A focus group interview with health professionals: establishing efficient transition care plan for older adult patients in Korea.

BACKGROUND: Although transition care planning can affect the functional status and quality of life after acute hospitalization in older adults, little is known on problems associated with discharge planning in acute care hospitals in Korea. We aimed to investigate barriers and possible solutions on transfer planning of complex older patients in this study. METHODS: We used focus group interviews with the application of framework analysis. Twelve physicians providing inpatient care from 6 different institutions in Korea participated in the interview. Facilitating questions were extracted from 2 roundtable meetings prior to the primary interview. From transcribed verbatim, themes were constructed from corresponding remarks by participants. RESULTS: We revealed two main domains of the barrier, which included multiple subdomains for each of them. The first domain was a patient factor barrier, a composite of misperception of medical providers' intentions, incomprehension of the healthcare system, and communication failure between the caregivers or decision-makers. The second domain, institutional factors included different fee structures across the different levels of care, high barrier to accessing health service in tertiary hospitals or to be referred to, the hardship of communication between institutions, and insufficient subacute rehabilitation service across the country. CONCLUSIONS: Through the interview, physicians in the field recognized barriers to a smooth transition care process from tertiary level hospitals to community care, especially for older adults. Participants emphasized both the patients and hospital sides of adjustment on behaviors, communication, and greater attention for the individuals during the transition period.

A Descriptive Study of Emergency Department Visits Within 30 Days of Discharge.

BACKGROUND: Unnecessary emergency department (ED) visits are a crucial consideration in discharge planning for acutely admitted patients. This study aimed to identify the reasons for unnecessary visits to the ED within 30 days of discharge from a medical hospitalist unit. METHODS: We performed a retrospective review of patients discharged in 2018 from a medical unit of tertiary teaching hospital in Korea. The authors discussed in-depth and determined whether or not an ED visit was unnecessary, and further classified the causes of unnecessary visits into three categories. RESULTS: The mean age of the patients was 62.9 years (range, 15-99 years), and among the 1,343 patients discharged from the unit, 720 (53.6%) were men. Overall, 215 patients (16.0%) visited the ED within 30 days after discharge; among them, 16.3% were readmitted. Of the 215 cases of ED visits within 30 days after discharge, 57 (26.5%) were considered unnecessary. Of these, 30 (52.6%) were categorized as having failed care transition, 15 (26.3%) had unestablished care plans for predictable issues, and 12 (21.1%) had insufficient patient education. CONCLUSION: A substantial number of short-term ED visits by discharged multimorbid or older medical patients were considered unnecessary. Discharging patients with a thorough discharge plan is essential to avoid unnecessary ED visits.

Clinical Frailty Scale, K-FRAIL questionnaire, and clinical outcomes in an acute hospitalist unit in Korea.

BACKGROUND/AIMS: Frailty increases the risks of in-hospital adverse events such as delirium, falls, and functional decline in older adults. We assessed the feasibility and clinical relevance of frailty status in Korean older inpatients using the Clinical Frailty Scale (CFS) and Korean version of the Fatigue, Resistance, Ambulation, Illnesses, & Loss of Weight scale (K-FRAIL) questionnaires. METHODS: Frailty status was measured using the Korean-translated version of the CFS and K-FRAIL questionnaire within 3 days from admission in 144 consecutive patients aged 60 years or older. The correlation between CFS and K-FRAIL score was assessed. The criterion validity of CFS was assessed using receiver operating characteristic analysis. As outcomes, delirium, bedsore, length of stay (LOS), in-hospital mortality, and unplanned 30-day readmission were measured by reviewing medical records. RESULTS: The mean age of the study population was 70.1 years (range, 60 to 91), and 75 (52.1%) were men. By linear regression analysis, CFS and K-FRAIL were positively correlated (B = 0.72, p < 0.001). A CFS cutoff of ≥ 5 maximized sensitivity + specificity to classify frailty using K-FRAIL as a reference (C-index = 0.893). Higher frailty burden by both CFS and K-FRAIL was associated with higher LOS and bedsores. Unplanned readmission and in-hospital mortality were associated with higher CFS score but not with K-FRAIL score, after adjusting for age, gender, polypharmacy, and multimorbidity. CONCLUSION: Frailty status by CFS was associated with LOS, bedsores, unplanned readmission, and in-hospital mortality. CFS can be used to screen high-risk patients who may benefit from geriatric interventions and discharge planning in acutely hospitalized older adults.

Clinical outcomes associated with anticholinergic burden in older hospitalized patients with advanced cancer: a single-center database study.

PURPOSE: Although anticholinergic burden has been known to be associated with adverse outcomes in older adults, its clinical importance has been less studied in patients with advanced cancer. We aimed to assess clinical impacts of using anticholinergic medications in older patients with cancer. METHODS: This is a single-center retrospective database study. This study included patients with stage IV solid cancer aged 65 years or older who were hospitalized in a hospitalist-operated medical unit of a tertiary hospital. We calculated anticholinergic cognitive burden (ACB) scores on admission and during hospitalization by reviewing all medications during hospital stays and collected the following data: demographic, medical history and clinical severity, occurrence of delirium, location of discharge, in-hospital mortality, and after discharge mortality data. RESULTS: When we divided the patients into two groups based on the change in ACB during hospitalization, the in-hospital mortality rate, incidence of delirium, frequency of transfers to long-term care hospitals, and length of hospital stay were higher in the ACB-increased group than those in the non-increased group. Even after excluding patients with clinically detected delirium, increased ACB were associated with increased in-hospital mortality. Patients in the ACB-increased group showed higher mortality risk after discharge than those in the non-increased group based on the Cox proportional hazard model. CONCLUSION: Increased ACB during hospitalization is a predictor of worsening clinical features and higher mortality in older patients with cancer. Further studies investigating causal relationship between an increased ACB and poor prognosis are warranted.

