Effectiveness of a On-site Medicalization Program for Nursing Homes With COVID-19 Outbreaks.

BACKGROUND: Nursing homes are highly vulnerable to the occurrence of COVID-19 outbreaks, which result in high lethality rates. Most of them are not prepared to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. METHOD: A coordinated on-site medicalization program (MP) in response to a sizeable COVID-19 outbreak in 4 nursing homes was organized, with the objectives of improving survival, offering humanistic palliative care to residents in their natural environment, and reducing hospital referrals. Ten key processes and interventions were established (provision of informatics infrastructure, medical equipment, and human resources, universal testing, separation of "clean" and "contaminated" areas, epidemiological surveys, and unified protocols stratifying for active or palliative care approach, among others). Main outcomes were a composite endpoint of survival or optimal palliative care (SOPC), survival, and referral to hospital. RESULTS: Two hundred and seventy-two of 457 (59.5%) residents and 85 of 320 (26.5%) staff members were affected. The SOPC, survival, and referrals to hospital occurred in 77%, 72.5%, and 29% of patients diagnosed before the start of MP, with respect to 97%, 83.7%, and 17% of those diagnosed during the program, respectively. The SOPC was independently associated to MP (OR = 15 [3-81]); and survival in patients stratified to active approach, to the use of any antiviral treatment (OR = 28 [5-160]). All outbreaks were controlled in 39 [37-42] days. CONCLUSIONS: A coordinated on-site MP of nursing homes with COVID-19 outbreaks achieved a higher SOPC rate, and a reduction in referrals to hospital, thus ensuring rigorous but also humanistic and gentle care to residents.

Death risk stratification in elderly patients with covid-19. A comparative cohort study in nursing homes outbreaks.

Elderly people are more severely affected by COVID-19. Nevertheless scarce information about specific prognostic scores for this population is available. The main objective was to compare the accuracy of recently developed COVID-19 prognostic scores to that of CURB-65, Charlson and PROFUND indices in a cohort of 272 elderly patients from four nursing homes, affected by COVID-19. Accuracy was measured by calibration (calibration curves and Hosmer-Lemeshov (H-L) test), and discriminative power (area under the receiver operation curve (AUC-ROC). Negative and positive predictive values (NPV and PPV) were also obtained. Overall mortality rate was 22.4 %. Only ACP and Shi et al. out of 10 specific COVID-19 indices could be assessed. All indices but CURB-65 showed a good calibration by H-L test, whilst PROFUND, ACP and CURB-65 showed best results in calibration curves. Only CURB-65 (AUC-ROC = 0.81 [0.75-0.87])) and PROFUND (AUC-ROC = 0.67 [0.6-0.75])) showed good discrimination power. The highest NPV was obtained by CURB-65 (95 % [90-98%]), PROFUND (93 % [77-98%]), and their combination (100 % [82-100%]); whereas CURB-65 (74 % [51-88%]), and its combination with PROFUND (80 % [50-94%]) showed highest PPV. PROFUND and CURB-65 indices showed the highest accuracy in predicting death-risk of elderly patients affected by COVID-19, whereas Charlson and recent developed COVID-19 specific tools lacked it, or were not available to assess. A comprehensive clinical stratification on two-level basis (basal death risk due to chronic conditions by PROFUND index, plus current death risk due to COVID-19 by CURB-65), could be an appropriate approach.

Comanejo de la fractura de cadera del anciano en un hospital de tercer nivel: un estudio de cohortes / Hip fracture co-management in the elderly in a tertiary referral hospital: a cohorts study

