Cost-effectiveness of a brief two-stage emergency department intervention for high-risk elders: results of a quasi-randomized controlled trial

STUDY OBJECTIVE: : We determine the cost-effectiveness of a 2-stage emergency department intervention in addition to usual ED care compared with that of usual care alone. METHODS: The intervention comprises 2 steps: (1) identification of high-risk patients by using a screening tool and (2) a brief standardized nursing assessment to identify unresolved problems, followed by referral to an appropriate community provider. The patient population was composed of individuals aged 65 years and older to be released from the EDs of 4 Montreal hospitals. Patients were randomized by day of ED visit. The perspective of the study is societal, including patients, caregivers, and the formal health care (government-funded) system. Outcomes, measured from randomization to 4 months after randomization, included (1) functional decline, as measured by an activities of daily living instrument, or death, and (2) changes in depressive symptoms. Costs include post-ED care, including hospitalization, physician services, community care, outpatient drugs, and patient and caregiver costs. Cost items were measured with administrative databases and self-reported questionnaires. Unit costs for these items were either province-wide rates or else were estimated directly by using provider data. Cost-effectiveness is assessed in qualitative terms, such that outcomes and costs are compared separately. RESULTS: The intervention was associated with a reduced rate of functional decline (including death) at 4 months. There was no effect of the intervention on change in the patient's depressive symptoms at 4 months relative to baseline. The estimated ratio of overall costs per patient in the intervention versus the control group, adjusted for covariates, was 0.94 (95% credible interval 0.75 to 1.17). Among patients who had visited the ED during the 30 days before the index visit, the ratio was 0.66 (95% credible interval 0.44 to 0.97). CONCLUSION: In this study setting, the intervention is preferred over usual care because beneficial functional outcomes were observed, and overall societal costs were no higher than if usual care only was given.     

The identification of seniors at risk screening tool: further evidence of concurrent and predictive validity

OBJECTIVES: To evaluate the validity of the Identification of Seniors at Risk (ISAR) screening tool for detecting severe functional impairment and depression and predicting increased depressive symptoms and increased utilization of health services. SETTING: Four university-affiliated hospitals in Montreal. DESIGN: Data from two previous studies were available: Study 1, in which the ISAR scale was developed (n=1,122), and Study 2, in which it was used to identify patients for a randomized trial of a nursing intervention (n=1,889 with administrative data, of which 520 also had clinical data). PARTICIPANTS: Patients aged 65 and older who were to be released from an emergency department (ED). MEASUREMENTS: Baseline validation criteria included premorbid functional status in both studies and depression in Study 2 only. Increase in depressive symptoms at 4-month follow-up was assessed in Study 2. Information on health services utilization during the 5 months after the ED visit (repeat ED visits and hospitalization in both studies, visits to community health centers in Study 2) was available by linkage with administrative databases. RESULTS: Estimates of the area under the receiver operating characteristic curve (AUC) for concurrent validity of the ISAR scale for severe functional impairment and depression ranged from 0.65 to 0.86. Estimates of the AUC for predictive validity for increased depressive symptoms and high utilization of health services ranged from 0.61 to 0.71. CONCLUSION: The ISAR scale has acceptable to excellent concurrent and predictive validity for a variety of outcomes, including clinical measures and utilization of health services.     

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.     

A randomized, controlled trial of comprehensive geriatric assessment and multidisciplinary intervention after discharge of elderly from the emergency department--the DEED II study

OBJECTIVES: To study the effects of comprehensive geriatric assessment (CGA) and multidisciplinary intervention on elderly patients sent home from the emergency department (ED). DESIGN: Prospective, randomized, controlled trial with 18 months of follow-up. SETTING: Large medical school-affiliated public hospital in an urban setting in Sydney, Australia. PARTICIPANTS: A total of 739 patients aged 75 and older discharged home from the ED were randomized into two groups. INTERVENTION: Patients randomized to the treatment group underwent initial CGA and were followed at home for up to 28 days by a hospital-based multidisciplinary outreach team. The team implemented or coordinated recommendations. The control group received usual care. MEASUREMENTS: The primary outcome measure was all admissions, to the hospital within 30 days of the initial ED visit. Secondary outcome measures were elective and emergency admissions, and nursing home admissions and mortality. Additional outcomes included physical function (Barthel Index (total possible score=20) and instrumental activities of daily living (/12) and cognitive function (mental status questionnaire (/10)). RESULTS: Intervention patients had a lower rate of all admissions to the hospital during the first 30 days after the initial ED visit (16.5% vs 22.2%; P=.048), a lower rate of emergency admissions during the 18-month follow-up (44.4% vs 54.3%; P=.007), and longer time to first emergency admission (382 vs 348 days; P=.011). There was no difference in admission to nursing homes or mortality. Patients randomized to the intervention group maintained a greater degree of physical and mental function (Barthel Index change from baseline at 6 months: -0.25 vs -0.75; P<.001; mental status questionnaire change from baseline at 12 months: -0.21 vs -0.64; P<.001). CONCLUSION: CGA and multidisciplinary intervention can improve health outcomes of older people at risk of deteriorating health and admission to hospital. Patients aged 75 and older should be referred for CGA after an ED visit.     

