Trends in Hospital Discharge Disposition for Elderly Patients with Infective Endocarditis: 1993 to 2003

OBJECTIVES: To examine hospital discharges of elderly patients hospitalized with infective endocarditis (IE).
DESIGN: A retrospective analysis of hospital discharges from 1993 to 2003.
SETTING: The Nationwide Inpatient Sample (NIS), which approximates a 20% sample of all U.S. acute care hospitals.
PARTICIPANTS: All patients aged 65 and older with a primary or secondary International Classification of Diseases, Ninth Revision , diagnosis code for IE were included.
MEASUREMENTS: The main outcome measures were in-hospital mortality and, for survivors, discharge disposition: to home (with home health care) or to a facility.
RESULTS: Hospitalizations for IE increased 26.0% over the 10-year period, from 3.19 per 10,000 elderly patients in 1993 to 3.95 per 10,000 in 2003. Over the study period, a trend toward increasing discharge to nursing home and decreasing discharge to home and home health care was evident. Discharge to home for survivors decreased from 57.7% to 35.0% over the study period, whereas discharge to nursing facilities increased from 27.7% to 44.3%. Over the 10-year study period, elderly patients hospitalized with IE were 2.3 times as likely to be discharged to a facility as to home.
CONCLUSION: Hospital discharge dispositions have changed for elderly patients admitted with IE. Changes in the patient's age, severity of illness, or comorbidities do not explain these trends. Financial incentives are the most likely factor influencing the substitution in discharge dispositions for elderly patients with IE.     

Level of care and complications among geriatric patients discharged from the medical service of a teaching hospital

To assess the effects of hospitalization on the subsequent placement and supportive care of elderly patients, the medical records of 233 consecutive patients aged 75 years or older, admitted to the medical service of a university hospital, were reviewed. The level of care on admission and at discharge, hospital-associated complications, and demographic data were abstracted for each patient. At discharge, 1 per cent returned to a nursing home, 6 per cent were newly placed in a nursing home, 65 per cent returned to the same level of care as on admission, 10 per cent returned home with an increased level of care, and 18 per cent died or were discharged to another acute care facility. Complications occurred in 30 per cent of patients but did not correlate with age, increased level of care at discharge, or increased rate of nursing home placement. Few elderly patients were discharged to nursing homes, and most returned home without arrangements for increased care.     

Can treatment with angiotensin-converting enzyme inhibitors in elderly patients with moderate to severe chronic heart failure be improved by a nurse-monitored structured care program? A randomized controlled trial

OBJECTIVE: The purpose of this study was to examine whether a nurse-monitored structured care program resulted in a more effective use of angiotensin-converting enzyme (ACE) inhibitors in elderly patients compared with standard care in patients with chronic heart failure (CHF). METHODS: Hospitalized patients were screened to identify individuals with CHF, age more than 65 years, New York Heart Association classification III to IV, and no contraindications to ACE inhibitor treatment. One hundred forty-five patients were randomized to a nurse-monitored structured care program that included uptitration of enalapril to a target dose of 10 mg twice a day or to standard care. Six-month follow-up data were collected. RESULTS: The mean age of the randomized patients was 81 years. Although the proportion of patients treated with an ACE inhibitor did not differ between structured care (70%) and standard care (64%), the number of patients with the target ACE inhibitor dose was significantly higher in the structured care group (26% versus 11% in the standard care group; P <.018). Treatment had to be discontinued in 26% of the patients because of adverse effects. CONCLUSION: The patients in this study were older than in previous intervention studies and had considerable comorbidity and reduced tolerance for ACE inhibitors. ACE inhibitor treatment was underused but improved with the structured care program, although achieved treatment levels were below those in the large intervention trials in patients with CHF.     