INTRODUCCIÓN: La fractura de cadera del anciano es de los diagnósticos más prevalentes en los servicios de Traumatología, con gran impacto en términos clínicos, económicos y sociales. Nuestro objetivo es analizar el impacto clínico de un modelo de comanejo entre Traumatología y Medicina Interna para pacientes ancianos ingresados por fractura de cadera en un hospital de tercer nivel. MATERIAL Y MÉTODOS: Cohortes retrospectivas de pacientes mayores de 65 años ingresados por fractura de cadera entre enero de 2005 y agosto de 2006 (cohorte HIST) sin modelo de comanejo, y entre enero de 2008 y agosto de 2010 (cohorte COFRAC) con dicho modelo. Se analizaron características demográficas, clínicas y quirúrgicas, incidencia de complicaciones, mortalidad y reingreso a los 30 días. RESULTADOS: Se incluyó a 701 pacientes (471 HIST, 230 COFRAC). No hubo diferencias en edad, género, demora quirúrgica, tiempo y tipo de cirugía e intervención, estancia, deambulación al alta, consulta en urgencias ni reingreso o mortalidad a 30 días. Hubo diferencias en identificación de pluripatológicos (16,8 vs. 24,4%; p = 0,02), osteoporosis (3,9 vs. 7,6%; p = 0,03) o déficit motor (3,5 vs. 8,8%; p = 0,03), fármacos del tratamiento (3,7+/-2,5 vs. 4,3+/-3,2; p < 0,01), aparición de delirium (15,6 vs. 20,9%, p = 0,048) e hipomotilidad intestinal (80,3 vs. 74,7%; p < 0,001), seguimiento de anemia (83,3 vs. 97,1%; p > 0,01) y de función renal (44,5 vs. 97,3%; p < 0,01) y mortalidad intrahospitalaria (4,6 vs. 1,3%; p = 0,02). CONCLUSIONES: El comanejo de pacientes ancianos ingresados por fractura de cadera permite mejorar la documentación de los problemas crónicos previos y el control de complicaciones hospitalarias y disminuye la mortalidad intrahospitalaria

INTRODUCTION: Hip fracture in the elderly is one of the most prevalent diagnoses in Orthopedic Surgery Departments. It has a great impact in medical, economic and social terms. Our objective is to analyze clinical impact of a co-management care model between orthopedic surgery and internal medicine departments for elderly patients admitted with hip fracture in a tertiary referral hospital. MATERIAL AND METHODS: Retrospective cohort study of patients older than 65 years old admitted with hip fracture between January 2005-August 2006 (HIST cohort) without a co-management care model, and between January 2008-August 2010 (COFRAC cohort) with a co-manEdadment care model. Analysis of demographic, clinical and surgery characteristics, complications incidence and mortality and re-admissions at 30 days was made. RESULTS: A total of 701 patients were included (471 HIST, 230 COFRAC). There were no differences in sex, gender, time to surgery, type of anesthesia and surgery, length of stay, ambulation at discharge and 30-days emergency room consultation, readmissions or mortality at 30 days. There were differences in identification of polypatological patients (16.8 vs. 24.4%, P=0.02), presence of osteoporosis (3.9 vs. 7.6%, P=0.03), motor deficit (3.5 vs. 8.8%, P=0.03), number of chronic drugs (3.7+/-2.5 vs. 4.3+/-3.2, P<0.01), diagnosis of delirium (15.6 vs. 20.9%, P=0.048), constipation (80.3 vs. 74.7%, p < 0.001), monitoring of anemia (83.3 vs. 97.1%, P>0.01) and renal failure at discharge (44.5 vs. 97.3%, P<0.01) and hospital mortality (4.6 vs. 1.3%, P=0.02). CONCLUSIONS: Co-management for elderly patients admitted with hip fracture provides a better information about previously chronic conditions, a higher control of hospital complications and decreases hospital mortality

Hip fracture co-management in the elderly in a tertiary referral hospital: A cohorts study. / Comanejo de la fractura de cadera del anciano en un hospital de tercer nivel: un estudio de cohortes.

INTRODUCTION: Hip fracture in the elderly is one of the most prevalent diagnoses in Orthopedic Surgery Departments. It has a great impact in medical, economic and social terms. Our objective is to analyze clinical impact of a co-management care model between orthopedic surgery and internal medicine departments for elderly patients admitted with hip fracture in a tertiary referral hospital. MATERIAL AND METHODS: Retrospective cohort study of patients older than 65 years old admitted with hip fracture between January 2005-August 2006 (HIST cohort) without a co-management care model, and between January 2008-August 2010 (COFRAC cohort) with a co-manEdadment care model. Analysis of demographic, clinical and surgery characteristics, complications incidence and mortality and re-admissions at 30 days was made. RESULTS: A total of 701 patients were included (471 HIST, 230 COFRAC). There were no differences in sex, gender, time to surgery, type of anesthesia and surgery, length of stay, ambulation at discharge and 30-days emergency room consultation, readmissions or mortality at 30 days. There were differences in identification of polypatological patients (16.8 vs. 24.4%, P=0.02), presence of osteoporosis (3.9 vs. 7.6%, P=0.03), motor deficit (3.5 vs. 8.8%, P=0.03), number of chronic drugs (3.7±2.5 vs. 4.3±3.2, P<0.01), diagnosis of delirium (15.6 vs. 20.9%, P=0.048), constipation (80.3 vs. 74.7%, p<0.001), monitoring of anemia (83.3 vs. 97.1%, P>0.01) and renal failure at discharge (44.5 vs. 97.3%, P<0.01) and hospital mortality (4.6 vs. 1.3%, P=0.02). CONCLUSIONS: Co-management for elderly patients admitted with hip fracture provides a better information about previously chronic conditions, a higher control of hospital complications and decreases hospital mortality.

