Identifying Older Patients at High Risk for Emergency Department Visits and Hospitalization.

Hospitalizations are costly, potentially hazardous for older patients, and sometimes preventable. With Medicare's implementation of hospital penalties for 30-day readmissions on certain index conditions, health care organizations have prioritized addressing those issues that lead to avoidable hospitalizations. Little is known about the utility and feasibility of using standardized tools to identify adults at risk for hospitalizations in primary care. In this study, the goal was to determine, from a sample of 60 adults aged 65 and older, whether the Probability of Repeat Admission (PRA), the Vulnerable Elders Survey (VES-13), or a provider estimate of likelihood of hospitalization could identify patients at high risk for emergency department (ED) visits or hospitalization at 6 and 12 months, while being feasible to administer in a primary care setting. PRA, VES-13, and provider estimate were administered in an outpatient practice. Number of ED visits and hospitalizations at 6 and 12 months were assessed through follow-up phone calls and chart review. PRA and provider estimate were not significant predictors of hospitalizations at 6 months (PRA odds ratio [OR] 1.95; P = 0.39; physician estimate OR 4.33, P = 0.08), but were at 12 months (PRA OR 6.00; P < 0.001; physician estimate OR 2.3; P < 0.05). Additionally, a hospitalization during the prior year was not a significant predictor of hospitalization at 6 months (OR 2.97; P = 0.15) but was at 12 months (OR 3.89, P < 0.05). No tool was a significant predictor of ED visits at either time. PRA and the physician estimate were easy to administer and feasible to implement in a primary care setting.

Diagnosing cancer in the symptomatic patient.

Finding cancer at its earliest, most treatable stage gives patients the greatest chance of survival. For a number of cancers, screening tests allow for early detection and treatment, and thereby, reduce cancer-related mortality. However, many cancers are discovered by symptomatic presentation rather than screening. This article addresses several symptoms commonly reported in the primary care setting, including rectal bleeding, a breast lump, cough, lymphadenopathy, and weight loss, and offers an evidence-based approach to the consideration and possibly the diagnosis of cancer.

Late diagnosis of early disseminated lyme disease: perplexing symptoms in a gardener.

The timely diagnosis of early disseminated Lyme disease presenting as multiple secondary erythema migrans lesions is sometimes delayed because this stage is infrequently encountered in a general practice. We report a case of a 60-year-old woman whose initial complaints of an erythematous, "burning" rash and flu-like symptoms led to several laboratory tests with no specific diagnosis. The correct diagnosis was only made after sorting through other possibilities in the differential diagnosis. By reproducing the medical images and reviewing the medical literature, we underscore the importance of including Lyme disease in the list of diagnoses pertaining to diffuse skin rashes in the febrile patient.