Detection of older people at increased risk of adverse health outcomes after an emergency visit: the ISAR screening tool.

OBJECTIVES: To develop a self-report screening tool to identify older people in the emergency department (ED) of a hospital at increased risk of adverse health outcomes, including: death, admission to a nursing home or long-term hospitalization, or a clinically significant decrease in functional status. DESIGN: Prospective (6-month) follow-up study of a cohort of ED patients aged 65 and older. SETTING: The EDs of four acute-care hospitals in Montreal, Quebec, Canada. PARTICIPANTS: Community-dwelling patients aged 65 and older who came to the EDs during the weekday shift over a 3-month recruitment period. Patients were excluded if they could not be interviewed either because of their medical condition or because of cognitive impairment and no other informant was available. MEASUREMENTS: Measures ascertained at the ED visit included: 27 self-report screening questions on social, physical, and mental risk factors; medical history; use of hospital services, medications, and alcohol; and the Older American Resources and Services (OARS) activities of daily living (ADL) scale. At follow-up, the OARS scale was readministered by telephone, and other adverse health outcomes were ascertained. RESULTS: Among 1673 patients who completed the follow-up measures, 488 (29.2%) had an adverse health outcome. Scale development and selection methods included logistic regression, receiver operating characteristic curves, and expert judgment. The proposed screening tool (ISAR) comprises six self-report questions on functional dependence (premorbid and acute change), recent hospitalization, impaired memory and vision, and polymedication. The tool performed well in the total cohort aged 65 and older, and in sub-groups defined by disposition (admitted or released from ED), language of questionnaire administration (French or English), information source (patient or other), and other characteristics. CONCLUSIONS: The ISAR is a short self-report questionnaire that can quickly identify older patients in the ED at increased risk of several adverse health outcomes and those with current disability.     

Effects of a multicomponent intervention on functional outcomes and process of care in hospitalized older patients: a randomized controlled trial of Acute Care for Elders (ACE) in a community hospital

BACKGROUND: Older persons frequently experience a decline in function following an acute medical illness and hospitalization. OBJECTIVE: To test the hypothesis that a multicomponent intervention, called Acute Care for Elders (ACE), will improve functional outcomes and the process of care in hospitalized older patients. DESIGN: Randomized controlled trial. SETTING: Community teaching hospital. PATIENTS: A total of 1,531 community-dwelling patients, aged 70 or older, admitted for an acute medical illness between November 1994 and May 1997. INTERVENTION: ACE includes a specially designed environment (with, for example, carpeting and uncluttered hallways); patient-centered care, including nursing care plans for prevention of disability and rehabilitation; planning for patient discharge to home; and review of medical care to prevent iatrogenic illness. MEASUREMENTS: The main outcome was change in the number of independent activities of daily living (ADL) from 2 weeks before admission (baseline) to discharge. Secondary outcomes included resource use, implementation of orders to promote function, and patient and provider satisfaction. RESULTS: Self-reported measures of function did not differ at discharge between the intervention and usual care groups by intention-to-treat analysis. The composite outcome of ADL decline from baseline or nursing home placement was less frequent in the intervention group at discharge (34% vs 40%; P = .027) and during the year following hospitalization (P = .022). There were no significant group differences in hospital length of stay and costs, home healthcare visits, or readmissions. Nursing care plans to promote independent function were more often implemented in the intervention group (79% vs 50%; P = .001), physical therapy consults were obtained more frequently (42% vs 36%; P = .027), and restraints were applied to fewer patients (2% vs 6%; P = .001). Satisfaction with care was higher for the intervention group than the usual care group among patients, caregivers, physicians, and nurses (P < .05). CONCLUSIONS: ACE in a community hospital improved the process of care and patient and provider satisfaction without increasing hospital length of stay or costs. A lower frequency of the composite outcome ADL decline or nursing home placement may indicate potentially beneficial effects on patient outcomes.     