Factors related with the appropriateness of pharmacological treatment in polypathological patients.

OBJECTIVE: To evaluate the association between the number of pharmacological inappropriateness and possible factors related with it. METHODS: All polyphatological patients of the IMPACTO project in a tertiary hospital were included (July 2010-March 2012). The pharmacist performed the interventions based on a combined strategy that included the modified MAI and the STOPP-START criteria. A greater number of interventions indicated smaller treatment appropriateness. In the analysis of the strength of association between two continuous variables the Pearson correlation coefficient was used. Test of Student's t or Mann-Whitney comparisons of quantitative data between two groups were applied. Subsequently, a multivariate analysis was performed to study possible variables which explain the inappropriateness of the pharmacological treatment. RESULTS: 242 patients were included. 838 inappropriateness were detected (average per patient of 3±2). The appropriateness was associated with: number of diagnoses, medications, and categories of polypathology, Charlson Comorbidity Index, sex, and categories A1 and B2. When diagnosing collinearity in the multivariate model, we observed that there was collinearity between "Charlson Comorbidity Index" and "number of categories of polypathological patients", so it was decided to conduct two multivariate models variables, one each. The number of drugs, the number of diagnoses and the gender remained significant in both multivariate models. CONCLUSIONS: The appropriateness of pharmacological treatment decreases with increasing number of drugs and number of diagnoses, as well as female gender. However, both multi variate models explain a low percentage of variability in the number of inappropriateness.

Objetivo: evaluar la asociación entre el número de inadecuaciones farmacológicas y posibles factores relacionados con la misma. Métodos: : Se incluyeron todos los pacientes pluripatológicos del proyecto IMPACTO en un hospital de tercer nivel (Julio 2010-Marzo 2012). El farmacéutico realizó las intervenciones en base a una estrategia combinada que incluía el MAI modificado y los criterios STOPP-START. A mayor número de intervenciones menor adecuación del tratamiento. En los análisis de la fuerza de asociación entre dos variables continuas se utilizó el coeficiente de correlación de Pearson. Se aplicó el test de la t de Student o U de Mann-Whitney en comparaciones de datos cuantitativos entre dos grupos. Posteriormente, se realizó un análisis multivariante, para estudiar posibles variables que explicasen las inadecuaciones del tratamiento farmacológico. Resultados: Se incluyeron un total de 242 pacientes. Se detectaron un total de 838 inadecuaciones, siendo la media por paciente de 3±2. La adecuación del tratamiento farmacológico se asoció con el número de diagnósticos, el número de medicamentos, el número de categorías de paciente pluripatológico, el índice de comorbilidad de Charlson, el sexo y las categorías A1 y B2. Al realizar el diagnóstico de colinealidad, en el modelo multivariante, de las variables se observó que existía colinealidad entre las variables "índice de comorbilidad de Charlson" y "número de categorías de paciente pluripatológico", por lo que se decidió realizar dos modelos multivariantes, uno con cada una de ellas. Se mantuvieron significativos con el multivariante y para ambos modelos el número de medicamentos, el número de diagnósticos y el sexo. Conclusiones: La adecuación del tratamiento farmacológico disminuyó al aumentar el número de medicamentos y el número de diagnósticos, así como en mujeres. No obstante, ambos modelos multivariantes, explicaron un porcentaje de variabilidad del número de inadecuaciones leve.

