Global ACE Forum 2017

Transcription

1 1 It s broke! Fix it! Challenging the status quo of geriatrics in acute care George A Heckman MD MSc FRCPC HTCP-1 Schlegel Research Chair in Geriatric Medicine Associate Professor, University of Waterloo Assistant Clinical Professor of Medicine, McMaster University February 20, 2017 Disclosures Schlegel Research Chair in Geriatric Medicine (Schlegel University of Waterloo Research Institute for Aging) Associate Fellow of interrai and collaborator within interrai Canada and the interrai Network of Excellence in Acute Care (ineac) Consultant / speaker fees from Astra Zeneca, Merck, Servier, Pfizer Cardiac Care Network of Ontario Unrestricted funding from CIHR, HSFO and the Alzheimer s Society of Canada Top health care users, Ontario, Canada Multinational interrai ED Study Gray et al, Annals Emerg Med 2013; Costa et al., Acad Emeg Med 2014 Mainly chronic disease (or complications thereof) Often same individuals: multimorbidity More to the story than multimorbidity Wodchis, CMAJ 216 Prospective observational cohort study ED patients aged 75 years or older 13 sites: Australia, Belgium, Canada, Germany, Iceland, India, Sweden 2,475 patients approached, 2,282 (92.2%) consented 98 to 549 across nations Mean age 83.2 yrs, 41% male, 7% from LTC Last 90 days: 36% ED visits, 28% hospital admissions Prevalence of ADL Impairment in ED Gray et al 2013 Factors that drive length-of-stay Source: Costa AP. Geriatric Syndromes Predict Post-discharge Outcomes Among Older Emergency Department Patients: Findings From the interrai Multinational Emergency Department Study. Acad Emerg Med. 2014;21(4):

2 Study conclusion: The Clinical Frailty Scale could be useful in identifying highrisk patients being discharged from general internal medicine wards. Or more simply put Discharge home Bye! You re frail. See you soon! If you don t die first! Or could we Treat frailty as a chronic state and apply Chronic Disease Management & Prevention (CDPM) model Systematic targeting and risk stratification Proactive Geriatric assessment Capacity building Comprehensive Geriatric Assessment: CGA Abellan 2010 CGA is a good thing in targeted (i.e. risk stratified) patients Specialized multidimensional interdisciplinary process focused on determining a frail older persons medical, psychological and functional capacity in order to develop a coordinated and integrated plan for treatment and long-term follow-up 1. Comprehensive data collection i. Includes standardized instruments 2. Diagnostic process and problem list formulation 3. Development of a comprehensive management plan Improved prescribing Fewer hospitalizations Lower institutionalization rate Improved function, cognition Reduced falls Lower mortality Cost-neutral to cost-reducing But how do we TARGET? CDM starts with risk stratification High-intensity CDM 5-10% Mid-intensity CDM 15-20% Low-intensity CDM 75% Is risk = frailty? Is this scenario familiar? 94 year old man is seen in a heart failure clinic 4 ED visits in last two months with HF, one resulting in admission Mild left ventricular systolic dysfunction (EF ~ 45%) No significant valvular problems On appropriate heart failure medications Comorbidities Mild Alzheimer s disease: saw geriatrician a year prior, no follow-up Mild-moderate renal insufficiency Atrial fibrillation Gout 2

3 Functional status What do you see here? Independent in activities of daily living Not depressed, aggressive or psychotic Financially secure So what s the problem?? Caregiver stress Has never received education about HF care They eat out a lot Ronald Wilson Reagan February 6, 1911 June 5, th president of the USA ( ) Died of Alzheimer s disease at age 93 at home Was Ronald Reagan frail? Was he at risk? Frailty and risk: related but not equal The Fundamental Equations of geriatrics Higher risk? HF/F&C Guy: 4 comorbidities Frailty = Vulnerability Risk of Ronald Reagan: Alz Disease, BPH Risk Frailty Stressor X = Implication: The less (obviously) frail can still be high risk Rockwood et al CMAJ 2005 Proactive targeting in the ED? interrai ED screener Emergency Medicine Single problem Acute disease Diagnose and Treat Rapid disposition Geriatrics Comprehensive Geriatric Assessment Multiple medical, functional and social problems Acute, sub-acute, and chronic all in one! Control symptoms, enhance function, support quality of life goals Continuity of care Geriatric syndromes often remain undiagnosed or unattended to in the ED Carpenter 2011; Rutschmann 2005 Yet, they are clearly related to ED post-discharge outcomes Grey 2013; Costa 2014 Identifies need for Comprehensive Geriatric Assessment Takes on average one minute 18 Courtesy: Andrew Costa 3

4 AUA Distribution by Discharge Destination N=2,282 (Canada, Iceland, Sweden, Germany, Belgium, India) Chronic Disease Management: A possible targeting approach 50% Community Acute Care Urgent specialized CGA High-intensity CDM 5-10% 40% 37% 30% 20% 10% 17% 12% 6% 6% 26% 16% 18% 16% 13% 10% 24% Elective specialized CGA / Enhanced primary care Mid-intensity CDM 15-20% 0% 1 - Low High 19 Usual care / prevention Low-intensity CDM 75% Courtesy Andrew Costa What about specialized geriatric services in acute care? GAUs, GARUs, geriatric rehab, consultation services Generally reactive approach to care (e.g. please see for hospital acquired ) Ellis et al Meta analysis Inpatient CGA works Dedicated wards effective Mobile consult teams not effective BMJ 2011 More recent innovations ACE units HELP programs Proactive but limited to acute care Target highest risk individuals: what about others? Geriatrician shortages: Canadian perspective 2014 National Physician Survey Main patient care setting Hospital-based practice 81.5% Community/solo/group 15.5% Urban/suburban 97.4% Main work setting Academic health sciences centre/teaching hospital 79.3% Community hospital 16.1% Community clinic 6.1% Nursing home 0% Are there other ways to deploy geriatricians? Fenton 2006; Aminzadeh 2012; Patterson 2012; Beaulieu 2013; Dhaliwal 2013 Shared care models Effective models in primary care Allows for capacity building, quality assurance, better coordination Indirect clinical services: Telemedicine Care conferences Intelligent EMR design: Point-of-care support for learning, care planning Checklists to make sure important issues not missed Push, not Pull Frailty or risk: geriatrics is everyone s business Final thoughts Risk is a more appropriate measure than simply frailty for planning services Proactive risk-stratification and targeting MUST happen early: ED Proactive CGA Adapt care processes, EMR support to optimized specialized geriatrics impact Potential for better patient AND system outcomes 4

5 Or else we keep doing this Thank you! QUESTIONS? 5