Randomized-controlled trial of a telephone and mail intervention for alcohol use disorders: three-month drinking outcomes

BACKGROUND: Alcohol screening, brief intervention, and referral to specialized treatment (ASBIR) reduce drinking and related harms. Unanswered questions are how to manage nondependent patients with poor response to brief interventions, how to manage dependent patients who do not obtain treatment, and how to ensure population-wide delivery of ASBIR. Telephone-administered counseling may provide answers. METHODS: We conducted a 12-month randomized controlled trial of a telephone and mail intervention for non-treatment-seeking primary care patients with alcohol use disorders. We enrolled 897 subjects after systematic screening in 18 primary care clinic waiting rooms in and around Madison and Milwaukee, Wisconsin, and subsequent telephone-administered diagnostic interviews. Experimental subjects received up to six sessions of protocol-driven telephone counseling based on principles of motivational interviewing and stages of readiness to change. Control subjects received a pamphlet on healthy lifestyles. The paper reports on 3-month drinking outcomes for men and women with alcohol abuse and dependence. RESULTS: Male experimental subjects (N=199) manifested a 30.6% decline in risky drinking days, compared with a 8.3% decline in controls (N=201, p<0.001). The total consumption declined by 17.3% compared with 12.9% by controls (p=0.001). Female experimental subjects (N=246) manifested a 17.2% decrease in risky drinking days compared with an 11.5% decrease by controls (N=251; p=NS) and a 13.9% decline in total consumption compared with 11.0% by controls (p=NS). Greater numbers of telephone counseling sessions were associated with greater declines in drinking. CONCLUSION: Following systematic screening, a six-session telephone and mail intervention is more effective than a pamphlet in reducing drinking at 3 months for non-treatment-seeking men with alcohol abuse and dependence. An intervention effect of the enrollment procedures may have obscured further intervention effectiveness. Telephone counseling shows promise for non-treatment-seeking primary care patients with alcohol use disorders.     

Case finding and referral model for emergency department elders: a randomized clinical trial

STUDY OBJECTIVE: Elderly emergency department patients have complex medical needs and limited social support. A transitional model of care adapted from hospitals was tested for its effectiveness in the ED in reducing subsequent service use. METHODS: A randomized clinical trial was conducted at 2 urban, academically affiliated hospitals. Participants were 650 community-residing individuals 65 years or older who were discharged home after an ED visit. Main outcomes were service use rates, defined as repeat ED visits, hospitalizations, or nursing home admissions, and health care costs at 30 and 120 days. Intervention consisted of comprehensive geriatric assessment in the ED by an advanced practice nurse and subsequent referral to a community or social agency, primary care provider, and/or geriatric clinic for unmet health, social, and medical needs. Control group participants received usual and customary ED care. RESULTS: The intervention had no effect on overall service use rates at 30 or 120 days. However, the intervention was effective in lowering nursing home admissions at 30 days (0.7% versus 3%; odds ratio 0.21; 95% confidence interval [CI] 0.05 to 0.99) and in increasing patient satisfaction with ED discharge care (3.41 versus 3.03; mean difference 0.37; 95% CI 0.13 to 0.62). The intervention was more effective for high-risk than low-risk elders. CONCLUSION: An ED-based transitional model of care reduced subsequent nursing home admissions but did not decrease overall service use for older ED patients. Further studies are needed to determine the best models of care for this setting and for at-risk patients.     

