period of 4 months; however, the quality of life at 4 months was worse than the quality of life reported in a reference population. Average costs amounted to euro (Euro) 15.338 (which at the time was nearly equivalent to the US dollar) per patient, with nearly 50% of the costs attributable to hospital costs and 30% attributable to nursing home costs. The results of this study show a poor outcome after hip fracture in elderly patients.

Using a personal digital assistant to document clinical pharmacy services in an intensive care unit.

Management Case Studies describe approaches to real-life management problems in health systems. Each installment is a brief description of a problem and how it was dealt with. The cases are intended to help readers deal with similar experiences in their own work sites. Problem solving, not hypothesis testing, is emphasized. Successful resolution of the management issue is not a criterion for publication--important lessons can be learned from failures, too.

Cost-effectiveness analysis of enoxaparin versus unfractionated heparin for acute coronary syndromes. A Canadian hospital perspective.

OBJECTIVE: To determine the cost effectiveness of enoxaparin therapy versus unfractionated heparin (UFH) therapy for patients with unstable coronary artery disease from the perspective of a Canadian hospital. DESIGN: A predictive decision analysis model using published clinical and economic evaluations and costs of medical care in Canada. PATIENTS: A hypothetical cohort of patients presenting to hospital with unstable angina or non-Q-wave myocardial infarction as defined by the Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events (ESSENCE) trial. INTERVENTIONS: Two antithrombotic treatment strategies were compared: (i) enoxaparin 1 mg/kg subcutaneously every 12 hours, and (ii) UFH intravenous bolus and constant infusion adjusted to maintain a therapeutic activated partial thromboplastin time. Both treatment strategies included 100 to 325 mg of oral aspirin daily. Enoxaparin or UFH was continued for a minimum of 48 hours to a maximum of 8 days. Cumulative outcomes were considered up to 30 days after initial presentation to hospital. RESULTS: At 30 days, 19.8% of patients who received enoxaparin compared with 23.3% of patients who received UFH reached one of the primary composite events. There was no difference in major bleeding between the 2 treatment groups (6.5% enoxaparin vs 6.8% UFH). The average total direct medical cost per patient was $Can848 with the enoxaparin strategy versus $Can892 with the UFH strategy (1999 values). Therapy with enoxaparin was, therefore, considered to be the dominant strategy. Univariate sensitivity analysis indicated that the decision model was not robust to changes in the 30-day composite end-point, probability of recurrent angina, or base costs for treatment of recurrent angina or enoxaparin therapy. CONCLUSION: Enoxaparin is the dominant antithrombotic pharmacotherapeutic strategy for patients with unstable coronary artery disease.

Valproic acid for seizure prophylaxis during clozapine therapy: Where's the evidence?

Clozapine, a dibenzodiazepine derivative, is the prototype atypical antipsychotic indicated for treatment-resistant patients with schizophrenia. Although considered by many to be the most effective antipsychotic, its clinical use has been hindered by some serious adverse reactions, one of the more serious of which is seizures. In response to this inherent risk of clozapine-induced seizures, some clinicians have been advocating the use of prophylactic valproic acid treatment. This article reviews the available literature to assess the evidence to support this practice.

An activity week for children with cancer: who wants to go and why?

Many children now live with cancer rather than die from it, and such children need both to continue their social, emotional and cognitive development and to make long-term psychological adjustments. This paper presents the findings of a research project set up to explore issues pertinent to the current provision of an activity week experience for a group of British paediatric cancer patients. The aims of the study included finding out which factors discriminate between families who apply for a place to attend the week for their child and families who do not, and to develop a knowledge of what factors are considered by parents and children. The findings suggest that the week appeals to children who are confident, active and able to separate from parents and whose parents are keen to encourage independence and new experiences. Children diagnosed and treated at a younger age and further away from treatment were more likely to express concerns about being homesick and safety and to not apply for the week. Issues of protection, independence and disability are discussed with reference to the importance of parental attitude on children's psychological accommodation to disease and treatment and to the experiences of adult survivors of childhood cancer.