Structural quality indicators to support quality of care for older people with cognitive impairment in emergency departments.

OBJECTIVES: The purpose of this study was to identify the structural quality of care domains and to establish a set of structural quality indicators (SQIs) for the assessment of care of older people with cognitive impairment in emergency departments (EDs). METHODS: A structured approach to SQI development was undertaken including: 1) a comprehensive search of peer-reviewed and gray literature focusing on identification of evidence-based interventions targeting structure of care of older patients with cognitive impairment and existing SQIs; 2) a consultative process engaging experts in the care of older people and epidemiologic methods (i.e., advisory panel) leading to development of a draft set of SQIs; 3) field testing of drafted SQIs in eight EDs, leading to refinement of the SQI set; and 4) an independent voting process among the panelists for SQI inclusion in a final set, using preestablished inclusion and exclusion criteria. RESULTS: At the conclusion of the process, five SQIs targeting the management of older ED patients with cognitive impairment were developed: 1) the ED has a policy outlining the management of older people with cognitive impairment during the ED episode of care; 2) the ED has a policy outlining issues relevant to carers of older people with cognitive impairment, encompassing the need to include the (family) carer in the ED episode of care; 3) the ED has a policy outlining the assessment and management of behavioral symptoms, with specific reference to older people with cognitive impairment; 4) the ED has a policy outlining delirium prevention strategies, including the assessment of patients' delirium risk factors; and 5) the ED has a policy outlining pain assessment and management for older people with cognitive impairment. CONCLUSIONS: This article presents a set of SQIs for the evaluation of performance in caring for older people with cognitive impairment in EDs.

Process quality indicators targeting cognitive impairment to support quality of care for older people with cognitive impairment in emergency departments.

OBJECTIVES: The objective of this study was to develop process quality indicators (PQIs) to support the improvement of care services for older people with cognitive impairment in emergency departments (ED). METHODS: A structured research approach was taken for the development of PQIs for the care of older people with cognitive impairment in EDs, including combining available evidence with expert opinion (phase 1), a field study (phase 2), and formal voting (phase 3). A systematic review of the literature identified ED processes targeting the specific care needs of older people with cognitive impairment. Existing relevant PQIs were also included. By integrating the scientific evidence and clinical expertise, new PQIs were drafted and, along with the existing PQIs, extensively discussed by an advisory panel. These indicators were field tested in eight hospitals using a cohort of older persons aged 70 years and older. After analysis of the field study data (indicator prevalence, variability across sites), in a second meeting, the advisory panel further defined the PQIs. The advisory panel formally voted for selection of those PQIs that were most appropriate for care evaluation. RESULTS: In addition to seven previously published PQIs relevant to the care of older persons, 15 new indicators were created. These 22 PQIs were then field tested. PQIs designed specifically for the older ED population with cognitive impairment were only scored for patients with identified cognitive impairment. Following formal voting, a total of 11 PQIs were included in the set. These PQIs targeted cognitive screening, delirium screening, delirium risk assessment, evaluation of acute change in mental status, delirium etiology, proxy notification, collateral history, involvement of a nominated support person, pain assessment, postdischarge follow-up, and ED length of stay. CONCLUSIONS: This article presents a set of PQIs for the evaluation of the care for older people with cognitive impairment in EDs. The variation in indicator triggering across different ED sites suggests that there are opportunities for quality improvement in care for this vulnerable group. Applied PQIs will identify an emergency services' implementation of care strategies for cognitively impaired older ED patients. Awareness of the PQI triggers at an ED level enables implementation of targeted interventions to improve any suboptimal processes of care. Further validation and utility of the indicators in a wider population is now indicated.

Potentially inappropriate prescribing in older patients discharged from acute care hospitals to residential aged care facilities.

BACKGROUND: The frequency of prescribing potentially inappropriate medications (PIMs) in older patients remains high despite evidence of adverse outcomes from their use. Little is known about whether admission to hospital has any effect on appropriateness of prescribing. OBJECTIVES: This study aimed to identify the prevalence and nature of PIMs and explore the association of risk factors for receiving a PIM. METHODS: This was a prospective study of 206 patients discharged to residential aged care facilities from acute care. All patients were at least 70 years old and were admitted between July 2005 and May 2010; their admission and discharge medications were evaluated. RESULTS: Mean patient age was 84.8±6.7 years; the majority (57%) were older than 85 years, and mean (SD) Frailty Index was 0.42 (0.15). At least 1 PIM was identified in 112 (54.4%) patients on admission and 102 (49.5%) patients on discharge. Of all medications prescribed at admission (1728), 10.8% were PIMs, and at discharge, of 1759 medications, 9.6% were PIMs. Of the total 187 PIMs on admission, 56 (30%) were stopped and 131 were continued; 32 new PIMs were introduced. Of the potential risk factors considered, in-hospital cognitive decline and frailty status were the only significant predictors of PIMs. CONCLUSIONS: Although admission to hospital is an opportunity to review the indications for specific medications, a high prevalence of inappropriate drug use was observed. The only associations with PIM use were the frailty status and in-hospital cognitive decline. Additional studies are needed to further evaluate this association.

