Jennifer K. Burton

Identifying who lives in a care home—a challenge to be conquered

doi: 10.1093/ageing/afx200 Published electronically 16 January 2018

Predicting Discharge to Institutional Long‐Term Care After Stroke: A Systematic Review and Metaanalysis

Stroke is a leading cause of disability worldwide, and a significant proportion of stroke survivors require long‐term institutional care. Understanding who cannot be discharged home is important for health and social care planning. Our aim was to establish predictive factors for discharge to institutional care after hospitalization for stroke.

New care home admission following hospitalisation: how do older people, families and professionals make decisions about discharge destination? A case-study narrative analysis

AIMS AND OBJECTIVESnTo gain an in-depth understanding of the decision-making processes involved in the discharge of older people admitted to hospital from home and discharged to a care home, as described in the case records.nnnBACKGROUNDnThe decision for an older person to move into a care home is significant and life-changing. The discharge planning literature for older people highlights the integral role of nurses in supporting and facilitating effective discharge. However, little research has been undertaken to explore the experiences of those discharged from hospital to a care home or the processes involved in decision-making.nnnMETHODnA purposive sample of 10 cases was selected from a cohort of 100 individuals admitted to hospital from home and discharged to a care home. Cases were selected to highlight important personal, relational and structural factors thought to affect the decision-making process. Narrative case studies were created and were thematically analysed to explore the perspectives of each stakeholder group and the conceptualisations of risk which influenced decision-making.nnnRESULTSnCare home discharge decision-making is a complex process involving stakeholders with a range of expertise, experience and perspectives. Decisions take time and considerable involvement of families and the multidisciplinary team. There were significant deficits in documentation which limit the understanding of the process and the patients voice is often absent from case records. The experiences of older people, families and multidisciplinary team members making care home decisions in the hospital setting require further exploration to identify and define best practice.nnnIMPLICATIONS FOR PRACTICEnNurses have a critical role in the involvement of older people making discharge decisions in hospital, improved documentation of the patients voice is essential. Health and social care systems must allow older people time to make significant decisions about their living arrangements, adapting to changing medical and social needs.

Statin Use is Not Associated with Future Long-Term Care Admission: Extended Follow-Up of Two Randomised Controlled Trials

BackgroundStatins have been associated with later life, long-term care admission in observational studies. However, by preventing vascular events, statins may also prevent or delay admission. We wished to determine statin and long-term care admission associations in a randomised controlled trial context, and describe associations between long-term care admission and other clinical and demographic factors.MethodsWe used extended follow-up of two randomised trial populations, using national data to assign the long-term care admission outcome, and included individuals screened or recruited to two large randomised trials of pravastatin 40xa0mg daily—the West of Scotland Coronary Prevention Study (WOSCOPS) and the pravastatin in elderly individuals at risk of vascular disease (PROSPER) study. We described univariable and multivariable analyses of potential predictors of long-term care admission with corresponding survival curves of incident long-term care admission and analyses adjusted for competing risk.ResultsIn total 11,015 (10%) of the trial participants were admitted to long-term care. There was no difference between participants in the statin or placebo arms of either trial in regard to admissions to long-term care. On multivariable analyses, independent associations with incident long-term care admission in the PROSPER trial were age (hazard ratio [HR] 1.06 per year, 95% confidence interval [CI] 1.03–1.09) and male sex (HR 0.72, 95% CI 0.53–0.99). In the WOSCOPS, age (HR 1.12 per year, 95% CI 1.10–1.13) and increasing social deprivation (HR 1.05, 95% CI 1.03–1.08) were associated with incident long-term care admission.ConclusionWe did not demonstrate an association between historical statin use and future long-term care admission. The strongest associations with incident long-term care admission were non-modifiable factors of age, sex and socioeconomic deprivation.

Identifying care-home residents in routine healthcare datasets: a diagnostic test accuracy study of five methods

Abstract Background there is no established method to identify care-home residents in routine healthcare datasets. Methods matching patient’s addresses to known care-home addresses have been proposed in the UK, but few have been formally evaluated. Study design prospective diagnostic test accuracy study. Methods four independent samples of 5,000 addresses from Community Health Index (CHI) population registers were sampled for two NHS Scotland Health Boards on 1 April 2017, with one sample of adults aged ≥65 years and one of all residents. To derive the reference standard, all 20,000 addresses were manually adjudicated as ‘care-home address’ or not. The performance of five methods (NHS Scotland assigned CHI Institution Flag, exact address matching, postcode matching, Phonics and Markov) was evaluated compared to the reference standard. Results the CHI Institution Flag had a high PPV 97–99% in all four test sets, but poorer sensitivity 55–89%. Exact address matching failed in every case. Postcode matching had higher sensitivity than the CHI flag 78–90%, but worse PPV 77–85%. Area under the receiver operating curve values for Phonics and Markov scores were 0.86–0.95 and 0.93–0.98, respectively. Phonics score with cut-off ≥13 had PPV 92–97% with sensitivity 72–87%. Markov PPVs were 90–95% with sensitivity 69–90% with cut-off ≥29.6. Conclusions more complex address matching methods greatly improve identification compared to the existing NHS Scotland flag or postcode matching, although no method achieved both sensitivity and positive predictive value > 95%. Choice of method and cut-offs will be determined by the specific needs of researchers and practitioners.

Reduced level of arousal and increased mortality in adult acute medical admissions: A systematic review and meta-analysis

BackgroundReduced level of arousal is commonly observed in medical admissions and may predict in-hospital mortality. Delirium and reduced level of arousal are closely related. We systematically reviewed and conducted a meta-analysis of studies in adult acute medical patients of the relationship between reduced level of arousal on admission and in-hospital mortality.MethodsWe conducted a systematic review (PROSPERO: CRD42016022048), searching MEDLINE and EMBASE. We included studies of adult patients admitted with acute medical illness with level of arousal assessed on admission and mortality rates reported. We performed meta-analysis using a random effects model.ResultsFrom 23,941 studies we included 21 with 14 included in the meta-analysis. Mean age range was 33.4 - 83.8 years. Studies considered unselected general medical admissions (8 studies, n=13,039) or specific medical conditions (13 studies, n=38,882). Methods of evaluating level of arousal varied. The prevalence of reduced level of arousal was 3.1%-76.9% (median 13.5%). Mortality rates were 1.7%-58% (median 15.9%). Reduced level of arousal was associated with higher in-hospital mortality (pooled OR 5.71; 95% CI 4.21-7.74; low quality evidence: high risk of bias, clinical heterogeneity and possible publication bias).ConclusionsReduced level of arousal on hospital admission may be a strong predictor of in-hospital mortality. Most evidence was of low quality. Reduced level of arousal is highly specific to delirium, better formal detection of hypoactive delirium and implementation of care pathways may improve outcomes. Future studies to assess the impact of interventions on in-hospital mortality should use validated assessments of both level of arousal and delirium.