Abdominal colon and rectal operations in the elderly

Sixty-seven abdominal operations for colon and rectal disorders were performed on 56 patients 80 years of age or older from January 1, 1984 to June 30, 1989. Nine patients required multiple operations. Sixty-two procedures (92 percent) were performed on patients in their ninth decade; two operations were performed on patients 95 years of age or older. Forty-five patients (80 percent) were operated upon for carcinoma. Operations included segmental colectomy (33 patients), low anterior resection (12 patients), total abdominal colectomy (3 patients) and abdominoperineal resection (2 patients). Forty patients were classified as ASA Class III; the majority were monitored in the surgical intensive care unit for a mean of 2.84 days. Thirty patients were monitored with arterial catheters and 21 with central invasive monitoring. Operative mortality was 7 percent (4 patients). Two patients died from diffuse carcinomatosis; one patient had a fatal myocardial infarction. The final death occurred from multisystem organ failure following anastomotic dehiscence. Twenty-seven operations were performed without postoperative complications; 18 operations were followed by a single minor complication. The average hospital stay was 18.96 days. All patients were admitted from home. Thirty-three returned home postoperatively; 16 were discharged to an extended care facility. In conclusion, elderly patients with colon and rectal disorders can be operated upon with acceptable morbidity and mortality. Age alone should not interdict surgical therapy.     

Relevance of readmission of elderly patients discharged from a geriatric unit

Eight percent of the elderly patients discharged from a geriatric unit in one year were readmitted within three months. Forty-six percent had been living alone and nearly all of these had received full community support at the time of discharge. Recurrent problems were the reason for readmission in 59% of cases, mainly due to falls, incontinence, and confusion. Only 54% of the readmitted patients were discharged home again--those with new additional problems tended to die in hospital, whereas those with recurrent problems often required institutional long-term care. It is concluded that even with careful discharge planning, a proportion of patients will require readmission, some of which will also require long-term institutional care. This number is quite small in terms of the total number of patients discharged from a geriatric unit and should not be a reason for seeking nursing home care at an early stage.     

Quality of care of nursing home residents hospitalized with heart failure

OBJECTIVES: To determine whether the quality of heart failure (HF) care of hospitalized nursing home (NH) residents is different from that of patients admitted from other locations. DESIGN: Retrospective chart review. SETTING: Nursing home residents discharged from hospitals. PARTICIPANTS: Medicare beneficiaries aged 65 and older. MEASUREMENTS: Subjects were discharged with a primary discharge diagnosis of HF in Alabama in 1994. They were categorized as having been admitted from a NH or other locations. Bivariate logistic regression analysis was used to estimate crude odds ratios (ORs) and 95% confidence intervals (CIs) for left ventricular function (LVF) evaluation and angiotensin-converting enzyme (ACE) inhibitor use for NH residents relative to nonresidents. Multivariate generalized linear models were developed to determine independence of associations. RESULTS: Subjects (N = 1,067 years) had a mean age +/- standard deviation of 79 +/- 7.4, 60% were female, and 18% were African Americans. Fewer NH residents (n = 95) received LVF evaluation (39% vs 60%, P <.001) and ACE inhibitors (50% vs 72%, P =.111). NH residents had lower odds for LVF evaluation (OR = 0.42, 95% CI = 0.27-0.64). The odds for ACE inhibitor use, although of similar magnitude, did not reach statistical significance (OR = 0.40, 95% CI = 0.12-1.28). After adjustment of patient and care characteristics, admission from a NH was significantly associated with lower LVF evaluation (adjusted OR = 0.64, 95% CI = 0.49-0.82) but not with ACE inhibitor use (adjusted OR = 0.59, 95% CI = 0.16-2.14). CONCLUSIONS: Quality of HF care received by hospitalized NH residents was lower than that received by others. Further studies are needed to determine reasons for the lack of appropriate evaluation and treatment of NH patients with HF who are admitted to hospitals.     

Characteristics and outcomes of older adults with community-acquired pneumococcal bacteremia

OBJECTIVES: To describe baseline characteristics and clinical outcomes of older adults with pneumococcal bacteremia, compare the frequency of serious outcomes according to pneumococcal vaccination status, and assess factors associated with mortality. DESIGN: Population-based case-series. SETTING: Group Health Cooperative, a health maintenance organization in Washington State. PARTICIPANTS: Community-dwelling adults aged 65 and older with a first episode of pneumococcal bacteremia between 1988 and 2002. MEASUREMENTS: Demographic characteristics, underlying medical conditions, vaccination status, and clinical outcomes, including death, hospitalization, length of hospital stay, and postdischarge care, were assessed using chart review. RESULTS: The mean age of the 200 elderly patients with pneumococcal bacteremia was 78; 61% were female. Forty percent had had chart-documented pneumococcal vaccination before the onset of bacteremia. The spectrum of clinical severity and consequences was broad. Ten percent were treated as outpatients. Of the 90% who were hospitalized, 16% were admitted to the intensive care unit. All-cause mortality at 30 days was 11%. Of survivors, 23% were discharged with home services, and another 20% were discharged to a nursing home. After controlling for age, sex, and pneumococcal vaccination status, predictors of death included coronary artery disease (odds ratio (OR)=4.6, 95% confidence interval (CI)=1.4-14.5) and immunocompromising conditions (OR=5.0, 95% CI=1.6-15.7). Outcomes were similar in patients who did and did not receive pneumococcal vaccination. CONCLUSION: In this elderly group, pneumococcal bacteremia was associated with substantial morbidity, mortality, and loss of independence. Coronary artery disease and immunocompromising conditions were independent predictors of death.     