Prospective observational study of dementia in older patients admitted to acute hospitals.

AIM: Few Australian studies have examined the impact of dementia on hospital outcomes. The aim of this study was to determine the relative contribution of dementia to adverse outcomes in older hospital patients. METHOD: Prospective observational cohort study (n = 493) of patients aged ≥70 years admitted to four acute hospitals in Queensland. Trained research nurses completed comprehensive geriatric assessments using standardised instruments and collected data regarding adverse outcomes. The diagnosis of dementia was established by independent physician review of patients' medical records and assessments. RESULTS: Patients with dementia (n = 102, 20.7%) were significantly older (P = 0.01), had poorer functional ability (P < 0.01), and were more likely to have delirium at admission (P < 0.01) than patients without dementia. Dementia (odds ratio = 4.8, P < 0.001) increased the risk of developing delirium during the hospital stay. CONCLUSION: Older patients with dementia are more impaired and vulnerable than patients without dementia and are at greater risk of adverse outcomes when hospitalised.

The distribution of health services for older people in Australia: where does transition care fit?

INTRODUCTION: The purpose of this study was to describe the distribution of hospital and aged care services for older people, with a particular focus on transition care places, across Australia and to determine the relationships between the provision of these services. METHODS: Aggregation of health and aged care service indicators by Aged Care Assessment Team (ACAT) region including: public and private acute and subacute (rehabilitation and geriatric evaluation and management) hospital beds, flexible and mainstream aged care places as at 30 June 2006. RESULTS: There was marked variation in the distribution of acute and subacute hospital beds among the 79 ACAT regions. Aged care places were more evenly distributed. However, the distribution of transition care places was uneven. Rural areas had poorer provision of all beds. There was no evidence of coordination in the allocation of hospital and aged care services between the Commonwealth and state/territory governments. There was a weak relationship between the allocation of transition care places and the distribution of health and aged care services. DISCUSSION: Overall, the distribution of services available to older persons is uneven across Australia. While the Transition Care Program is flexible and is providing rural communities with access to rehabilitation, it will not be adequate to address the increasing needs associated with the ageing of the Australian population. An integrated national plan for aged care and rehabilitation services should be considered.

The acute-aged care interface: exploring the dynamics of 'bed blocking'.

OBJECTIVE: To understand the dynamics underlying 'bed-blocking' in Australian public hospitals that is frequently blamed on older patients. METHODS: Analysis of primary and secondary data of utilisation patterns of hospital and aged care services by older Australians. RESULTS: A model of the dynamics at the acute-aged care interface was developed, in which the pathway into permanent high-care Residential Aged Care (RAC) is conceptualised as competing queues for available places by applicants from the hospital, the community and from within RAC facilities. The hospital effectively becomes a safety net to accommodate people with high-care needs who cannot be admitted into RAC in a timely manner. CONCLUSION: The model provides a useful tool to explore some of the issues that give rise to access-block within the public hospital system. Access-block cannot be understood by viewing the hospital system in isolation from other sectors that support the health and well-being of older Australians.

Transition care: will it deliver?

Transition care is a new program to Australia that is designed to facilitate transitions of frail older people between the hospital and aged care systems. This program is designed to deliver potentially important improvements to the Australian health care system--but will it deliver? The current evidence base regarding the efficacy of this type of program is mixed, and there is little evidence to indicate improved patient outcomes. An average transition care episode is expensive (about $11 000). Therefore, careful consideration of the relative cost-effectiveness compared with other interface programs such as inpatient subacute services is essential. Transition care services should be established within the context of overall regional plans for aged care, incorporating hospital acute and subacute inpatient services, and long-term community and residential care programs.

Standardizing assessment of elderly people in acute care: the interRAI Acute Care instrument.

OBJECTIVES: To examine the frequency distributions and interrater reliability of individual items of the interRAI Acute Care instrument. DESIGN: Observational study of a representative sample of older inpatients; duplicate assessments conducted on a subsample by independent assessors to examine interrater reliability. SETTING: Acute medical, acute geriatric and orthopedic units in 13 hospitals in nine countries. PARTICIPANTS: Five hundred thirty-three patients aged 70 and older (mean age 82.4, range 70-102) with an anticipated stay of 48 hours or longer of whom 161 received duplicate assessments. MEASUREMENTS: Sixty-two clinical items across 11 domains. Premorbid (3-day observation period before onset of the acute illness) and admission (the first 24 hours of hospital stay) assessments were conducted. RESULTS: The frequency of deficits exceeded 30% for most items, ranging from 1% for physically abusive behavior to 86% for the need for support in activities of daily living after discharge. Common deficits were in cognitive skills for daily decision-making (38% premorbid, 54% at admission), personal hygiene (37%, 65%), and walking (39%, 71%). Interrater reliability was substantial in the premorbid period (average kappa=0.61) and admission period (average kappa=0.66). Of the 69 items tested, less than moderate agreement (kappa<0.4) was recorded for six (9%), moderate agreement (kappa=0.41-0.6) for 14 (20%), substantial agreement (kappa=0.61-0.8) for 40 (58%), and almost perfect agreement (kappa>0.8) for nine (13%). CONCLUSION: Initial assessment of the psychometric properties of the interRAI Acute Care instrument provided evidence that item selection and interrater reliability are appropriate for clinical application. Further studies are required to examine the validity of embedded scales, diagnostic algorithms, and clinical protocols.

