QT Interval and Long‐Term Mortality Risk in the Framingham Heart Study

Background : The association between QT interval and mortality has been demonstrated in large, prospective population‐based studies, but the strength of the association varies considerably based on the method of heart rate correction. We examined the QT‐mortality relationship in the Framingham Heart Study (FHS). Methods : Participants in the first (original cohort, n = 2,365) and second generation (offspring cohort, n = 4,530) cohorts were included in this study with a mean follow up of 27.5 years. QT interval measurements were obtained manually using a reproducible digital caliper technique. Results : Using Cox proportional hazards regression adjusting for age and sex, a 20 millisecond increase in QTc (using Bazett's correction; QT/RR^1/2 interval) was associated with a modest increase in risk of all‐cause mortality (HR 1.14, 95% CI 1.10–1.18, P < 0.0001), coronary heart disease (CHD) mortality (HR 1.15, 95% CI 1.05–1.26, P = 0.003), and sudden cardiac death (SCD, HR 1.19, 95% CI 1.03–1.37, P = 0.02). However, adjustment for heart rate using RR interval in linear regression attenuated this association. The association of QT interval with all‐cause mortality persisted after adjustment for cardiovascular risk factors, but associations with CHD mortality and SCD were no longer significant. Conclusion : In FHS, there is evidence of a graded relation between QTc and all‐cause mortality, CHD death, and SCD; however, this association is attenuated by adjustment for RR interval. These data confirm that using Bazett's heart rate correction, QTc, overestimates the association with mortality. An association with all‐cause mortality persists despite a more complete adjustment for heart rate and known cardiovascular risk factors.     

Frequency and Pattern of Emergency Department Visits by Long‐Term Care Residents—A Population‐Based Study

OBJECTIVES: To obtain population‐based estimates of emergency department (ED) visits by long‐term care (LTC) residents. DESIGN: Retrospective cohort study using administrative data. SETTING: All LTC facilities in Ontario, Canada. PARTICIPANTS: All LTC residents who visited an ED at least once during a 6‐month period. MEASUREMENTS: All ED visits were described using the National Ambulatory Care Reporting System. Two distinct visit types were defined. Potentially preventable visits were defined as those for any ambulatory care sensitive condition; these are conditions for which exacerbations that result in hospital use suggest lack of access to adequate primary care. Low‐acuity visits were defined as those triaged as nonurgent at ED registration and ended with return to the LTC facility without hospital admission. RESULTS: Nearly one‐quarter of LTC residents visited the ED at least once in 6 months. Of all visits, 24.6% were for a potentially preventable reason, most commonly pneumonia, urinary tract infection, and congestive heart failure. These visits had a high frequency of ambulance transport (90.4%), emergent triage (35.3%), hospital admission (62.4%), and death within 30 days (23.6%). Of all visits, 11.0% were low acuity. Fall‐related injury was the most common cause. Low‐acuity visits were the shortest (mean length 4.5 ± 4.0 hours) and had the lowest frequency of death within 30 days (4.3%). CONCLUSION: LTC residents made frequent visits to the ED. The visit types showed distinct patterns that suggest a need for better access to medical care for common conditions and a greater emphasis on fall prevention in LTC.     

Older adults discharged from the hospital with delirium: 1-year outcomes

OBJECTIVES: To compare 1-year institutionalization and mortality rates of patients who were delirious at discharge, patients whose delirium resolved by discharge, and patients who were never delirious in the hospital. DESIGN: Secondary analysis of prospective cohort data from the Delirium Prevention Trial. SETTING: General medicine service at Yale New Haven Hospital, March 25, 1995, through March 18, 1998, with follow-up interviews completed in 2000. PARTICIPANTS: Four hundred thirty-three patients aged 70 and older who were not delirious at admission. MEASUREMENTS: Patients underwent daily assessments of delirium from admission to discharge using the Confusion Assessment Method. Nursing home placement and mortality were determined at 1-year follow up. RESULTS: Of the 433 study patients, 24 (5.5%) had delirium at discharge, 31 (7.2%) had delirium that resolved during hospitalization, and 378 (87.3%) were never delirious. After 1 year of follow-up, 20 of 24 (83.3%) patients discharged with delirium, 21 of 31 (67.7%) patients whose delirium resolved, and 157 of 378 (41.5%) patients who were never delirious were admitted to a nursing home or died. Compared with patients who were never delirious, patients with delirium at discharge had a multivariable adjusted hazard ratio (HR) of 2.64 (95% confidence interval (CI)=1.60-4.35) for nursing home placement or mortality, whereas resolved cases had a HR of 1.53 (95% CI=0.96-2.43). CONCLUSION: Delirium at discharge is associated with a high rate of nursing home placement and mortality over a 1-year follow-up period. Interventions to increase detection of delirium and improvements in transitional care may help reduce these negative outcomes.     