Cardiovascular Effects of Long-Term Exposure to Air Pollution: A Population-Based Study With 900 845 Person-Years of Follow-up.

BACKGROUND: Studies have shown that long-term exposure to air pollution such as fine particulate matter (≤2.5 µm in aerodynamic diameter [PM2.5]) increases the risk of all-cause and cardiovascular mortality. To date, however, there are limited data on the impact of air pollution on specific cardiovascular diseases. This study aimed to evaluate cardiovascular effects of long-term exposure to air pollution among residents of Seoul, Korea. METHODS AND RESULTS: Healthy participants with no previous history of cardiovascular disease were evaluated between 2007 and 2013. Exposure to air pollutants was estimated by linking the location of outdoor monitors to the ZIP code of each participant's residence. Crude and adjusted analyses were performed using Cox regression models to evaluate the risk for composite cardiovascular events including cardiovascular mortality, acute myocardial infarction, congestive heart failure, and stroke. A total of 136 094 participants were followed for a median of 7.0 years (900 845 person-years). The risk of major cardiovascular events increased with higher mean concentrations of PM2.5 in a linear relationship, with a hazard ratio of 1.36 (95% confidence interval, 1.29-1.43) per 1 µg/m3 PM2.5. Other pollutants including PM2.5-10 of CO, SO2, and NO2, but not O3, were significantly associated with increased risk of cardiovascular events. The burden from air pollution was comparable to that from hypertension and diabetes mellitus. CONCLUSIONS: This large-scale population-based study demonstrated that long-term exposure to air pollution including PM2.5 increases the risk of major cardiovascular disease and mortality. Air pollution should be considered an important modifiable environmental cardiovascular risk factor.

Nephrotic syndrome associated with metastatic thymoma treated with chemotherapy.

RATIONALE: Nephropathy with concurrent invasive thymoma is a type of paraneoplastic syndrome. PATIENT CONCERNS AND DIAGNOSES: We report a 32-year-old female with nephrotic syndrome that was first diagnosed along with invasive thymoma and treated by means of cisplatin-based chemotherapy for the thymoma. The patient initially presented with dyspnea and generalized edema. Chest radiography and computed tomography scans revealed right pleural effusion and a mass in the right middle lung field, which were confirmed by a percutaneous lung biopsy as metastatic invasive thymoma. Severe hypoalbuminemia, heavy proteinuria, hyponatremia, and hypercholesterolemia were features of the nephrotic syndrome. A kidney needle biopsy suggested focal segmental glomerulosclerosis. INTERVENTIONS AND OUTCOMES: All of the symptoms of nephrotic syndrome were resolved simultaneously during the first 2 cycles of chemotherapy. The patient was on regular follow-up with no specific treatment for nephrotic syndrome and underwent successful resection of the left pleura and anterior thymoma. The patient has shown no evidence of recurrence for 2 years. LESSONS: We conclude that chemotherapy for invasive thymoma is an effective treatment for nephrotic syndrome accompanying the thymoma.

Incremental Prognostic Value of Brachial-Ankle Pulse Wave Velocity to Single-Photon Emission Computed Tomography in Patients with Suspected Coronary Artery Disease.

AIM: Arterial stiffness assessed by brachial-ankle pulse wave velocity (baPWV) is predictive of cardiovascular events. This study was designed to investigate whether baPWV has an additional prognostic value to single-photon emission computed tomography (SPECT) in patients with suspected coronary artery disease (CAD). METHODS: A total of 350 subjects (age, 66.2 ± 10.5 years, 53.4% male) with suspected CAD undergoing myocardial SPECT and baPWV within 30 days were retrospectively analyzed. Cardiovascular events, including cardiovascular death, acute coronary syndrome and ischemic stroke, were assessed. Both fixed and reversible perfusion defects on SPECT were considered abnormal myocardial perfusion imaging (MPI) findings. RESULTS: During the median follow-up period of 441 days (interquartile range 169-719 days), cardiovascular events occurred in 21 patients (6.0%). In multivariable Cox regression analysis, abnormal MPI [hazard ratio (HR), 2.67; 95% confidence interval (CI), 1.21-10.37; p=0.024] and high baPWV (≥ 1,790 cm/s) (HR, 2.03; 95% CI, 1.08-6.38; p=0.007) were independent predictors of clinical events even after adjusting for possible confounders. Also, high baPWV had an incremental prognostic value to traditional risk factors and abnormal MPI in predicting cardiovascular events (overall Chi-square, from 24.08 to 27.42; p ＜ 0.001). Kaplan-Meier survival curves stratified by baPWV and MPI proved significantly improved prediction of cardiovascular events (log-rank p=0.001). CONCLUSIONS: baPWV has an incremental prognostic value to traditional risk factors and MPI. Therefore, baPWV can be used to identify subjects at higher risk of cardiovascular events in patients undergoing SPECT.