Health assessment of elderly patients.

BACKGROUND: Comprehensive health assessment of the elderly in primary care will become a more important element of general practice as population aging proceeds and evidence of efficacy emerges. OBJECTIVE: This article describes approaches to provision of health assessment in primary care based on the best available evidence. DISCUSSION: Current best practice includes the use of structured health assessment protocols, an integrated multidisciplinary approach, targeting patient groups with intermediate levels of disability and handicap, in-home assessments and carefully structured follow up mechanisms.

Trends in the use of hospital beds by older people in Australia: 1993-2002.

OBJECTIVE: To determine trends in use of Australian acute hospital inpatient services by older patients. DESIGN AND DATA SOURCES: Secondary analysis of hospital data from the Australian Institute of Health and Welfare in the period 1993-94 to 2001-02, with population data for this period from the Australian Bureau of Statistics. OUTCOME MEASURES: Population-based rates of hospital separations and bed utilisation. RESULTS: The Australian aged population (65 years and older) increased by 18% compared with total population growth of 10%, yet the proportion of hospital beds occupied by older patients remained stable at 47%. The most substantial changes were observed in the population aged 75 years and older, with separations increasing by 89%, length of stay reducing by 35% and bed utilisation increasing by 23%. However, rates of bed utilisation (in relation to population) declined among older groups (10% decline in per capita use in population 75 years and older), but increased in the younger population (1% increase in per capita use in people younger than 65 years). CONCLUSION: Important trends in use of inpatient services were identified in this study. These trends are contrary to common perception. Ageing of the Australian population was not associated with an increase in the proportion of hospital beds used by older patients.

Effectiveness of case management and post-acute services in older people after hospital discharge.

OBJECTIVE: To evaluate the benefits of coordinating community services through the Post-Acute Care (PAC) program in older patients after discharge from hospital. DESIGN: Prospective multicentre, randomised controlled trial with six months of follow-up with blinded outcome measurement. SETTING: Four university-affiliated metropolitan general hospitals in Victoria. PARTICIPANTS: All patients aged 65 years and over who were discharged between August 1998 and October 1999 and required community services after discharge. INTERVENTIONS: Participants were randomly allocated to receive services of a Post-Acute Care (PAC) coordinator (intervention) versus usual discharge planning (control). MAIN OUTCOME MEASURES: Comparison of quality of life and carer stress at one-month post-discharge, mortality, hospital readmissions, use of community services and community and hospital costs over the six months post-discharge. RESULTS: 654 patients were randomised, and 598 were included in the analysis (311 in the PAC group and 287 in the control group). There was no difference in mortality between the groups (both 6%), but significantly greater overall quality-of-life scores at one-month follow-up in the PAC group. There was no difference in unplanned readmissions, but PAC patients used significantly fewer hospital bed-days in the six months after discharge (mean, 3.0 days; 95% CI, 2.1-3.9) than control patients (5.2 days; 95% CI, 3.8-6.7). Total costs (including hospitalisation, community services and the intervention) were lower in the PAC than the control group (mean difference, $1545; 95% CI, $11-$3078). CONCLUSIONS: The PAC program is beneficial in the transition from hospital to the community in older patients.

Quality of life assessment in the community-dwelling elderly: validation of the Assessment of Quality of Life (AQoL) Instrument and comparison with the SF-36.

Measurement of Health-Related Quality of Life (HRQoL) of the elderly requires instruments with demonstrated sensitivity, reliability, and validity, particularly with the increasing proportion of older people entering the health care system. This article reports the psychometric properties of the 12-item Assessment of Quality of Life (AQoL) instrument in chronically ill community-dwelling elderly people with an 18-month follow-up. Comparator instruments included the SF-36 and the OARS. Construct validity of the AQoL was strong when examined via factor analysis and convergent and divergent validity against other scales. Receiver Operator Characteristic (ROC) curve analyses and relative efficiency estimates indicated the AQoL is sensitive, responsive, and had the strongest predicative validity for nursing home entry. It was also sensitive to economic prediction over the follow-up. Given these robust psychometric properties and the brevity of the scale, AQoL appears to be a suitable instrument for epidemiologic studies where HRQoL and utility data are required from elderly populations.