Prevalence of factors contributing to unplanned hospital readmission of older medical patients when assessed by patients, their significant others and healthcare professionals: a cross-sectional survey.

OBJECTIVE: To describe the prevalence of factors contributing to readmission of older medical patients perceived by patients, significant others and healthcare professionals and to examine the agreement of factors contributing to readmission. METHODS: This cross-sectional survey was conducted at Horsens Regional Hospital from September 2020 to June 2021. Patients aged ≥ 65 years and who were readmitted within 30 days were included. The questionnaire covered eight themes: disease; diagnosing, treatment and care; network; organisation; communication; skills and knowledge; resources; and practical arrangements. Response groups were patients, significant others, GPs, district nurses and hospital physicians. Outcomes were the prevalence of factors contributing to 30-day readmission and inter-rater agreement between respondents. RESULTS: In total, 165 patients, 147 significant others, 115 GPs, 75 district nurses and 165 hospital physicians were included. The patients' median age was 79 years (IQR 74-85), and 44% were women. The following were the most prevalent contributing factors: (1) relapse of the condition that caused the index admission, (2) the patient could not manage the symptoms or illness, (3) worsening of other illnesses or conditions, (4) the patient was not fully treated at the time of discharge and (5) the patient's situation was too complex for the medical practice to handle. Kappas ranged from 0.0142 to 0.2421 for patient-significant other dyads and 0.0032 to 0.2459 for GP-hospital physician dyads. CONCLUSION: From the perspectives of the included respondents, factors associated with the disease and its management were the most prevalent contributors to readmission for older medical patients. Agreement on the contributing factors was generally low. TRIAL REGISTRATION: Clinical trial number NCT05116644. Registration date October 27, 2021.

Effects of a transitional care intervention on readmission among older medical inpatients: a quasi-experimental study.

PURPOSE: To evaluate the effect of a transitional care intervention (TCI) on readmission among older medical inpatients. METHODS: This non-randomised quasi-experimental study was conducted at Horsens Regional Hospital in Denmark from 1 February 2017 to 31 December 2018. Inclusion criteria were patients ≥ 75 years old admitted for at least 48 h. First, patients were screened for eligibility. Then, the allocation to the intervention or control group was performed according to the municipality of residence. Patients living in three municipalities were offered the hospital-based intervention, and patients living in a fourth municipality were allocated to the control group. The intervention components were (1) discharge transportation with a home visit, (2) a post-discharge cross-sectorial video conference and (3) seven-day telephone consultation. The primary outcome was 30-day unplanned readmission. Secondary outcomes were 30- and 90-day mortality and days alive and out of hospital (DAOH). RESULTS: The study included 1205 patients (intervention: n = 615; usual care: n = 590). In the intervention group, the median age was 84.3 years and 53.7% were females. In the control group, the median age was 84.9 years and 57.5% were females. The 30-day readmission rates were 20.8% in the intervention group and 20.2% in the control group. Adjusted relative risk was 1.00 (95% confidence interval: 0.80, 1.26; p = 0.99). No significant difference was found between the groups for the secondary outcomes. CONCLUSION: The TCI did not impact readmission, mortality or DAOH. Future research should conduct a pilot test, address intervention fidelity and consider real-world challenges. TRIAL REGISTRATION: Clinical trial number: NCT04796701. Registration date: 24 February 2021.

Impact of transitional care interventions on hospital readmissions in older medical patients: a systematic review.