Top Ten List of Long‐Term Care Facility Preparations for the Upcoming Influenza Season

A novel influenza A partly of virus of swine origin (2009 H1N1) emerged this spring, resulting in an influenza pandemic. This pandemic is anticipated to continue into the next influenza season. Given that the 2009 H1N1 and seasonal influenza A appear to be somewhat different in the human populations affected and that two influenza vaccines will be recommended this fall, those who manage long‐term care facilities and treat patients in them will be faced with many uncertainties as they approach the 2009/10 influenza season. Ten specific suggestions are offered to those responsible for the care of patients in long‐term care facilities regarding the upcoming influenza season. These practical suggestions are the clinical opinions of the authors and do not represent official recommendations of the American Geriatrics Society or any agency.     

Predictors of Long‐Term Risk for Heart Failure Hospitalization after Acute Myocardial Infarction

Background: Data on the value of baseline brain natriuretic peptide (BNP) and autonomic markers in predicting heart failure (HF) hospitalization after an acute myocardial infarction (AMI) are limited. Methods: A consecutive series of patients with AMI without a previous history of HF (n = 569) were followed up for 8 years. At baseline, the patients had a blood sample for determination of BNP, a 24‐hour Holter recording for evaluating heart rate variability (HRV) and heart rate turbulence (HRT), and an assessment of baroreflex sensitivity (BRS) using phenylephrine test. Results: During the follow‐up, 79 (14%) patients were hospitalized due to HF. Increased baseline BNP, decreased HRV, HRT, and BRS had a significant association with HF hospitalization in univariate comparisons (P < 0.001 for all). After adjusting with all the relevant clinical parameters, BNP, HRV, and HRT still significantly predicted HF hospitalization (P < 0.001 for BNP and for the short‐term scaling exponent α₁, P < 0.01 for turbulence slope). In the receiver operator characteristics curve analysis, the area under the curve for BNP was 0.77, for the short‐term scaling exponent α₁ 0.69, for turbulence slope 0.71, and for BNP/standard deviation of all N‐N intervals ratio 0.80. Conclusion: Baseline increased BNP and impaired autonomic function after AMI yield significant information on the long‐term risk for HF hospitalization. Ann Noninvasive Electrocardiol 2010;15(3):250–258     

Improving the Quality of Care of Long‐Stay Nursing Home Residents in France

The aim of the Impact d'une démarche QUAlité sur l’évolution des pratiques et le déclin fonctionnel des Résidents en Établissement d'hébergement pour personnes âgées dépendantes (IQUARE) study was to examine the effects of a global intervention comprising professional support and education for nursing home (NH) staff on quality indicators (QIs) and functional decline and emergency department (ED) transfers of residents. One hundred seventy‐five NHs in France (a total of 6,275 residents randomly selected from NHs) volunteered and were enrolled in a nonrandomized controlled multicenter individually customize trial with 18‐month follow‐up. NHs were allocated to a quality audit and feedback intervention (control group: 90 NHs, 3,258 residents) or to the quality audit and feedback intervention plus collaborative work meetings between a hospital geriatrician and NH staff (experimental group: 85 NHs, 3,017 residents). At the NH level, prevalence of assessment of kidney function, cognitive function, risk of pressure ulcers, behavioral disturbances, depression, pain, weight measurement, and transfer to the ED were recorded. Ability to perform basic activities of daily living was assessed at the resident level. At baseline, NH QIs were generally low (with large standard deviations), and annual rate of transfer to the ED was high (~20%) and similar in both groups. The intervention had a significant positive effect on the prevalence of assessment of pressure ulcer risk, depression, pain, and prevalence of ED transfers. It had no significant effect on functional decline. Large‐scale efforts to improve QIs involving collaboration between hospital and NH providers and based on audit and collaborative discussion are feasible and improve some aspects of quality of care in NHs.     

Home nursing and home help for dementia patients: Predictors for utilization and expected quality from a family caregiver's point of view

Little is known about the factors that influence utilization of home nursing and home help or about quality expectations of family caregivers of a dementia patient. These questions are addressed in the following paper. The cross-sectional study was carried out as an anonymous written survey of family caregivers of dementia patients in four regions of Germany. Quantitative and qualitative data from 404 family caregivers were analyzed using binary logistic regression analysis and content analysis. We found that subjective need of home nursing respectively of home help and the age of the dementia patient are significant predictors for utilization. Utilization of home nursing is also predicted by the age of the family caregiver. Punctuality of the staff is the dominant quality criterion. Hence, in order to reduce the number of those Alzheimer's disease (AD) caregivers who think they don’t need home nursing or home help compared with the number who really don’t need it, caregivers should be transparently informed of the relevant advantages and quality principles of using home nursing respectively home help.