Factors related with the appropriateness of pharmacological treatment in polypathological patients / Factores relacionados con la adecuación del tratamiento farmacológico en pacientes pluripatológicos

Objective: To evaluate the association between the number of pharmacological inappropriateness and possible factors related with it. Methods: All polyphatological patients of the IMPACTO project in a tertiary hospital were included (July 2010-March 2012). The pharmacist performed the interventions based on a combined strategy that included the modified MAI and the STOPP-START criteria. A greater number of interventions indicated smaller treatment appropriateness. In the analysis of the strength of association between two continuous variables the Pearson correlation coefficient was used. Test of Student’s t or Mann-Whitney comparisons of quantitative data between two groups were applied. Subsequently, a multivariate analysis was performed to study possible variables which explain the inappropriateness of the pharmacological treatment. Results: 242 patients were included. 838 inappropriateness were detected (average per patient of 3±2). The appropriateness was associated with: number of diagnoses, medications, and categories of polypathology, Charlson Comorbidity Index, sex, and categories A1 and B2. When diagnosing collinearity in the multivariate model, we observed that there was collinearity between «Charlson Comorbidity Index» and «number of categories of polypathological patients», so it was decided to conduct two multivariate models variables, one each. The number of drugs, the number of diagnoses and the gender remained significant in both multivariate models. Conclusions: The appropriateness of pharmacological treatment decreases with increasing number of drugs and number of diagnoses, as well as female gender. However, both multivariate models explain a low percentage of variability in the number of inappropriateness (AU)

Objetivo: evaluar la asociación entre el número de inadecuaciones farmacológicas y posibles factores relacionados con la misma. Métodos: Se incluyeron todos los pacientes pluripatológicos del proyecto IMPACTO en un hospital de tercer nivel (Julio 2010-Marzo 2012). El farmacéutico realizó las intervenciones en base a una estrategia combinada que incluía el MAI modificado y los criterios STOPP-START. A mayor número de intervenciones menor adecuación del tratamiento. En los análisis de la fuerza de asociación entre dos variables continuas se utilizó el coeficiente de correlación de Pearson. Se aplicó el test de la t de Student o U de Mann-Whitney en comparaciones de datos cuantitativos entre dos grupos. Posteriormente, se realizó un análisis multivariante, para estudiar posibles variables que explicasen las inadecuaciones del tratamiento farmacológico. Resultados: Se incluyeron un total de 242 pacientes. Se detectaron un total de 838 inadecuaciones, siendo la media por paciente de 3±2. La adecuación del tratamiento farmacológico se asoció con el número de diagnósticos, el número de medicamentos, el número de categorías de paciente pluripatológico, el índice de comorbilidad de Charlson, el sexo y las categorías A1 y B2. Al realizar el diagnóstico de colinealidad, en el modelo multivariante, de las variables se observó que existía colinealidad entre las variables «índice de comorbilidad de Charlson» y «número de categorías de paciente pluripatológico», por lo que se decidió realizar dos modelos multivariantes, uno con cada una de ellas. Se mantuvieron significativos con el multivariante y para ambos modelos el número de medicamentos, el número de diagnósticos y el sexo. Conclusiones: La adecuación del tratamiento farmacológico disminuyó al aumentar el número de medicamentos y el número de diagnósticos, así como en mujeres. No obstante, ambos modelos multivariantes, explicaron un porcentaje de variabilidad del número de inadecuaciones leve (AU)

[Clinical, functional, mental and sociofamiliar features in pluripathological patients. One-year prospective study in Primary Health Care]. / Características clínicas, funcionales, mentales y sociales de pacientes pluripatológicos. Estudio prospectivo durante un año en Atención Primaria.

OBJECTIVES: To analyze clinical, functional, mental, sociofamiliar, and evolutional characteristics of pluripathological patients (PP) in Primary Health Care setting. PATIENTS AND METHOD: Prospective, multiinstitutional cohort study in four Primary Health Care Institutions by active identification of PP from a computerized registry using the Spanish Andalusian Health Care Council criteria. A clinical interview was proposed to all identified patients. The clinical data, Barthel index (BI), Pfeiffer scale, clinical vulnerability (CV), sociofamiliar features by the Gijon scale, and 1-year admissions and mortality were analyzed. An univariant and multivariant analysis was performed in order to know the risk factors associated to previously described variables. RESULTS: Overall, 806 PP were detected (1.38% of the population). Cardiovascular categories were the most prevalent. A total of 662 patients (69%) were eligible for the interview. Median BI was 90 (0-100), and 24% of patients had severe functional impairment (BI < 60). Twenty-nine percent of them had been admitted to hospital at least once in the last 3 months. Patients with more functional impairment and CV were older, having more defining categories, especially E category. A total of 174 patients (37.75%) had cognitive impairment. This group was older, with more functional impairment, and worse sociofamiliar support. One-year mortality was 6.1%, and was correlated with CV and older age. CONCLUSIONS: The definition of PP used selects in the Primary Care setting a population with a high level of multidimensional frailty having a high prevalence of functional, cognitive deterioration, sociofamiliar problems, CV and consumption of health care resources. Due to this multidimensional deterioration, it is recommendable to make an integral evaluation in the health care practice of these patients.