OBJECTIVES: To identify and synthesise available evidence on the impact of transitional care interventions with both predischarge and postdischarge elements on readmission rates in older medical patients. DESIGN: A systematic review. METHOD: Inclusion criteria were: medical patients ≥65 years or mean age in study population of ≥75 years; interventions were transitional care interventions between hospital and home with both predischarge and postdischarge components; outcome was hospital readmissions. Studies were excluded if they: included other patient groups than medical patients, included patients with only one diagnosis or patients with only psychiatric disorders. PubMed, The Cochrane Library, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Web of Science were searched from January 2008 to August 2019. Study selection at title level was undertaken by one author; the remaining selection process, data extraction and methodological quality assessment were undertaken by two authors independently. A narrative synthesis was performed, and effect sizes were estimated. RESULT: We identified 1951 records and included 11 studies: five randomised trials, four non-randomised controlled trials and two pre-post cohort studies. The 11 studies represent 15 different interventions and 29 outcome results measuring readmission rates within 7-182 days after discharge. Twenty-two of the 29 outcome results showed a drop in readmission rates in the intervention groups compared with the control groups. The most significant impact was seen when interventions were of high intensity, lasted at least 1 month and targeted patients at risk. The methodological quality of the included studies was generally poor. CONCLUSION: Transitional care interventions reduce readmission rates among older medical patients although the impact varies at different times of outcome assessment. High-quality studies examining the impact of interventions are needed, preferably complimented by a process evaluation to refine and improve future interventions. PROSPERO REGISTRATION NUMBER: CRD42019121795.

Avoidable readmissions seem to be reduced by early follow-up visits for geriatric patients discharged from hospital.

PURPOSE: The aim of this study was to look specifically at patients readmitted in our previously published study. We wanted to assess the percentage of avoidable readmissions among patients receiving an early geriatric follow-up visit compared to a control group receiving usual care. METHOD: The original population was geriatric patients primarily admitted to hospital with one of nine medical diagnoses and included in a quasi randomized controlled trial. They received either an early geriatric follow-up visit or usual care after hospital discharge. Only patients with an unplanned readmission were included in this subgroup analysis. Medical records of the readmitted patients were assessed by two reviewers. Each readmission was classified as either avoidable or unavoidable. An avoidable readmission was defined as being clinically related to index admissions. RESULTS: Between June 2014 and November 2015, 2076 patients were included in the original study. Of these, 216 patients were readmitted. Almost half of avoidable readmissions happened during the first week after hospital discharge. Thirty-four (41%) of 83 readmissions in the intervention group were assessed as avoidable compared to 72 (54%) of 133 readmissions in the control group (p = 0.06). CONCLUSION: An early follow-up visit after hospital discharge seems to reduce avoidable readmissions among geriatric patients.

Early geriatric follow-up visits to nursing home residents reduce the number of readmissions: a quasi-randomised controlled trial.

INTRODUCTION: Nursing home residents have a high risk of being readmitted after hospitalisation. The objective of this study is to test whether an early geriatric follow-up visit can reduce readmissions among nursing home residents without increasing mortality. The main components of the intervention will also be quantified. MATERIALS AND METHOD: A quasi-randomised controlled design. A population of nursing-home residents aged 75 years or older admitted to hospital with one of nine medical diagnoses. All patients received comprehensive geriatric assessment before discharge. The intervention comprised a visit by a nurse and a doctor from a geriatric team the first weekday after discharge. Control group patients were offered a follow-up visit by their general practitioner 7-14 days after discharge. RESULTS: Six hundred and forty-eight patients were included in the study between June 1st 2014 and December 15th 2016. In the intervention group, 13% were readmitted within 30 days after discharge, compared to 19% in the control group (p = 0.04). Adjusted hazard ratio = 0.63 (95% CI 0.42-0.95). The median length of hospital stay was 1 day for both groups. Neither 30 nor 90-day mortality were affected by the intervention. The most commonly registered intervention element was direct person-to-person contact between hospital and nursing home staff or relatives, followed by changes in medication and blood tests. CONCLUSION: Early geriatric follow-up visits to recently discharged nursing home residents are a safe and effective way of reducing readmissions. Communication, changes in medication, and blood tests were the most frequently performed elements.

Correlation between the use of 'over-the-counter' medicines and adherence in elderly patients on multiple medications.