Age-related differences in care receipt and symptom experience of elderly cancer patients dying at home: Lessons from the DEATH project

Background:   Data on the differences between older and younger elderly cancer patients dying at home is sparse. To clarify age-related differences in symptom experience and care receipt of elderly cancer patients at end-of-life, we conducted a subanalysis study of the Dying Elderly at Home (DEATH) project, a multicenter study of 240 elderly aged 65 and older dying at home.
Methods:   We assessed the frequency of symptom experience and end-of-life care receipt in home elderly patients during the last 2 days of their lives and evaluated the differences between younger elderly (aged 65–74) and older elderly (aged 75+) cancer decedents. The general practitioners were asked to fill out a questionnaire immediately after the death of study patients. A total of 66 younger and 51 older elderly cancer decedents were included in the analysis.
Results:   Coma and dementia were common among younger and older elderly patients. Older decedents were less likely to experience anxiety, but, after adjustment for baseline characteristics, this age-related difference did not clearly appear. Older decedents were also less likely to receive opioids than younger decedents. There were no significant differences in volume of i.v. hydration between the two groups.
Conclusions:   Our results suggested that there were no differences in symptom experience and care receipt among older and younger decedents, except in opioid use, at end-of-life. These findings imply a similar need of end-of-life care for younger and older elderly cancer patients who opt for home death.     

An inpatient bed for acute nursing home admissions

BACKGROUND: Some older patients are admitted directly to nursing homes without a comprehensive assessment. OBJECTIVE: To determine whether a hospital assessment bed might provide better assessment, treatment and a more appropriate placement for selected older people. Setting a single bed in an elderly care unit of a district general hospital. SUBJECTS: Older people who general practitioners thought needed nursing home care but whose social workers felt might benefit from inpatient assessment. MAIN OUTCOME MEASURES: Type of treatment needed (acute care, rehabilitation, palliation, long-term care) and placement (home, nursing home, residential home or hospital). RESULTS: of 34 patients assessed, 22 (65%) needed further clinical assessment or care and 26 (75%) left hospital for places other than nursing homes. CONCLUSIONS: Inpatient assessment is a successful way of assessing the needs of some older people who would otherwise have been admitted directly from their homes to nursing homes.     

Subintensive care unit for the elderly: a new model of care for critically ill frail elderly medical patients

OBJECTIVE: An increasing number of elderly patients are admitted to the hospital for critical diseases and the gap between supply and demand of intensive care resources is a growing problem. To meet this challenge, 4 beds in a 24-bed acute care for the elderly (ACE) medical unit were dedicated to a subintensive care unit (SICU). Severely ill elderly medical patients, requiring a higher level of care than provided in ordinary wards, are admitted. The aim of the study was to describe the characteristics of the setting and to discuss its usefulness based on data obtained after the first period of implementation. METHODS: This article describes the development, management, economics and patient characteristics of the SICU. Patient care combines the ACE model with a highly specialised medical care. Patients admitted to the SICU are compared with patients treated in the ordinary ACE unit before the SICU opened. All patients received a multidimensional evaluation, including demographics, main diagnosis, number of chronic somatic diseases, Charlson index, APACHE II score, APACHE-APS subscore, number of currently administered drugs, serum albumin, cognitive status (Mini-Mental State Examination), depression (Geriatric Depression Scale) and functional status (basic and instrumental activities of daily living). Ward physicians performed assessment and collection of data. RESULTS: During the first 16 months, 489 patients were admitted, 401 according to the selection criteria (60 +/- years and APACHE II score > or =5 and/or APACHE-APS score > or =3). Mean age was 78.1 years, mean APACHE II score 14.5 (moderate severity) and non-invasive mechanical ventilation was received by 87 (21.7%). The most common diagnoses were respiratory failure, cardiac disease and stroke. Mean length of stay in the SICU was 61.8 h, and 6.0 days in the hospital. Compared with ACE-unit patients admitted during 2002 (n=1380), SICU patients were obviously more seriously ill (APACHE II score 14.5 vs 6.7). When comparing patients of same illness severity (APACHE-APS score > or =3) (n=125), patients treated in the SICU had lower in-hospital mortality than those treated in the ordinary ACE ward (12.5 vs 19.2%). Only a few patients (3.5%) were transferred to the intensive care unit as a consequence of increased severity of illness. CONCLUSIONS: The SICU is an innovative method to treat frail elderly patients with more severe conditions. Low hospital mortality compared with that of severe patients in the ACE unit supports the usefulness of this model. It could be implemented in medical units of large hospitals in order to give optimal care and advanced interventions to the frail elderly and to avoid intensive care unit overcrowding.     

