Outpatient Interventions for Managing Acute Complications of Chronic Diseases: A Scoping Review and Implications for Patients With CKD.

RATIONALE & OBJECTIVE: Patients with chronic kidney disease (CKD) have high rates of emergency department (ED) use and hospitalization. Outpatient care may provide an alternative to ED and inpatient care in this population. We aimed to explore the scope of outpatient interventions used to manage acute complications of chronic diseases and highlight opportunities to adapt and test interventions in the CKD population. STUDY DESIGN: Scoping review of quantitative and qualitative studies. SETTING & POPULATION: Outpatient interventions for adults experiencing acute complications related to 1 of 5 eligible chronic diseases (ie, CKD, chronic respiratory disease, cardiovascular disease, cancer, and diabetes). SELECTION CRITERIA FOR STUDIES: MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, grey literature, and conference abstracts were searched to December 2019. DATA EXTRACTION: Intervention and study characteristics were extracted using standardized tools. ANALYTICAL APPROACH: Quantitative data were summarized descriptively; qualitative data were summarized thematically. Our approach observed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) extension for scoping reviews. RESULTS: 77 studies (25 randomized controlled trials, 29 observational, 12 uncontrolled before-after, 5 quasi-experimental, 4 qualitative, and 2 mixed method) describing 57 unique interventions were included. Of identified intervention types (hospital at home [n = 16], observation unit [n = 9], ED-based specialist service [n = 4], ambulatory program [n = 18], and telemonitoring [n = 10]), most were studied in chronic respiratory and cardiovascular disease populations. None targeted the CKD population. Interventions were delivered in the home, ED, hospital, and ambulatory setting by a variety of health care providers. Cost savings were demonstrated for most interventions, although improvements in other outcome domains were not consistently observed. LIMITATIONS: Heterogeneity of included studies; lack of data for outpatient interventions for acute complications related to CKD. CONCLUSIONS: Several interventions for outpatient management of acute complications of chronic disease were identified. Although none was specific to the CKD population, features could be adapted and tested to address the complex acute-care needs of patients with CKD.

Keeping Long-Term Care Patients Out of Hospital During Acute Medical Illness: Proposal for Common Elements of an Integrated Healthcare Delivery System for Long-Term Care.

Integration of acute and palliative care services for long-term care (LTC) residents reduces the morbidity and mortality associated with avoidable hospitalizations while contributing to healthcare system sustainability. This paper explores patient, provider and system factors contributing to potentially avoidable emergency room visits from LTC homes, based on our clinical and quality improvement work in the Greater Toronto Area and Calgary, as well as reviews the existing literature. Commonalities are used to identify key elements for developing an integrated healthcare delivery system to manage acute medical changes in LTC residents and minimize the need for in-patient hospitalization.

Goals of care discussions among hospitalized long-term care residents: Predictors and associated outcomes of care.

INTRODUCTION: There are limited data on the occurrence, predictors, and impact of goals of care (GOC) discussions during hospitalization for seriously ill elderly patients, particularly for long-term care (LTC) residents. METHODS: The study was a retrospective chart review of 200 randomly sampled LTC residents hospitalized via the emergency department and admitted to the general internal medicine service of 2 Canadian academic hospitals, from January 2012 through December 2012. We applied logistic regression models to identify factors associated with, and outcomes of, these discussions. RESULTS: Overall, 9.4% (665 of 7084) of hospitalizations were patients from LTC. In the sample of 200 patients, 37.5% had a documented discussion. No baseline patient characteristic was associated with GOC discussions. Low Glasgow Coma Scale, high respiratory rate, and low oxygen saturation were associated with discussions. Patients with discussions had higher rates of orders for no resuscitation (80% vs 55%) and orders for comfort measures only (7% vs 0%). In adjusted analyses, patients with discussions had higher odds of in-hospital death (52.0, 95% confidence interval [CI]: 6.2-440.4) and 1-year mortality (4.1, 95% CI: 1.7-9.6). Nearly 75% of patients with a change in their GOC did not have this documented in the discharge summary. CONCLUSION: In hospitalized LTC patients, GOC discussions occurred infrequently and appeared to be triggered by illness severity. Orders for advance directives, in-hospital death, and 1-year mortality were associated with discussions. Rates of GOC documentation in the discharge summary were poor. This study provides direction for developing education and practice standards to improve GOC discussion rates and their communication back to LTC. Journal of Hospital Medicine 2015;11:824-831. © 2015 Society of Hospital Medicine.

Delayed Diagnosis of Metastatic Ewing Sarcoma Masked by Charcot-Marie-Tooth Disease.

An 18-year-old male with a history of Charcot-Marie-Tooth disease (CMT) presented with metastatic Ewing sarcoma to the lungs. He had been followed by several healthcare professionals who ascribed his enlarging 23 cm gluteal mass to his CMT. The patient experienced a significant delay in diagnosis, not uncommon in sarcoma. This case explores the various system and cognitive errors that contributed to this delay.

Drug problems among homeless individuals in Toronto, Canada: prevalence, drugs of choice, and relation to health status.

BACKGROUND: Drug use is believed to be an important factor contributing to the poor health and increased mortality risk that has been widely observed among homeless individuals. The objective of this study was to determine the prevalence and characteristics of drug use among a representative sample of homeless individuals and to examine the association between drug problems and physical and mental health status. METHODS: Recruitment of 603 single men, 304 single women, and 284 adults with dependent children occurred at homeless shelters and meal programs in Toronto, Canada. Information was collected on demographic characteristics and patterns of drug use. The Addiction Severity Index was used to assess whether participants suffered from drug problems. Associations of drug problems with physical and mental health status (measured by the SF-12 scale) were examined using regression analyses. RESULTS: Forty percent of the study sample had drug problems in the last 30 days. These individuals were more likely to be single men and less educated than those without drug problems. They were also more likely to have become homeless at a younger age (mean 24.8 vs. 30.9 years) and for a longer duration (mean 4.8 vs. 2.9 years). Marijuana and cocaine were the most frequently used drugs in the past two years (40% and 27%, respectively). Drug problems within the last 30 days were associated with significantly poorer mental health status (-4.9 points, 95% CI -6.5 to -3.2) but not with poorer physical health status (-0.03 points, 95% CI -1.3 to 1.3)). CONCLUSIONS: Drug use is common among homeless individuals in Toronto. Current drug problems are associated with poorer mental health status but not with poorer physical health status.