Predictors of rehabilitation outcomes: a comparison of Israeli and Italian geriatric post-acute care (PAC) facilities using the minimum data set (MDS).

OBJECTIVES: To understand the relative contribution of sociodemographic, clinical, and health care features to rehabilitation outcomes in Israel and in Italy in post-acute care (PAC) facilities. DESIGN: Prospective cross-national study SETTING: Two hospital geriatric PAC departments: Harzfeld Geriatric Hospital, Gedera, Israel, and Catholic University of Sacred Heart Geriatric Hospital, Rome, Italy. PARTICIPANTS: Post-acute care patients aged 65 and older admitted consecutively for stabilization, improvement, or rehabilitation to 3 departments in Harzfeld Geriatric Hospital, Gedera, Israel from April, 1999 through February, 2002 (N = 364), and to the post-acute Geriatric Rehabilitation Unit of the "A. Gemelli" Hospital, Catholic University of Sacred Heart, Rome, Italy, between February, 1999, and April, 2002 (N = 351), for whom there were complete assessments at admission and discharge (the total number admitted in Israel was 505, and in Italy, 409). MEASUREMENTS: Minimum Data Set for Post-Acute Care (MDS-PAC) assessments conducted within 4 days of admission and at discharge; data collected identically in both sites. Predictors of functional recovery> were identified using multivariate binary logistic regression. The dependent variable: improvement of 1 or more points in the ADL scale. RESULTS: The staffing pattern of the PAC department in Italy had about double the physicians and physio- and occupational therapists than in Israel, but about the same number of nurses and somewhat fewer aides than in Israel. Multivariate binary logistic regression that includes country, age, sex, and marital status, found that the patients in Italy had about triple the probability of improvement in ADL function (OR 3.3, CI 2.4-4.6) (P < .001) than PAC patients in Israel. Even after health system characteristics were added to the model, ADL improvement was most significantly associated with higher cognitive ability and a diagnosis of hip fracture, as well as longer length of stay and being admitted to PAC directly from an acute hospital. For each additional point (worse cognition) in a cognitive scale, there was a 30% decrease in the probability of ADL improvement (OR 0.7, CI 0.6-0.8, P < .001). Those who had a stroke were about half as likely to show ADL improvement (OR 0.5, CI 0.3-0.7) than those without stroke, but those with a hip fracture had more than double the probability of ADL improvement (OR 2.7, CI 1.7-4.2) than those without hip fracture. Those who stayed in the PAC ward an additional block of time had a 30% higher probability of ADL improvement (P < .1), and those who were admitted directly to PAC from an acute hospital had more than 4 times the probability of ADL improvement (OR 4.1, CI 2.3-7.0, P < .001) than those who were admitted from a private home. CONCLUSIONS: We found support for the hypothesis that differences in sociodemographic and clinical factors cannot account for all differences in ADL improvement, and that the organization of care and constraints of the health system also influence functional outcomes. Policymakers should examine the policy-amenable features of the Italian and Israeli systems so that optimal ADL recovery can be encouraged. Any reduction in disability will help both patients and the health care system; slightly higher short-term PAC treatment costs may have large long-term future benefits, if they result in the reduction of ADL disability. This study is one of the first to examine outcomes of PAC in 2 countries, and can provide an initial assessment of how rehabilitation can be enhanced or limited by health policies and staffing patterns.

Profile and prognosis of febrile elderly patients with bacteremic urinary tract infection.

OBJECTIVE: To describe the profile of elderly patients with bacteremic urinary tract infections (UTI) and correlate clinical and laboratory findings with the outcome in order to identify independent predictors of mortality. METHODS: This retrospective study took place in a large community-based, geriatric hospital and included 191 patients aged 75-105 years with urine and blood cultures simultaneously positive for bacterial organisms. Records were analysed for demographic information, clinical and laboratory data over a 29 month period. Mortality was assessed and was correlated with these findings. RESULTS: Most of the patients (80.1%) had community-acquired infection. Gram-negative organisms accounted for 87.6% of bacterial isolates, with Escherichia coli accounting for 46.1% of cases. Non-Escherichia coli Gram-negative organisms were highly resistant to two common urinary tract antibiotics (gentamicin and ceftriaxone). Patients with chronic urinary catheter had Gram-negative bacteria significantly less sensitive to ciprofloxacin, gentamycin, ampicillin and ceftriaxon than patients without catheter (p<0.05). In-hospital mortality was 33%. Multiple logistic regression analysis revealed that mortality was significantly related to the number of underlying diagnoses (p<0.0203), cognitive status (p<0.0003), length of hospitalization (p<0.0397), low level of serum albumin (p<0.0021), high neutrophil count (p<0.0001) and high level of lactate dehydrogenase (p<0.0351). Fatality was not associated with advanced age in the very old. CONCLUSION: Bacteremic UTI in the elderly has a high mortality rate. In frail elderly patients with age-associated multiple severe underlying disorders and cognitive impairment, early recognition of bacteremic UTI and prompt, appropriate treatment are critical in reducing the mortality.

A "fishy remedy": an unusual transmission of Vibrio vulnificus infection.

This case report describes a unique transmission of Vibrio vulnificus infection. A 38-year-old woman with recurrent cellulitis and chronic ulcer on her leg developed necrotizing cellulitis and sepsis caused by V. vulnificus. Meticulous history investigation revealed the link to contaminated fish blood that had been applied on the ulcer by a traditional healer. Through this case, it may be stressed that a traditional remedy can sometimes be harmful and life-threatening.

Risk factors for recurrence of Clostridium difficile-associated diarrhea in the elderly.

Risk factors that influence the recurrence of nosocomial Clostridium difficile-associated diarrhea (CDAD) were determined in an 18-month follow-up study in a subacute geriatric department. A case-control study was conducted, comparing 43 patients with recurrent C. difficile-associated diarrhea (RCDAD) (case patients) with 38 patients who had only 1 episode of CDAD (control patients). The mean age of patients was 81.6 +/- 7.2 y (range 64-95 y). All cases with CDAD were receiving antibiotic therapy. RCDAD occurred in 53.1% of patients. Risk factors for RCDAD included fecal incontinence (p < or = 0.04), longer duration of fever from admission until first episode of CDAD (p < or = 0.02) and H2-antagonist treatment (p < or = 0.02). This study shows that RCDAD is a common clinical event in elderly hospitalized patients and may be predictable in some groups of patients.