Feasible model for prevention of functional decline in older people: municipality-randomized, controlled trial

OBJECTIVES: To investigate the effect of an educational program for preventive healthcare professionals in routine primary care on functional ability, nursing home admissions, and mortality in older adults. DESIGN: A prospective, controlled 3-year follow-up study (1999-2001) in primary care with randomization and intervention at the municipality level and outcomes measured at the individual level in two age cohorts. SETTING: Primary care. PARTICIPANTS: Of 81 eligible municipalities in four counties, 34 agreed to participate. A total study population of 5,788 home-dwelling subjects aged 75 and 80 were asked to participate. Written consent was obtained from 4,060 persons (70.1%), of whom 2,104 were living in 17 intervention municipalities and 1,956 were living in 17 matched control municipalities. INTERVENTION: Intervention municipality visitors received ongoing education, and local general practitioners were introduced to a short geriatric assessment program early in the study period. Control municipalities visitors and general practitioners received no education. MEASUREMENTS: At the 3-year follow-up, the outcome measures of mortality and nursing home admissions were obtained from all, and the outcome measure of functional ability was obtained from 3,383 (95.6%) of 3,540 surviving participants. RESULTS: Education improved functional ability (odds ratio=1.20, 95% confidence interval (CI)=1.01-1.42, P=.04) in intervention municipality participants, notably in the 80-year-olds. There were no differences in mortality (relative risk (RR)=1.06, 95% CI=0.87-1.28, P=.59) or rates of nursing home admissions after 3 years (RR=0.74, 95% CI=0.50-1.09, P=.13). Subjects aged 80 benefited from accepting and receiving in-home assessment with regular follow-ups. CONCLUSION: A brief, feasible educational program for primary care professionals helps preserve older people's functional ability.     

A randomised trial of a geriatric evaluation and management consultation services in frail hospitalised patients

BACKGROUND: the usefulness of geriatric evaluation and management (GEM) approaches in the care of frail elderly patients remains uncertain. We examined whether an inpatient geriatric consultation service might be beneficial in a country with a social welfare system. METHODS: we conducted a randomised trial with 345 patients from five centres. Ninety additional patients from four separate centres without GEM teams served as an external comparison. All patients were hospitalised, at least 65 years and frail. Patients were randomly assigned to either comprehensive geriatric assessment and management in the form of consultations and follow-up or usual care. Primary outcomes were rehospitalisation and nursing home placement 1 year after randomisation. Secondary outcomes were survival, functional, emotional and cognitive status, social situation and quality of life. FINDINGS: at 12 months, the groups did not differ in the rate of rehospitalisation (intervention 67%, control 60%, P=0.30), nursing home placement (intervention 19%, control 14%, P=0.27), survival (intervention 81%, control 85%, P=0.56) or any of the other secondary measures. The external comparison groups were also similar in nursing home placement (16%, P=0.40), survival (80%, P=0.88) and all the secondary variables, but rehospitalisation was less (48%, P=0.04). No subgroup benefited from the intervention. INTERPRETATION: care provided by consultation teams did not improve the rates of rehospitalisation or nursing home placement. This is not due to carry-over effects of geriatric knowledge into the control group.     

Enhancing quality of life of families who use adult day services: Short- and long-term effects of the adult day services plus program

PURPOSE: This study examined the short- and long-term effects of Adult Day Services Plus (ADS Plus), a low-cost care management intervention designed to enhance family caregiver well-being, increase service utilization, and decrease nursing home placement of impaired older adults enrolled in adult day care. DESIGN AND METHODS: We used a quasi-experimental design, to recruit 129 caregivers from three adult day centers. Two centers offered adult day services and ADS Plus (n = 67); the third center (n = 62) offered only routine adult day services. ADS Plus involved a staff social worker who provided care management and support to family caregivers through face-to-face and telephone contact. Education, counseling, and referral services were offered for 12 months. RESULTS: At 3-month follow-up, ADS Plus participants (n = 106) reported less depression (p =.016), improved confidence managing behaviors (p =.013) and enhanced well-being (p = .001) compared with controls. Long-term effects analyses (n = 69) showed that, compared with controls, ADS Plus participants continued to report less depression (p = .005) and enhanced confidence managing behaviors (p = .007). Also, intervention participants used adult day services on average 37 days more than controls (p = .003) and had fewer nursing home placements (n = 8) than controls (n = 17). IMPLICATIONS: ADS Plus is cost efficient and is easy to implement within adult day centers. It affords important clinical and public health benefits, including enhanced caregiver well-being, greater adult day service use, and fewer nursing home placements.     

