Aged Care and Health Services Research A/Prof Kwang Lim Sep 2016
Accumulating evidence 20% of health care interventions is based on hard evidence. Feasibility of doing randomised controlled trials on all interventions. Translating Practice into Research Merging service requirements and outcome evaluation.
Why aged care? Demographics Population aged 65 years or more, Australia - At 30 June Population change
Focus: hospital based interventions Using service delivery to enhance outcomes: Delivering interventions during hospitalisation Post Acute Care Preadmission
Orthogeriatrics Hip fracture has an in-hospital mortality that exceeds 10%. One year mortality of 30%. 50% require long term assistance with their daily activities and cannot walk unaided. 25% end up in institutional care.
OARS (Orthogeriatric interventions) Acute orthopaedic-geriatric co-management is the only model to demonstrate reductions in mortality 319 patients over the age of 65 years were randomly assigned to daily multidisciplinary geriatric intervention or usual care mortality was lower in patients assigned to geriatric intervention (0.6% vs 5.8%, P = 0.03) major medical complications were reduced (45.2% vs 61.7%). At 3 months more patients in the geriatric intervention group had achieved a partial recovery (57% vs 44%, P = 0.03) Vidan M, et al. Efficacy of a comprehensive geriatric intervention in older patients hospitalized for hip fracture: A randomized, controlled trial. [see comment]. Journal of the American Geriatrics Society 2005; 53: 1476 1482.
Why do patients die Care is not ideal : Medical-Time to surgery, pre op and post op care Nursing-focus-prevention of pressure ulcers and delirium Physiotherapy-early mobilisation Cardiac comorbidity coronary heart disease
Chong et al.description of an orthopaedic-geriatric model of care in Australia with 3 years data. Geriatr Gerontol Int 2008; 8: 86 92 OARS (Orthopaedic Aged Care and Rehabilitation Service) Acute co-management with dedicated medical team and multidisciplinary team including a nurse coordinator and allied health Review of outcomes over a 3 year period. 834 consecutive patients Inpatient fractured NOF mortality of 3.5% c/w state average of 5.2% 90% who died had 3 significant comorbidities 70% had a premorbid cardiac condition
Peri-operative Myocardial Infarction Mostly silent Occur early after surgery ECG changes non-q wave Either end of surgery or 24-96 hours later Circulation 2006,Am Heart J 2007,Anesthesiology 1998
Cardiac Troponin I Troponin I retrospectively added onto blood ordered by unit Pre-op Days 1,2,3 post-op Tested after 30 days (mean 46 days) Architect STAT Troponin I assay (Abbott Diagnostics
Methods Demographic and medical data reviewed including complications and mortality 100/102 patients followed up at 1 year
Results 102 patients consented Mean age 79 (SD 10) 73% women 85% from home and 15% residential care Incidence of post-op troponin rise was 52.9% (54/102) Mean time to peak troponin = 2 days post-op
Results Mortality 21/102 (20.6%) 20 patients with a troponin rise versus 1 without (p<0.0001) Post-op troponin rise (OR 12.0,p=0.025) 50% died of cardiovascular cause
(a) Kaplan Meier survival curve of all patients divided into whether troponin was elevated post-operatively. Chong C P et al. Age Ageing 2009;38:168-174
Findings Troponin I rise independently and significantly associated with increased mortality and cardiac events at 1 year Significant relationship between magnitude of peak troponin and one year mortality Prognostic marker for older patients undergoing emergency orthopaedic surgery Can prevention or treatment of troponin rises improve outcome?
Troponin elevation If elevated, patients were randomised to the intervention (cardiology care) versus standard care. Intervention: management in coronary care, telemetry for at least 24 hours, review by cardiologist within 24 hrs who made recommendations about medications, investigations outpatient follow up + functional tests if appropriate.
Main intervention Changes to medications as a result of a troponin elevation CC: 29 (82.9%) SC: 8 (22.9%), p<0.001 Aspirin and b-blocker use significantly different Aspirin 16 commenced CC, 2 SC(p=0.022) BBlocker 9 commenced CC, 1 SC (p=0.034) No difference with statins 12, 14 (p=0.806)
Intervention No patients received an inpatient coronary angiogram. All patients randomised to CC received telemetry for 24 hours. Non-sustained VT seen in 5/35 (14.3%), one dead at one year.