BACKGROUND: Medication adherence is a multifaceted issue that is influenced by various factors. One factor may be the concurrent use of over-the-counter (OTC)medicines. The use of OTC medicine has been reported as common amongst elderly patients. OBJECTIVE: To determine if a correlation exists between the use of OTC medicines and adherence to prescribed medications in elderly patients. SETTING: Non-institutionalised elderly patients in Denmark. METHODS: Elderly unassisted patients aged ≥65 prescribed five or more prescription drugs were included in the study. Information on the use of concurrent OTC medications (herbal medicines, dietary supplements, or non-prescribed drugs) was elicited during home visit interviews. Prescription drug adherence was determined by pill counts. A patient was categorised as non-adherent if the me an adherence rate for all drugs consumed was\80 %. Different sensitivity analyses were made where adherence was defined different. MAIN OUTCOME MEASURE: Medication adherence based on pill-count. RESULTS: A total of 253 participants included 72 % who used OTC medicines and 11 % who did not adhere to their prescriptions. Users of OTC medicines, however, were significantly more likely to be adherent than were non-users (odds ratio 0.41; 95 %confidence interval 0.18­0.91). Sensitivity analyses where adherence was defined different show no relationship between adherence and use of OTC medicine. Furthermore,separate analyses of herbal medicines, dietary supplements,or non-prescribed drugs did not correlate with adherence to prescriptions. CONCLUSION: Amongst elderly patients on multiple medications a positive relationship was found between the overall use of OTC medicines and adherence to prescription drugs, in contrast to none when adherence were defined different or herbal medicines, dietary supplements, or non-prescribed drugs were analysed separately.

Impact of pharmaceutical care on adherence, hospitalisations and mortality in elderly patients.

BACKGROUND: Elderly polypharmacy patients may be more at risk of not adhering to medication. If so, the underlying reasons may be more readily disclosed during private discussions with patients. Hence pharmaceutical care discussions at home might improve treatment adherence. OBJECTIVE: The aim of this study was to investigate the impact of pharmaceutical care on medication adherence, hospitalisation and mortality in elderly patients prescribed polypharmacy. SETTING: Pharmaceutical care discussed at home. METHODS: A randomised controlled trial with two arms; pharmaceutical care (n = 315) and controls (n = 315) was designed. It involved patients aged 65+ years living in Aarhus, Denmark who used five drugs or more without assistance. Pharmacists visited the pharmaceuticalcare patients at home, once only, and followed them during the subsequent year with three telephone calls. Non-adherence was measured by a pill-count. Patients were categorised as non-adherent if their mean adherence rate for all drugs consumed was <80 %. The impact of pharmaceutical care on non-adherence and hospitalisation was analysed by 2 × 2 tables, and mortality by Cox regression. MAIN OUTCOME MEASURE: Medication adherence, hospitalisation and mortality. RESULTS: The final analyses included 517 patients (median age 74 years; females 52 %). Dropouts were more frequent for the pharmaceutical-care group than for controls. Pharmacists encountered drug-related problems amongst 72 % of pharmaceutical-care patients. Pharmaceutical-care patients (11 %) and control patients (10 %) were similarly nonadherent (Odds ratio 1.14; 95 % confidence interval 0.65-2.00), and similar with respect to hospitalisation frequency (30 vs. 28 %; Odds ratio 1.14; 95 % confidence interval 0.78-1.67) and mortality (7.5 vs. 5 %; Hazard ratio 1.41; 95 % confidence interval 0.71-2.82). CONCLUSIONS: Pharmaceutical care given to our elderly polypharmacy patients made no significant impact on medication adherence, hospitalisation or mortality, when compared to comparable control patients.

Correlation between the use of 'over-the-counter' medicines and adherence in elderly patients on multiple medications.