Kenosha County falls prevention study: a randomized, controlled trial of an intermediate-intensity, community-based multifactorial falls intervention

OBJECTIVES: To decrease the rate of falls in high-risk community-dwelling older adults. DESIGN: Randomized, controlled trial. SETTING: Community-based. PARTICIPANTS: Three hundred forty-nine adults aged 65 and older with two falls in the previous year or one fall in the previous 2 years with injury or balance problems. INTERVENTION: Subjects received two in-home visits from a trained nurse or physical therapist who assessed falls risk factors using an algorithm. The intervention consisted of recommendations to the subject and their primary physician, referrals to physical therapy and other providers, 11 monthly telephone calls, and a balance exercise plan. Control subjects received a home safety assessment. MEASUREMENTS: The primary outcome was rate of falls per year in the community. Secondary outcomes included all-cause hospitalizations and nursing home admissions per year. RESULTS: There was no difference in rate of falls between the intervention and control groups (rate ratio (RR)=0.81, P=.27). Nursing home days were fewer in the intervention group (10.3 vs 20.5 days, P=.04). Intervention subjects with a Mini-Mental State Examination (MMSE) score of 27 or less had a lower rate of falls (RR=0.55; P=.05) and, if they lived with someone, had fewer hospitalizations (RR=0.44, P=.05), nursing home admissions (RR=0.15, P=.003), and nursing home days (7.5 vs 58.2, P=.008). CONCLUSION: This multifactorial intervention did not decrease falls in at-risk community-living adults but did decrease nursing home utilization. There was evidence of efficacy in the subgroup who had an MMSE score of 27 or less and lived with a caregiver, but validation is required.     

A randomized trial of comprehensive geriatric assessment and home intervention in the care of hospitalized patients

OBJECTIVE: to prove the effectiveness of geriatric evaluation and management for elderly, hospitalized patients, combined with post-discharge home intervention by an interdisciplinary team. DESIGN: randomized controlled trial with outcome and costs assessed for 12 months after the date of admission. SETTING: university-affiliated geriatric hospital and the homes of elderly patients. SUBJECTS: 545 patients with acute illnesses admitted from home to the geriatric hospital. INTERVENTIONS: patients were randomly assigned to receive either comprehensive geriatric assessment and post-discharge home intervention (intervention), comprehensive geriatric assessment alone (assessment) or usual care. MAIN OUTCOME MEASURES: survival, functional status, rehospitalization, nursing home placement and direct costs over 12 months. RESULTS: the intervention group showed a significant reduction in length of hospital stay (33.49 days vs 40.7 days in the assessment group and 42.7 days in the control group; P < 0.05) and rate of immediate nursing home placement (4.4% vs 7.3% and 8.1%; P < 0.05). There was no difference in survival, acute care hospital readmissions or new admissions to nursing homes but the intervention group had significantly shorter hospital readmissions (22.2 days vs 34.2 days and 35.7 days; P < 0.05) and nursing home placements (114.7 days vs 161.6 days and 170.0 days; P < 0.05). Direct costs were lower in the intervention group [about DM 7000 (US $4000) per person per year]. Functional capacities were significantly better in the intervention group. CONCLUSIONS: comprehensive geriatric assessment in combination with post-discharge home intervention does not improve survival, but does improve functional status and can reduce the length of the initial hospital stay and of subsequent readmissions. It can reduce the rate of immediate nursing home admissions and delay permanent nursing home placement. It may also substantially reduce direct costs of hospitalized patients.     

Factors Associated with Completion of a Behavioral Intervention for Caregivers of Urban Children with Asthma

Background. Rates of preventive follow-up asthma care after an acute emergency department (ED) visit are low among inner-city children. We implemented a novel behavioral asthma intervention, Pediatric Asthma Alert (PAAL) intervention, to improve outpatient follow-up and preventive care for urban children with a recent ED visit for asthma. Objective. The objective of this article is to describe the PAAL intervention and examine factors associated with intervention completers and noncompleters. Methods. Children with persistent asthma and recurrent ED visits (N = 300) were enrolled in a randomized controlled trial of the PAAL intervention that included two home visits and a facilitated follow-up visit with the child’s primary care provider (PCP). Children were categorized as intervention completers, that is, completed home and PCP visits compared with noncompleters, who completed at least one home visit but did not complete the PCP visit. Using chi-square test of independence, analysis of variance, and multiple logistic regression, the intervention completion status was examined by several sociodemographic, health, and caregiver psychological variables. Results. Children were African-American (95%), Medicaid insured (91%), and young (aged 3–5 years, 56%). Overall, 71% of children randomized to the intervention successfully completed all home and PCP visits (completers). Factors significantly associated with completing the intervention included younger age (age 3–5 years: completers, 65.4%; noncompleters, 34.1%; p < .001) and having an asthma action plan in the home at baseline (completers: 40%; noncompleters: 21%; p = .02). In a logistic regression model, younger child age, having an asthma action plan, and lower caregiver daily asthma stress were significantly associated with successful completion of the intervention. Conclusions. The majority of caregivers of high-risk children with asthma were successfully engaged in this home and PCP-based intervention. Caregivers of older children with asthma and those with high stress may need additional support for program completion. Further, the lack of an asthma action plan may be a marker of preexisting barriers to preventive care.     