Upper extremity fractures in the elderly: consequences on utilization of rehabilitation care

BACKGROUND AND AIMS: While hip fractures represent the most dramatic consequence of osteoporosis, fractures of the humerus, forearm and wrist account for one-third of the total incidence of fractures due to osteoporosis in the older population. The aim of this retrospective cohort study was to evaluate rehabilitation care utilization and associated factors in elderly individuals with upper limb fracture. METHODS: Over two years, 667 patients 65 years of age or older were studied, who presented to the emergency department either from their private homes or nursing homes with an upper extremity fracture. The following outcome variables were collected: gender; age; residence; location of fracture; treatment; discharge destination; length of hospitalization; length of stay in a rehabilitation facility; and ultimate place of habitation after the event. RESULTS: The most frequent sites of fracture were distal radius (37.2%) and proximal humerus (29.1%). Two-thirds of the patients were treated non-operatively. Inpatient rehabilitation care was necessary for 248 patients (37.2%; length of stay, 46 days). Factors associated with increased care included older age (> or = 80 years), coming from private home, sustaining two fractures, fractures of the humerus, and operative treatment. Six percent of the patients required permanent nursing home care. CONCLUSIONS: Upper extremity fractures in older people often require prolonged hospitalization and therefore account for considerable health care costs. Reasons are more related to advanced age and living conditions than to particular injury or treatment.     

Warfarin for stroke prevention in octogenarians with atrial fibrillation

The authors examined warfarin use in elderly patients with atrial fibrillation. Medical records were abstracted from a random sample of Medicare beneficiaries with atrial fibrillation who were discharged from Kansas hospitals. Data were analyzed for warfarin and aspirin use and risk factors for stroke or bleeding in patients 65–79 years of age or 80 years and older. Stroke risk factors other than age and atrial fibrillation were seen in 98% of 142 patients less than 80 years of age and 100% of 141 octogenarians. Warfarin use was similar in the younger and older age groups (50% vs. 45%, respectively; p= ns) and was not associated with the number of stroke or bleeding risk factors. Compared to patients less than 80 years of age, octogenarians were less likely to receive aspirin (38% vs. 27%, respectively; p< 0.05). Anticoagulation rates for high-risk patients with atrial fibrillation were low and poorly explained by stroke or bleeding risks.     

Predictors of length of stay between the young and aged in hospitalized community‐acquired pneumonia patients

Aim: To determine the factors that may prolong the length of stay (LOS) for older patients hospitalized for community‐acquired pneumonia (CAP) and also to see if they are applicable to the younger patients. Methods: A retrospective case record review was conducted of all adult patients who were discharged from the general medical service or the geriatric medicine service of an acute care hospital over 6 months. Results: During the study period, 393 patients were discharged with the diagnosis of pneumonia. Based on the study criteria, 200 patients were included in the study. Of the elderly patients, 39% had severe pneumonia compared to 9.3% in the younger group (P < 0.001), resulting in a higher mortality rate. All patients with severe pneumonia had serum albumin levels of less than 3.7 g/dL. The median LOS was significantly shorter in the younger patients (4 days) compared to the elderly patients (9 days, P < 0.001). Severe pneumonia, dysphagia, chronic renal disease, hypoalbuminemia and older age group were found to be significantly associated with longer LOS. Conclusion: Compared to younger patients, older subjects aged 65 years and above hospitalized with CAP were more likely to have severe pneumonia and longer LOS. Presence of severe pneumonia, dysphagia, chronic renal disease, hypoalbuminaemia and age of more than 65 years were significantly associated with longer LOS for all patients. However, in the younger group, only hypoalbuminaemia remained a significant factor. In the elderly patients, severe pneumonia, dysphagia and type of residence were important factors predicting longer LOS.     