Características clínicas, funcionales, mentales y sociales de pacientes pluripatológicos. Estudio prospectivo durante un año en Atención Primaria / Clinical, functional, mental and sociofamiliar features in pluripathological patients. One-year prospective study in Primary Health Care

Objetivos. Analizar las características clínicas, funcionales, mentales, sociofamiliares y evolutivas de los pacientes pluripatológicos (PP) en Atención Primaria (AP). Pacientes y método. Estudio prospectivo multicéntrico de cuatro Centros de Salud mediante identificación activa de PP desde la historia informatizada, según los criterios de la Consejería de Salud de la Junta de Andalucía. A todos los pacientes se les propuso una entrevista, en la que se analizaron datos clínicos, el índice de Barthel (IB), la escala de Pfeiffer, la vulnerabilidad clínica (VC) y la escala de Gijón, así como la mortalidad y las hospitalizaciones tras un año de seguimiento. Posteriormente se realizó un análisis univariante y multivariante de los factores asociados a dichas variables. Resultados. Los PP identificados fueron 806 (1,38% de la población) y las categorías más prevalentes fueron las de daño vascular. Fueron elegibles para hacer la entrevista un total de 662 (69%) pacientes. La mediana del IB fue 90 (0-100) y un 24% presentó un IB < 60. Un 29,1% había tenido al menos un ingreso en los últimos 3 meses. Los PP con mayor deterioro funcional y VC fueron los de mayor edad, mayor número de categorías y los que tenían la categoría E. Un total de 174 (37,75%) pacientes presentó deterioro cognitivo y este grupo se caracterizó por tener mayor edad, mayor deterioro funcional y peor soporte familiar. La mortalidad al año fue del 6,1% y se relacionó con la VC y con la edad. Conclusiones. La definición de PP utilizada selecciona en AP a una población frágil con una alta prevalencia de deterioro funcional, cognitivo, problemas sociofamiliares, VC y consumo de recursos sanitarios. Este deterioro multidimensional hace aconsejable la realización de una valoración integral en la práctica asistencial de estos pacientes (AU)

Objectives. To analyze clinical, functional, mental, sociofamiliar, and evolutional characteristics of pluripathological patients (PP) in Primary Health Care setting. Patients and method. Prospective, multiinstitutional cohort study in four Primary Health Care Institutions by active identification of PP from a computerized registry using the Spanish Andalusian Health Care Council criteria. A clinical interview was proposed to all identified patients. The clinical data, Barthel index (BI), Pfeiffer scale, clinical vulnerability (CV), sociofamiliar features by the Gijon scale, and 1-year admissions and mortality were analyzed. An univariant and multivariant analysis was performed in order to know the risk factors associated to previously described variables. Results. Overall, 806 PP were detected (1.38% of the population). Cardiovascular categories were the most prevalent. A total of 662 patients (69%) were eligible for the interview. Median BI was 90 (0-100), and 24% of patients had severe functional impairment (BI < 60). Twenty-nine percent of them had been admitted to hospital at least once in the last 3 months. Patients with more functional impairment and CV were older, having more defining categories, especially E category. A total of 174 patients (37.75%) had cognitive impairment. This group was older, with more functional impairment, and worse sociofamiliar support. One-year mortality was 6.1%, and was correlated with CV and older age. Conclusions. The definition of PP used selects in the Primary Care setting a population with a high level of multidimensional frailty having a high prevalence of functional, cognitive deterioration, sociofamiliar problems, CV and consumption of health care resources. Due to this multidimensional deterioration, it is recommendable to make an integral evaluation in the health care practice of these patients (AU)