Bronagh Walsh

Economic evaluation of nurse led intermediate care versus standard care for post-acute medical patients: cost minimisation analysis of data from a randomised controlled trial

Abstract Objective To undertake an economic evaluation of nurse led intermediate care compared with standard hospital care for post-acute medical patients. Design Cost minimisation analysis from an NHS perspective, comprising secondary care, primary care, and community care, using data from a pragmatic randomised controlled trial. Setting Nurse led unit and acute general medical wards in large, urban, UK teaching hospital. Participants 238 patients. Outcome measure Costs to acute hospital trusts and to the NHS over six months. Results On an intention to treat basis, nurse led care was associated with higher costs during the initial admission period (nurse led care £7892 (

Inflammation in aging part 1: physiology and immunological mechanisms

14 970; €11 503), standard care £4810, difference £3082 (95% confidence interval £1161 to £5002)). During the readmission period, costs were similar (nurse led care £1444, standard care £1879, difference -£435, -£1406 to £536). Total costs at six months were significantly higher (nurse led care £10 529, standard care £7819, difference £2710, £518 to £4903). Sensitivity analyses suggested that the trend for nurse led care to be more expensive was maintained even with substantial cost reductions, although differences were no longer significant. Conclusion Acute hospitals may not be cost effective settings for nurse led intermediate care. Both inpatient and total costs were significantly higher for nurse led care than for standard care of post-acute medical patients, suggesting that this model of care should not be pursued unless clinical or organisational benefits justify the increased investment.

Features and outcomes of unplanned hospital admissions of older people due to ill-defined (R-coded) conditions: Retrospective analysis of hospital admissions data in England

During the aging process, remodeling of several body systems occurs, and these changes can have a startling effect upon the immune system. The reduction in sex steroids and growth hormones and declines in vitamin D concentration that accompany the aging process are associated with increases in the baseline levels of inflammatory proteins. At the same time, inflammation arising from atherosclerosis and other chronic diseases further contributes to the inflammatory milieu and effects a state of chronic inflammation. This chronic inflammation, or ‘‘inflammaging’’ as it has been termed, seems to be associated with a host of adverse effects contributing to many of the health problems that increase morbidity and decrease both quality of life and the ability to maintain independence in old age. For nurses to be truly informed when caring for older people and to ensure that they have a detailed understanding of the complexities of older people’s health needs, they must have a knowledge of the physiological and immunological changes with age. This is the first of a two-part article on inflammatory processes in aging. These age-related changes are presented here, including an examination of the impact of genetic and lifestyle factors. The effect of these changes on the health of the individual and implications for practice are described in Part 2.

Markers of inflammatory status are associated with hearing threshold in older people: findings from the Hertfordshire Ageing Study.

BackgroundRising rates of unplanned admissions among older people are placing unprecedented demand on health services internationally. Unplanned hospital admissions for ill-defined conditions (coded with an R prefix within Chapter XVIII of the International Classification of Diseases-10) have been targeted for admission avoidance strategies, but little is known about these admissions. The aim of this study was to determine the incidence and factors predicting ill-defined (R-coded) hospital admissions of older people and their association with health outcomes.MethodsRetrospective analysis of unplanned hospital admissions to general internal and geriatric medicine wards in one hospital over 12 months (2002) with follow-up for 36 months. The study was carried out in an acute teaching hospital in England. The participants were all people aged 65 and over with unplanned hospital admissions to general internal and geriatric medicine. Independent variables included time of admission, residence at admission, route of admission to hospital, age, gender, comorbidity measured by count of diagnoses. Main outcome measures were primary diagnosis (ill-defined versus other diagnostic code), death during the hospital stay, deaths to 36 months, readmissions within 36 months, discharge destination and length of hospital stay.ResultsIncidence of R-codes at discharge was 21.6%, but was higher in general internal than geriatric medicine (25.6% v 14.1% respectively). Age, gender and co-morbidity were not significant predictors of R-code diagnoses. Admission via the emergency department (ED), out of normal general practitioner (GP) hours, under the care of general medicine and from non-residential care settings increased the risk of receiving R-codes. R-coded patients had a significantly shorter length of stay (5.91 days difference, 95% CI 4.47, 7.35), were less likely to die (hazard ratio 0.71, 95%CI 0.59, 0.85) at any point, but were as likely to be readmitted as other patients (hazard ratio 0.96 (95% CI 0.88, 1.05).ConclusionsR-coded diagnoses accounted for 1/5 of emergency admission episodes, higher than anticipated from total English hospital admissions, but comparable with rates reported in similar settings in other countries. Unexpectedly, age did not predict R-coded diagnosis at discharge. Lower mortality and length of stay support the view that these are avoidable admissions, but readmission rates particularly for further R-coded admissions indicate on-going health care needs. Patient characteristics did not predict R-coding, but organisational features, particularly admission via the ED, out of normal GP hours and via general internal medicine, were important and may offer opportunity for admission reduction strategies.