Intensive care unit use and mortality in the elderly

OBJECTIVE : To examine utilization and outcomes of intensive care unit (ICU) use for the elderly in the United States.
DESIGN : We used 1992 data from the Health Care Financing Administration to examine ICU utilization and mortality by age and admission reason for hospitalizations of elderly Medicare beneficiaries.
MAIN RESULTS : Use of the ICU was least likely for the oldest elderly overall (85+ years, 21.1% of admissions involved ICU; 75–84 years, 27.9%; 65–74 years, 29.7%), but more likely during surgical admissions. Eighty-three percent of the Medicare patients who received intensive care survived at least 90 days. Of the oldest elderly, 74% survived. Even among the 10% most expensive ICU hospitalizations, 77% of all patients and 62% of those 85 years and older survived at least 90 days.
CONCLUSIONS : The likelihood of ICU use among these elderly decreased with age, especially among those 85 years or older. Diagnostic mix importantly influenced ICU use by age. The great majority of the elderly, including those 85 years and older and those receiving the most expensive ICU care, survived at least 90 days.     

Disparity between influenza vaccination rates and risks for influenza-associated hospital discharge and death in Manitoba in 1982-1983.

OBJECTIVE: To determine, in a defined population, the percentage of persons who were discharged from a hospital or died of influenza-associated respiratory conditions who had a health care contact during the preceding vaccination season and to determine the relation between risk status for influenza-associated hospitalization and death and influenza vaccination rates. DESIGN: An observational study using linked-record analysis of medical claims data. SETTING AND PATIENTS: A probability sample of 100,000 noninstitutionalized adults living in Manitoba in 1982 to 1983. MEASUREMENTS: Analysis of medical claims for influenza vaccination and hospital discharges and deaths for influenza-associated respiratory conditions during the 1982-83 influenza vaccination season and influenza outbreak period. RESULTS: For the population as a whole, 50% to 60% of elderly persons (greater than or equal to 65 years of age) and 30% to 40% of younger persons had one or more health care contacts during the influenza vaccination season but fewer than 10% of all persons had been discharged from a hospital. In contrast, for elderly persons hospitalized with respiratory conditions during the influenza outbreak period, approximately 80% had at least one health care contact during the vaccination season. Among the elderly, 39% to 46% of all those discharged for influenza-associated respiratory conditions and 62% to 67% of those who died had been discharged from hospital during the previous vaccination season. Persons discharged with high-risk conditions during the vaccination season were at greater risk for hospitalization with influenza-associated respiratory conditions but were less likely to be vaccinated than were those at lower risk. CONCLUSIONS: Most persons who were hospitalized with influenza-associated respiratory conditions had contact with health care providers during the preceding influenza vaccination season. Among elderly patients, previous hospital care was common, especially among those who died. The disparity between influenza vaccination rates and risks for influenza-associated hospital discharge and death supports a strategy of hospital-based influenza vaccination.     

Prediction of hospital utilization among elderly patients during the 6 months after an emergency department visit

STUDY OBJECTIVE: A simple screening tool, Identification of Seniors at Risk (ISAR), developed for administration in the emergency department for patients 65 years and older, predicts adverse health outcomes during the 6 months after the ED visit. In this study, we investigated whether the ISAR tool can also predict acute care hospital utilization in the same population. METHODS: Patients 65 years and older who visited the EDs of 4 acute care Montreal hospitals during the weekday shift over a 3-month period were enrolled. At the initial (index) ED visit, 27 self-report screening questions (including the 6 ISAR items) were administered. The number of acute care hospital days during the 6 months after the index visit were abstracted from the provincial hospital discharge database. High utilization was defined as the top decile of the distribution of acute care hospital days. RESULTS: Among 1,620 patients with linked data, a score of 2+ on the ISAR tool predicted high hospital utilization with a sensitivity of 73% and a specificity of 51%; the area under the receiver operating characteristic curve was 0.68. The ISAR tool also performed well in subgroups defined by disposition (admitted versus discharged) and by age (65 to 74 years versus 75 years and older). CONCLUSION: The ISAR tool, a 6-item self-report questionnaire, can be used in the ED to identify elderly patients who will experience high acute care hospital utilization as well as adverse health outcomes.     