Results No difference between randomised groups 6/35 (17.1%) dead in each group (p=1.000) Cardiology care did not improve immediate outcomes nor one year mortality Treatment at discretion of cardiology unit Difficulty with follow up
Where to from here Intervention too late In collaboration with Department of Cardiology and Orthopaedics?RCT looking at preoperative Statins and Ivabradine
Adapating the lessons from orthogeriatrics Extension into elective surgery
Care for older patients undergoing elective surgery POPS (Proactive care of older people undergoing surgery) service at Guys Hypothesis- Multidisciplinary preoperative intervention targeting potentially modifiable risk factors will improve post-operative outcomes Harari et al. Proactive care of older people undergoing surgery ('POPS'): Designing, embedding evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients Age Ageing 2007:36:190-6
Surgical Outpatients Proactive referral of all patients aged 75 or over Patients at risk according to screening criteria Patients diagnosed as medically unfit Post Discharge Intermediate Care Links with primary care/ social care Specialist clinic follow up (falls etc) POP S Geriatrician Nurse Specialist OT Physiotherapi st Social Worker Hospital Admission Post-op consultant geriatrician/ specialist nurse intervention Therapy liaison Discharge planning Teaching/ training Pre-operative Multidisciplinary assessment, treatment and liaison with surgical and anaesthetic team Consultant assessment: Comprehensive medical management Specialist Nurse: Comprehensive assessment and patient/ carer education Physiotherapy: Domiciliary assessment, muscle strengthening (cardiovascular training and breathing exercises) OT: Home visit, equipment provision Social Care: Post-op discharge planning
Medical complications MR Pre-POPS Post-POPS N=54 N=54 Delirium 18.5% (10) 5.6% (3)* Pneumonia 20% (11) 4% (2)* Wound sepsis 22.2% (12) 3.7% (2)* ACS 7.4% (4) 3.7% (2) Arrhythmia 13% (7) 7.4% (4) Heart failure 3.7% (2) 0 Thrombosis 11% (6) 2% (1)
Multidisciplinary complications MR Pre-POPS N=54 N=54 Post-POPS Uncontrolled pain 29.6 (16) 1.9 (1)* NBM >4days 9.3 (5) 0* Catheter>4/7 20.4 (11) 7.4 (4)* Constipation 29.6 (16) 16.7 (9) Dependent 14.8 (8) 0* transfers Bedridden >3days 27.8 (15) 9.3 (5)* Pressure sores 18.5 (10) 3.7 (2)*
Resource issues MR Pre-POPS Post-POPS N=54 N=54 Length of stay 15.8+13.2 (2-80) 11.5+ 5.2 (4-26)* Delayed discharge 70.4% (38) 24.1% (13)* - medical problems 37% (20) 13% (7) - slow rehabn. 13% (7) 7.4% (4) - wait for OT or equipment 20.4% (11) 3.7% (2)
PRIME (Proactive medical intervention for elective surgical patients in the CGA pre op elderly) Operative risk determined Perioperative management Case control analysis in process
Pilot study examining the intervention 30 patients vs 60 controls Controls recruited from previous yearsame time period and matched for procedure, age and sex.
Results (JAGS 2014 ) No diff in outcomes, LOS Charlson comorbidity aged adjusted: PRIME (4.8) vs Control (3.9), p= 0.046 Post op cardiac complication: PRIME 0, Control 7/60, p=0.051 Notice of admission to surgery PRIME 78 days, control 132 days, p= 0.002 Summary-treating sicker patients, faster with equivalent results
Other hospital based studies Delirium prevention study Does exercise and reorientation prevent delirium in hospital? Largest randomised controlled trial in the world (> 600 patients)- Dr Kim Jeffs and NCRC. The Ethics of cardiopulmonary resuscitation-dr Barbara Hayes PhD
Interface with the community The Post Acute Care Study Lim WK, Lambert SF, Gray LC. Effectiveness of case management and postacute services in older people after hospital discharge. Med J Aust 2003. 178:262-6.
Background: Definition The Victorian Post Acute Care (PAC) Program is a time limited short-term intervention designed to assist patients to fully recuperate following an acute hospital admission.
Post Acute Care Study The PAC study was a multicentre randomised controlled study involving four Melbourne hospitals funded by the Victorian DHS. The hypotheses was that: The PAC intervention reduces the readmission rate or the overall hospital utilisation rates in the 6 month period after discharge. The PAC intervention improves health status, quality of life and reduces continuing community service use 6 months after discharge.
Recruitment Patients were eligible for study enrolment if they met the following risk screening criteria: The patient was likely to have mobility and/or self care management problems OR met two or more of the following three criteria: AND The patient lived alone The patient had responsibilities for caring for others at home The patient used community services prior to their hospital admission Patient required community services on discharge.