Inflammation in Aging Part 2: Implications for the Health of Older People and Recommendations for Nursing Practice

BACKGROUND Age-related hearing loss is a common disabling condition but its causes are not well understood and the role of inflammation as an influencing factor has received little consideration in the literature. OBJECTIVE To investigate the association between inflammatory markers and hearing in community-dwelling older men and women. DESIGN Cross-sectional analysis within a cohort study. SETTING The Hertfordshire Ageing Study. PARTICIPANTS A total of 343 men and 268 women aged 63-74 years on whom data on audiometric testing, inflammatory markers and covariates were available at follow-up in 1995. MAIN OUTCOME MEASURES Average hearing threshold level (across 500-4,000 Hz) of the worst hearing ear and audiometric slope in dB/octave from 500 to 4,000 Hz. RESULTS Older age, smoking, history of noise exposure and male gender (all P < 0.001) were associated with higher mean hearing threshold in the worse ear in univariate analysis. After adjustment for these factors in multiple regression models, four measures of immune or inflammatory status were significantly associated with hearing threshold, namely white blood cell count (r = 0.13, P = 0.001), neutrophil count (r = 0.13, P = 0.002), IL-6 (r = 0.10, P = 0.05) and C-reactive protein (r = 0.11, P = 0.01). None of the inflammatory markers was associated with maximum audiometric slope in adjusted analyses. CONCLUSIONS Markers of inflammatory status were significantly associated with degree of hearing loss in older people. The findings are consistent with the possibility that inflammatory changes occurring with ageing may be involved in age-related hearing loss. Longitudinal data would enable this hypothesis to be explored further.

Living into old age with the consequences of breast cancer

Aging is accompanied by declining function and remodeling of body systems. In particular, changes to the immune and endocrine systems have far-reaching effects that cause an increase in cytokine release and decrease in anti-inflammatory feedback systems. The chronic inflammation that ensues has been named ‘‘inflammaging.’’ Inflammaging is associated with many detrimental effects that combine to increase morbidity and mortality. The sickness behavior that arises from inflammatory processes and the side effects of chronic diseases lead to a constellation of symptoms that decrease quality of life and affect the well-being of the individual. Part 2 of this two-part article provides an overview of the health effects of inflammaging, addressing the extent to which it contributes to the syndromes of frailty and disability with aging.