Characteristics and Outcomes of Injured Older Adults After Hospital Admission

OBJECTIVES: To describe the seriously injured adult population aged 65 and older; compare the differences in injury characteristics and outcomes in three subgroups aged 65 to 74, 75 to 84, and 85 and older; and identify predictors of death, complications, and hospital discharge destination. DESIGN: Retrospective secondary analysis of data from the Queensland Trauma Registry (QTR) using all patients aged 65 and older admitted from 2003 through 2006. SETTING: Data from 15 regional and tertiary hospitals throughout Queensland, Australia. PARTICIPANTS: Six thousand sixty‐nine patients: 2,291 (37.7%) aged 65 to 74, 2,265 (37.3%) aged 75 to 84, and 1,513 (24.9%) aged 85 and older. MEASUREMENTS: Outcome variables included mortality, complications, and discharge destination (usual residence, rehabilitation, nursing home, convalescence). Predictive factors incorporated demographic details, injury characteristics, and acute care factors. RESULTS: Hospital survival was 95.0%, with a median length of hospital stay of 8 days (interquartile range 5–15), and 33.8% of cases with a major injury developed a complication. Predictors of death included older age, male sex, admission to the intensive care unit (ICU), greater Injury Severity Score (ISS), injury caused by a fall, and two or more injuries; those who had surgery were less likely to die. Predictors of complications included ICU admission, older age, longer hospital stay, and two or more injuries. Predictors of discharge to a nursing home included older age, greater ISS, longer hospital stay, and injury caused by a fall, among others. CONCLUSION: Older adults with severe injuries are at risk of poor outcomes. These findings suggest opportunities for improving geriatric trauma care that could lead to better outcomes.     

The use and effectiveness of an emergency department observation unit for elderly patients

STUDY OBJECTIVE: Emergency department observation units are cost-effective alternatives to hospital admission for selected patients. However, the use and effectiveness of these units in the elderly population is unclear. We sought to describe the use of an ED observation unit by elderly patients (>or=65 years), to determine whether the ED observation unit is effective for them in terms of ED observation unit length of stay and hospital admission rates, and to compare efficacy and return visit rates between younger and older patients. METHODS: This is a retrospective observational cohort study of consecutive adult patients sent to an ED observation unit from 1996 to 2000 at a high-volume tertiary care suburban teaching hospital. ED observation unit length of stay of less than 18 hours and admittance rates of less than 30% were used as indicators of efficacy. Diagnosis, length of stay, hospital admission rates, and 30-day return visit rates were compared between younger and older patients. RESULTS: Twenty-two thousand five hundred and thirty adult patients were observed, with 37.2% older than 65 years of age. The most common diagnoses in elderly patients were chest pain (24.0%), dehydration (11.7%), syncope (6.5%), back pain (4.6%), and chronic obstructive pulmonary disease (3.8%). Length of stay in the ED observation unit was longer for the elderly than younger patients but still averaged less than 18 hours (15.8 hours [95% confidence interval (CI) 15.7 to 16.0] versus 14.4 hours [95% CI 14.3 to 14.5], respectively). Elderly patients were more likely to be admitted from the ED observation unit than younger patients (26.1% versus 18.5%); however, their overall admission rate remained less than 30%. Compared with younger patients, the odds ratios for inpatient admission of elderly patients was highest for back pain (2.10; 95% CI 1.62 to 2.73), pyelonephritis (1.78; 95% CI 1.16 to 2.71), and chest pain (1.65; 95% CI 1.44 to 1.89). Thirty-day related return visit rates between age groups were similar (9.4% versus 7.6%). CONCLUSION: Elderly ED observation unit patients had ED observation unit lengths of stay and hospital admission rates that were effective for an ED observation unit setting and ED return visits rates that were comparable with those of younger patients.