An outreach geriatric medication advisory service in residential aged care: a randomised controlled trial of case conferencing

BACKGROUND: efficient strategies are needed to provide specialist advice in nursing homes to ensure quality medical care. We describe a case conference intervention involving a multidisciplinary team of health professionals. OBJECTIVES: to evaluate the impact of multidisciplinary case conferences on the appropriateness of medications and on patient behaviours in high-level residential aged care facilities. DESIGN: cluster-randomised controlled trial. SETTING: ten high-level aged care facilities. PARTICIPANTS: 154 residents with medication problems and/or challenging behaviours were selected for case conference by residential care staff. INTERVENTION: two multidisciplinary case conferences involving the resident's general practitioner, a geriatrician, a pharmacist and residential care staff were held at the nursing home for each resident. MEASUREMENTS: outcomes were assessed at baseline and 3 months. The primary outcome was the Medication Appropriateness Index (MAI). The behaviour of each resident was assessed via the Nursing Home Behaviour Problem Scale. RESULTS: 45 residents died before follow-up. Medication appropriateness improved in the intervention group [MAI mean change 4.1, 95% confidence interval (CI) 2.1-6.1] compared with the control group (MAI mean change 0.4, 95% CI -0.4-1.2; P < 0.001). There was a significant reduction in the MAI for benzodiazepines (mean change control -0.38, 95% CI -1.02-0.27 versus intervention 0.73, 95% CI 0.16-1.30; P = 0.017). Resident behaviours were unchanged after the intervention and the improved medication appropriateness did not extend to other residents in the facility. CONCLUSION: multidisciplinary case conferences in nursing homes can improve care. Outreach specialist services can be delivered without direct patient contact and achieve improvements in prescribing.     

Caregiving and institutionalization of cognitively impaired older people: utilizing dynamic predictors of change

PURPOSE: The purpose of this study was to identify reliable predictors of nursing home entry over a 3-year period in a sample of 3,944 persons with dementia who resided in a home setting at baseline. Strengths of the analysis include a multiregional recruitment strategy, incorporation of salient caregiver characteristics, and a 3-year prospective design that allows for the modeling of change in important variables (e.g., care recipient functional status or caregiving indicators) when time to institutionalization is predicted. DESIGN AND METHODS: Data were derived from the control sample of the Medicare Alzheimer's Disease Demonstration Evaluation (MADDE). A Cox proportional hazards model was used to predict time to institutionalization among individuals with dementia (baseline was enrollment into MADDE). Predictors included care recipient demographics, caregiver demographics, and time-varying measurements of care recipient functional status, caregiving indicators, and service utilization. Indicators of change were also incorporated to capitalize on the prospective data available. RESULTS: Although several results were consistent with prior findings, caregiving indicators (i.e., burden and self-rated health) and community-based service use were significant predictors of earlier placement. Change in caregiver instrumental activities of daily living and care recipient activities of daily living were also related to expedited institutionalization. IMPLICATIONS: The findings emphasize the importance of incorporating both care recipient and caregiver function and service use patterns when targeting programs designed to prevent or delay institutionalization for people with dementia.     

