Admission Diagnosis of FTT vs. Discharge Diagnosis in Older Adults on a Clinical Teaching Medicine Service in a Tertiary Care Teaching Hospital

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1 Admission Diagnosis of FTT vs. Discharge Diagnosis in Older Adults on a Clinical Teaching Medicine Service in a Tertiary Care Teaching Hospital Kristine Kim Preceptor: Dr. Martha Spencer PGY 5 Geriatric Medicine Fellow UBC Geriatric Medicine Krissy.kim@gmail.com

2 Presenter Disclosure Faculty: Kristine Kim Relationships with financial sponsors: None

3 Disclosure of Financial Support I have no financial disclosures I have no conflicts of interest

4 Failure To Thrive FTT associated w/ weight loss, PO intake, poor nutrition and inactivity (NIA) NOT normal aging Associated with Morbidity Mortality Rates Medical Care/Readmission Institutionalization Kumeliauskas L et al, 2013, Berkman et al, 1989, Egbert A.M, 1996, Sarkisian 1996

5 Current Thoughts A quick feeler Better than...circling...the..drain "The Dwindles Dwindling It is to avoid the sort of workup someone our age would deserve and would get. I would not give that DX to the average 70 year old. In a 90 year old with chronic problems who took a sudden turn, I would rule out the obvious easy to fix things and then use FTT. Often would suspect occult malignancy, but without some mass somewhere, need a hospice diagnosis. or piss poor protoplasm I prefer Wasting Syndrome. The patient will need a medical and neurocognitive evaluation in hope to find a reversible condition. Palliative referral is a common outcome.

6 Goals of Study To determine the disparities between the initial diagnosis of FTT and final discharge diagnosis in a clinical teaching medical service. We propose the term FTT is being utilized when an alternative diagnosis for an underlying medical condition is determined as a diagnosis prior to discharge.

7 Methods Subjects Recruited (n= 94) Retrospective cohort study Tertiary university hospital (St. Paul s Hospital) Excluded: Concurrent Acute Admission Diagnosis (n= 18) Subjects included (n=76) Excluded: Not admitted to CTU/FM (n= 1) Admitted prior Jan (n=1) Subjects Eligible (n=74)

8 Methods Electronic Chart Review Descriptive statistical analysis (means, proportions, ranges)

9 TABLE 1: Demographics Age (years) Number of patients % of patients % % % Gender Range (y) Mean ±SD (y) 80 ±9.2 Female 33 45% Male 41 55%

10 KK1 TABLE 2: Results Length of Stays (Days) No. patients % patients % % % % > % Multimorbidity % % More than % P=0.03 P<0.01 Geriatric Consults Yes % No %

11 Slide 10 KK1 Kristine Kim, 4/4/2018

12 TABLE 3: Presentation Presentation Number of patients % of patients Acute only % Chronic only % Mixed 2 2.7% Acute vs Chronic: 77% (65.8% 86%, CI 95%) No less than 2/3 still have an acute medical illness with 95% confidence

13 Diagnosis Acute Reversible Acute Non reversible Chronic Medication s/e (10) Infectious disease (12) Cardiac Disease (11) Malignancy new/metastasis (9) Dementia (9) Neurological Disorder (2) Deconditioning (5) Malignancy Sx (2) Respirology (4) GI (3) Endo (6) Renal (9) Fractures (9) Depression (4) Delirium (5) Anxiety (1)

14 Diagnosis Acute Reversible Acute Non reversible Chronic Medication s/e (10) Infectious disease (12) Cardiac Disease (11) Malignancy new/metastasis (9) Dementia (9) Neurological Disorder (2) Deconditioning (5) Malignancy Sx (2) Respirology (4) GI (3) Endo (6) Renal (9) Fractures (9) Depression (4) Delirium (5) Anxiety (1)

15 Diagnosis Acute Reversible Acute Non reversible Chronic Medication s/e (10) Infectious disease (12) Cardiac Disease (11) Malignancy new/metastasis (9) Dementia (9) Neurological Disorder (2) Deconditioning (5) Malignancy Sx (2) Respirology (4) GI (3) Endo (6) Renal (9) Fractures (9) Depression (4) Delirium (5) Anxiety (1)

16 FTT in Discharge Diagnosis 17.6% 17.6 % (9.7% 28.2%, CI 95%) FEWER than 1/3 contain FTT in discharge diagnosis 82.4% FTT included Acute Medical Diagnosis

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18 Discussion Misuse of FTT on admission in older adults High rate of acute medical illnesses High degree of multimorbidity?delay diagnosis/medical care Further study needed Reasons for using FTT (ie focus groups residents/ed staff) Outcomes: morbidity/mortality Intervention: education (residents/ed staff)

19 Strengths and Limitations Strengths: Builds on current literature Tertiary Hospital in Canada Practical goal of leading to practice change Limitations: Systemic bias limited algorithmic accessibility Small sample size Limited to internal medicine and family medicine

20 Special Thanks CGS (host) Dr. Martha Spencer (PI) Elena Szefer (Statistician) Darby Thompson (Statistician)

21 Thank you Questions?