Chylothorax development in infants and children in the UK

PURPOSE OF THE RESEARCH Breast cancer survival rates are improving with over 60% likely to live 20 years. As 30% diagnoses occur in women over 70 the prevalence of breast cancer survivors living into older age is increasing. The specific needs and experiences of this group have rarely been addressed. This study aimed to explore older womens experience of living with breast cancer alongside other health conditions, and to identify their information and support needs and preferences. METHODS AND SAMPLE Data were collected from 28 semi-structured qualitative interviews and 2 focus groups (n = 14), with breast cancer survivors aged 70-90, and were analysed using thematic analysis. KEY RESULTS These older breast cancer survivors experienced a range of long-term physical problems resulting from treatment, including poor cosmetic results and poor shoulder movements, and bras and prostheses were often unsuitable. Many were keen to preserve their body image ideal irrespective of age. Reconstruction was rarely discussed, but all would have liked this option. Older women wanted to be treated as individuals rather than uniformly as older people, with their personal physical and social needs (including co-morbidities) taken into account. They expressed a preference for information direct from health professionals. CONCLUSIONS Many breast cancer survivors will live into advanced old age with permanent physical and emotional consequences of their treatment. Holistic and personalized assessment of needs becomes increasingly important with age, particularly with comorbidity. Effective rehabilitative care is important to reduce the impact of breast cancer into old age.

Emergency hospital admissions for ill‐defined conditions amongst older people: a review of the literature

Aim To describe the incidence, patient profile, management strategies and outcome for infants and children who developed a chylothorax in the UK. Methods A prospective study of infants and children ≥24 weeks’ gestation—≤16 years, who developed a chylothorax in the UK and were reported through the British Paediatric Surveillance Unit (BPSU). Clinicians completed a questionnaire on the presentation, diagnosis, management and outcome of these children. Three further data sources were accessed to confirm these data. Results The incidence in children in the UK was 0.0014% (1.4 per 100 000) and 3.2% (3200 per 100 000) for those developing a chylothorax following a cardiac surgical procedure. The incidence was highest in infants ≤12 months at 16 per 100 000 (0.016%). A total of 219 questionnaires were returned with 172 cases meeting the eligibility criteria. Development of a chylothorax was most commonly associated with cardiac surgical procedure (65.1%) and was most frequently confirmed by laboratory verification of triglyceride content of the pleural fluid ≥1.1 mmol/L (66%). Although a variety of management strategies were employed, treatment with an intercostal pleural catheter (86.5%) and a medium chain triglyceride (MCT) diet (89%) was most commonly reported. The majority of the children had a prolonged hospital stay with a reported mortality of 12.2%. Conclusions Development of a chylothorax in infants and children in the UK was not common. The primary association was with a cardiac surgical procedure. The childs hospital stay was lengthy and therefore the impact on the child, family and hospital resources were significant. Common management strategies existed but national guidance is required to optimise practice. This study allows for better information relating to this serious complication to be given to patients and families and provides the basis for future research and practice development.

Outcomes after unplanned admission to hospital in older people: ill-defined conditions as potential indicators of the frailty trajectory.

Objective.  To conduct a review of the literature on frequency and characteristics of emergency hospital admissions of older people for ill-defined conditions. Background.  Emergency hospital admissions for ill-defined conditions are increasing for older people. Despite concern about this trend little is known about the frequency or characteristics of such admissions in emergency medical settings. Method.  Relevant papers were identified by searching Medline, Cinahl, Web of Science and other databases. Papers that met inclusion criteria were selected. A descriptive analysis approach was taken. Results.  Eighteen studies met the inclusion criteria for the review, all descriptive, survey or cohort studies. None directly investigated the patient group. Some relevant data were available, particularly in relation to frequency of admissions for ill-defined conditions. Conclusions.  There is a paucity of research on the patient group, but the evidence available suggests the incidence of these admissions is high in emergency settings and in many countries. Future research on incidence in specific settings, appropriateness of admissions and patient characteristics is urgently required. Relevance to clinical practice.  As the population ages increased numbers of older people will be admitted to hospital for ill-defined conditions. Nursing interventions may contribute to future management of these patients.

Leukocyte filtration of the cardiotomy suction. Does it affect systemic leukocyte activation or pulmonary function

To describe outcomes after unplanned hospital admission in older people and to determine whether disease trajectories in those admitted with ill‐defined conditions (symptoms and signs) are distinct from other diagnostic groups and consistent with known disease trajectories.