Delirium is independently associated with poor functional recovery after hip fracture

OBJECTIVE: To evaluate the role of delirium in the natural history of functional recovery after hip fracture surgery, independent of prefracture status. DESIGN: Prospective cohort study. SETTING: Orthopedic surgery service at a large academic tertiary hospital, with follow-up extending into rehabilitation hospitals, nursing homes, and the community. PARTICIPANTS: One hundred twenty-six consenting subjects older than 65 years (mean age 79 +/- 8 years, 79% women) admitted emergently for surgical repair of hip fracture. MEASUREMENTS: Detailed assessment at enrollment to ascertain prefracture status through interviews with the patient and designated proxy and review of the medical record. Interviews included administration of standardized instruments (Activities of Daily Living (ADL) Scale, Blessed Dementia Rating Scale, Delirium Symptom Interview) and assessment of ambulation, and prefracture living situation. Medical comorbidity, the nature of the hip fracture, and the surgical repair were obtained from the medical record. All subjects underwent daily interviews for the duration of the hospitalization, including the Mini-Mental State Examination and Delirium Symptom Interview, and delirium was diagnosed using the Confusion Assessment Methods algorithm. Patients and proxies were recontacted 1 and 6 months after fracture, and underwent interviews similar to those at enrollment to determine death, persistent delirium, decline in ADL function, decline in ambulation, or new nursing home placement. RESULTS: Delirium occurred in 52/126 (41%) of patients, and persisted in 20/52 (39%) at hospital discharge, 15/52 (32%) at 1 month, and 3/52 (6%) at 6 months. Patients aged 80 years or older, and those with prefracture cognitive impairment, ADL functional impairment, and high medical comorbidity were more likely to develop delirium. However, after adjusting for these factors, delirium was still significantly associated with outcomes indicative of poor functional recovery 1 month after hip fracture: ADL decline (odds ratio (OR) = 2.6; 95% confidence interval (95% CI), 1.1- 6.1), decline in ambulation (OR = 2.6; 95% CI, 1.03-6.5), and death or new nursing home placement (OR = 3.0; 95% CI, 1.1-8.4). Patients whose delirium persisted at 1 month had worse outcomes than those whose delirium had resolved. CONCLUSIONS: Delirium is common, persistent, and independently associated with poor functional recovery 1 month after hip fracture even after adjusting for prefracture frailty. Further research is necessary to identify the mechanisms by which delirium contributes to poor functional recovery, and to determine whether interventions designed to prevent or reduce delirium can improve recovery after hip fracture.     

Effects of a care protocol on care outcomes in older nursing home patients with chronic obstructive pulmonary disease

OBJECTIVES: To evaluate the effects of a care protocol used by community nurses to support nursing home staff in the care of patients with chronic obstructive pulmonary disease (COPD). DESIGN: Matched, randomized case-control trial. SETTING: Forty-five nursing homes of the New Territories South (NTS) cluster of Hong Kong. PARTICIPANTS: Eighty-nine older people (> or =65, present resident of a nursing home in the NTS region, main diagnosis of COPD, at least one hospital admission in previous 6 months) discharged to the nursing homes from the geriatric units of two hospitals. INTERVENTION: Using a care protocol, community nurses followed up older patients in the experimental group for 6 months after their discharge from the hospitals to the nursing homes. MEASUREMENTS: Data on functional, respiratory, and psychological parameters were collected at entry to study and 6 months later with standard measures. Data on hospital service utilization, nursing home staff, and patient satisfaction were also collected at 6 months. RESULTS: Experimental group participants had significant (P =.008) improvements in psychological well-being. Nursing home staff and experimental group patients were highly satisfied with the use of the protocol. There was no significant difference between the two groups in functional and respiratory outcomes or hospital service utilization. CONCLUSION: Psychological well-being as an important factor in rehabilitation in chronic illness has been much neglected in the literature. Supporting nursing home staff in the care of COPD patients through community nursing visits can enhance older residents' psychological well-being. Psychological aspects of care should be emphasized and incorporated into the delivery of regular nursing home care.     

Reduced employment in caregivers of frail elders: impact of ethnicity, patient clinical characteristics, and caregiver characteristics.