Results 946 PAC eligible: Not able to recruit 266, Declined 205, Missed 61 679 consented, 598 available for analysis 311 intervention, 287 controls
Results for readmitted patients
Results Improvement in Independent Living and AQoL score. Cost effective. Post Acute Care now available across the state.
Interface with residential care The HARP experience
RECIPE Residential Care Intervention Program in the Elderly Harvey P, Storer M, Berlowitz DJ, Jackson B, Hutchinson A, Lim WK. Feasibility and impact of a post-discharge geriatric evaluation and management service for patients from residential care: the Residential Care Intervention Program in the Elderly (RECIPE). BMC Geriatrics. 2014
RECIPE: intervention Comprehensive (geriatric) assessment in RCF after discharge from hospital Referral to appropriate medical and allied health professionals Education and information sharing with residents, carers/family, facility staff and general practitioners ( family meetings, typed care-plan faxed on day of visit, telephone calls, liaison with hospital units) Advanced Care Planning Rapid response to intercurrent illness Hospital-in-the-facility Mobile diagnostics (radiology, pathology) Medication imprest & temporary drug chart
Baseline measures QOL-AD MMSE Barthel index Zung for depression No diff at baseline Follow-up 3 visits over 6 months
Baseline Characteristics n=116 Control n=52 Intervention n=51 P value Age, years, mean ± SD 86.7 ± 7.0 83.8 ± 6.5 0.02 Male, n (%) 24(40.7) 19 (33.3) 0.45 Hostel, n (%) 26(44.1) 27(47.4) 0.85 Australian born, n (%) 34(59.6) 38(64.4) 0.43 English speaking, n (%) 44(77.2) 45(76.3) 0.66 Index length of stay 12.14 10.05 0.53
Hospital Readmissions n=116 Control n=59 Intervention n=57 P value At least one readmission in 6/12 (%) 32.2 38 0.56 Readmissions/pt, mean 0.44 0.49 0.58 Acute inpatient LOS (days)/pt mean 3.31 3.33 0.71 ED presentations/pt, mean 0.47 0.33 0.51 Subacute LOS (days), mean 3.22 1.37 0.56 Total (index,acute,subacute) LOS, mean 18.80 14.40 0.32
Advanced Care Planning 39/57(68.4%) of intervention group completed a written Advanced Treatment Plan 22/57(38.6%)died in intervention group and 22/59(37.2%)p=0.518 in the control group Not all who died had written Advanced Treatment Plans but all had discussions None of the control group completed Advanced Treatment Plans
Satisfaction -Family/patient Intervention Control n=17 P value n=19 Overall satisfaction 16 11 0.04 Medical assessment 16 8 <0.01 Advice/phone contact 10 8 <0.01 Coordination of care 10 4 0.04 Advanced Care Planning 14 8 0.04 Family Discussion 16 10 0.02
Hospital treatment in residential care Lau L, Chong C, Lim WK. Hospital treatment in residential care facilities is a viable alternative to hospital admission for selected patients. Geriatrics and Gerontology International. 2013 ;13:378-383.
Aim To determine if hospital treatment in residential care facilities, led by a geriatric team, might be a viable alternative to inpatient admission for selected patients
Methods Case series with a new intervention were compared with historical controls receiving the conventional treatment. Treatment in residential care facilities (TRC) by the Residential Care Intervention Program in The Elderly (RECIPE) service was compared against the conventional treatment group, aged care unit (ACU) inpatients.
Hospital treatment in RC
Conclusion Hospital treatment in residential care is viable for most patients, including those with dementia and those who need palliative care support. This model of care offers a valuable geriatric service to residents who would prefer to avoid hospital transfers, with no difference in mortality or rehospitalization rates for those treated in residential care.
What happened after the randomised trial
Methods Retrospective cohort study with 1327 patients enrolled in the RECIPE service between 2004 and 2011. 73 RCF involved. Interrupted time series analysis. Outcomes-acute health utilisation.
Results Mortality-73% residents died during followup with a mean survival of 311 days. Comparison between pre and post enrolment to RECIPE, mean reduction of 0.13 admissions per patient per quarter or 0.52 admissions per patient per year (p=0.046). Average reduction in annual bed days per patient of 12 days
Summary A multicomponent geriatrician led outreach service to RCFs has the potential to: Reduce acute care utilisation Improve ACP and provision of Palliative care Improve patient and family satisfaction
The Future No shortage of research in older populations Clinical Frailty End of life care in residential care Perioperative care
Funding Grants Recurrent income-interface with education Future collaborations