Background Medication adherence is a multifaceted issue that is influenced by various factors. One factor may be the concurrent use of over-the-counter (OTC) medicines. The use of OTC medicine has been reported as common amongst elderly patients. Objective To determine if a correlation exists between the use of OTC medicines and adherence to prescribed medications in elderly patients. Setting Non-institutionalised elderly patients in Denmark. Methods Elderly unassisted patients aged ≥65 prescribed five or more prescription drugs were included in the study. Information on the use of concurrent OTC medications (herbal medicines, dietary supplements, or non-prescribed drugs) was elicited during home visit interviews. Prescription drug adherence was determined by pill counts. A patient was categorised as non-adherent if the mean adherence rate for all drugs consumed was <80 %. Different sensitivity analyses were made where adherence was defined different. Main outcome measure Medication adherence based on pill-count. Results A total of 253 participants included 72 % who used OTC medicines and 11 % who did not adhere to their prescriptions. Users of OTC medicines, however, were significantly more likely to be adherent than were non-users (odds ratio 0.41; 95 % confidence interval 0.18-0.91). Sensitivity analyses where adherence was defined different show no relationship between adherence and use of OTC medicine. Furthermore, separate analyses of herbal medicines, dietary supplements, or non-prescribed drugs did not correlate with adherence to prescriptions. Conclusion Amongst elderly patients on multiple medications a positive relationship was found between the overall use of OTC medicines and adherence to prescription drugs, in contrast to none when adherence were defined different or herbal medicines, dietary supplements, or non-prescribed drugs were analysed separately.

Generic substitution does not seem to affect adherence negatively in elderly polypharmacy patients.

PURPOSE: To investigate the association between generic substitutions and medication adherence in elderly patients with prescribed polypharmacy. METHODS: Our study included 672 patients aged 65+ years, living at home in the municipality of Aarhus (Denmark), who at the time of enrolment took at least five prescription drugs daily including both short-term and long-term treatment independently of kind of administration route but without assistance. In this paper, only oral drugs for long-term treatment are included in the analysis resulting in median of three drugs per patient. Adherence was assessed by pill counts. Patients with a mean adherence rate <80% across all oral drugs consumed for long-term treatment were categorised as non-adherent. The number of generic substitutions during 1 year was retrieved from the National Health Insurance prescription database. Each change in either a drug's or a manufacturer's name was regarded as a substitution. The association between generic substitution and the mean adherence rate to all drugs was analysed by contingency table analyses and a trend test. RESULTS: During 1 year, at least one substitution was experienced by 83.6% of patients (n = 562). Patients non-adherent to long-term oral treatment (n = 46) amounted to 8% of all patients who experienced substitutions. Amongst 110 elderly patients (16.4%) who did not experience substitutions, 16% were non-adherent (odds ratio 0.46; 95% confidence interval 0.25-0.82). CONCLUSION: As generic substitution in elderly patients undergoing polypharmacy appears not to affect adherence to long-term drug treatment negatively, there seems to be no obvious reason for avoiding generic substitution in such patients.

Suitability of an electronic reminder device for measuring drug adherence in elderly patients with complex medication.

We evaluated an electronic reminder device for detecting non-adherence in elderly patients with complex medication regimens. Randomly selected, home-living elderly patients were studied. The patients were aged over 65 years and were taking more than four drugs. Patients received an electronic reminder device which contained a GSM communications module. They were visited three times over a one-year period by a nurse who counted their medicine supply. We compared the adherence measured by the electronic device with the actual adherence measured by the pill count. Almost half of the 315 patients dropped out of the study for various reasons, so the calculations were performed on 168 patients. The adherence measured by the electronic reminder system was 79% and was 92% measured by pill count (P<0.0001). The limits of agreement estimated by a Bland-Altman analysis were -57 to +30. We also compared electronically measured adherence at morning/evening intake times with pill count adherence in the morning/evening only. For the pill count, there was almost no difference between morning and evening adherence rates (93%). For electronic measurement, adherence rates were lower in the evening (75%) than in the morning (81%). Electronic reminders were less reliable than the pill count in measuring adherence. However, the electronic system may be a useful supplement to other, more time consuming methods for measuring adherence.