BACKGROUND: Without family caregivers, many frail elders who live at home would require nursing home care. However, providing care to frail elders requires a large time commitment that may interfere with the caregiver's ability to work. Our goal was to determine the patient and caregiver characteristics associated with the reduction of employment hours in caregivers of frail elders. METHODS: This was a cross-sectional study of 2806 patients (mean age 78, 73% women, 29% African American, 12% Hispanic, 54% with dementia) with at least one potentially working caregiver (defined as one who is either currently employed or who would have been employed if they had not been providing care) and their 4592 potentially working caregivers. Patients were enrollees at 11 sites of the Program of All-Inclusive Care for the Elderly (PACE). Social workers interviewed patients and caregivers at the time of PACE enrollment. Caregivers were asked if they had reduced the hours they worked or had stopped working to care for the patient. Nurses interviewed patients and caregivers to assess independence in activities of daily living (ADLs) and the presence of behavioral disturbances. Comorbid conditions were assessed by physicians during enrollment examinations. RESULTS: A total of 604 (22%) of the 2806 patients had at least one caregiver who either reduced the number of hours they worked or quit working to care for the patient. Patient characteristics independently associated with a caregiver reducing hours or quitting work were ethnicity, 95% confidence interval [CI] 1.14-1.78 for African American;, 95% CI 1.43-2.52 for Hispanic), ADL function below the median (, 95% CI 1.44-2.15), a diagnosis of dementia (, 95% -2.17 if associated with a behavioral disturbance;, 95% CI 1.06-1.63 if not associated with a behavioral disturbance), or a history of stroke (OR = 1.42, 95% CI 1.16-1.73). After controlling for these patient characteristics, caregiver characteristics associated with reducing work hours included being the daughter or daughter-in-law of the patient (OR = 1.69, 95% CI 1.37-2.08) and living with the patient (OR = 4.66, 95% CI 3.65-5.95 if no other caregiver lived at home, OR = 2.53, 95% CI 2.03-3.14 if another caregiver lived at home). CONCLUSIONS: Many caregivers reduce the number of hours they work to care for frail elderly relatives. The burden of reduced employment is more likely to be incurred by the families of ethnic minorities and of patients with specific clinical characteristics. Daughters and caregivers who live with the patient are more likely to reduce work hours than other caregivers. Future research should examine the impact of lost caregiver employment on patients' families and the ways in which the societal responsibility of caring for frail elders can be equitably shared.     

A specialized home care intervention improves survival among older post-surgical cancer patients

CONTEXT: Changes in the healthcare system have resulted in shortened hospital stays, moving the focus of care from the hospital to the home. Patients are discharged post-operatively with ongoing needs, and whether they receive nursing care post-hospitalization can influence their recovery and survival. Little information is available about the factors that influence outcomes, including the survival of older cancer patients after cancer surgery. OBJECTIVE: To compare the length of survival of older post-surgical cancer patients who received a specialized home care intervention provided by advanced practice nurses (APNs) with that of patients who received usual follow-up care in an ambulatory setting. We also assessed potential predictors of survival in terms of depressive symptoms, symptom distress, functional status, comorbidities, length of hospital stay, age of patient, and stage of disease. DESIGN: A randomized controlled intervention study. SETTING: Discharged older cancer patients after surgery at a Comprehensive Cancer Center in southeastern Pennsylvania. PATIENTS: Three hundred seventy-five patients aged 60 to 92, newly diagnosed with solid cancers, were treated surgically between February 1993 and December 1995. One hundred ninety patients were randomized to the intervention groups and 185 to the usual care group. INTERVENTION: The intervention was a standardized protocol that consisted of standard assessment and management post-surgical guidelines, doses of instructional content, and schedules of contacts. The intervention lasted 4 weeks and consisted of three home visits and five telephone contacts provided by APNs. Both the patients and their family caregivers received comprehensive clinical assessments, monitoring, and teaching, including skills training. MAIN OUTCOME MEASURE: Time from enrollment of patients into the study until death or last date known alive at the end of November 1996. RESULTS: During the 44-month follow-up period, 93 (24.8%) of 375 patients died. Forty-one (22%) of those who died were patients in the specialized home care intervention group, compared with 52 (28%) in the usual care group. Stage of disease at diagnosis differed between the two groups at baseline (38% late stage patients in the intervention group compared with 26% in the control group, P = .01), so stratified analysis was performed. Overall, the specialized home care intervention group was found to have increased survival (P = .002 using stratified log-rank test). Among early stage patients only, there was no difference in survival between the intervention and control groups. Among late stage patients, there was improved survival in the intervention group. For example, 2-year survival among late stage intervention group cases was 67% compared with 40% among control cases. When Cox's proportional hazard model was used to adjust for significant baseline covariates, the relative hazard of death in the usual care group was 2.04 (CI: 1.33 to 3.12; P = .001) after adjusting for stage of disease and surgical hospitalization length of stay. CONCLUSIONS: This is the first empirical study of post-surgical cancer patients to link a specialized home care intervention by advanced practice nurses with improved survival. Additional research is needed to test home care interventions aimed at maintaining quality of life outcomes and their effects on survival of post-surgical cancer patients.