Joanne Tropea

Do patient reported outcome measures in hip and knee arthroplasty rehabilitation have robust measurement attributes? A systematic review.

OBJECTIVE The aim of this study was to systematically review and compare the measurement attributes of multidimensional, patient-reported outcome measures used in hip and knee arthroplasty rehabilitation. METHODS A search of PubMed, CINAHL, Cochrane Central Registry, SCOPUS and PEDro databases up to December 2009 identified the validation studies. The quality of the measurement properties were assessed based on the Terwee and Bot criteria, and Scientific Advisory Committee of the Medical Outcomes Trust guidelines. RESULTS A total of 68 studies examining 28 instruments were identified. Three instruments had positive ratings for content validity. None of the instruments satisfied both factor analysis and Cronbachs α criteria for internal consistency. Four measures were positively-rated for agreement. Nine tools had positive ratings for construct validity. Twenty-four of the instruments had indeterminate ratings for responsiveness to clinical change. Only certain subscales of 2 instruments were positively-rated for responsiveness to clinical change. CONCLUSION A wide variety of multidimensional patient-reported instruments has been used to assess rehabilitation outcomes after hip and knee arthroplasty, but information about their measurement attributes in these populations is inadequate. More data are needed to clarify their reproducibility and responsiveness to clinical change. :

Clinical practice guidelines for the management of delirium in older people in Australia

Delirium is a common and serious condition which is often overlooked or misdiagnosed in older people. In 2006, the first set of national clinical practice guidelines for the management of delirium in older people were developed. This paper provides an abbreviated version of the guideline document which includes recommendations for the detection of delirium (diagnosis and screening), assessment and prediction of risk factors for delirium, prevention of delirium and interventions to manage people with delirium. The guidelines reflect the available evidence base and highlight the limited high level research in delirium care, particularly in the areas of symptom management and screening for delirium.

Management of Osteoarthritis in General Practice in Australia

To describe management of osteoarthritis (OA) of the hip (OA‐hip) and knee (OA‐knee) by Australian general practitioners (GPs).

Patients Who Leave Without Being Seen in Emergency Departments: An Analysis of Predictive Factors and Outcomes

OBJECTIVES The objective was to identify predictive factors and outcomes associated with patients who leave emergency departments (EDs) without being seen in Victoria, Australia. METHODS This was a retrospective observational study of Victorian ED patient visits between July 1, 2000, and June 30, 2005, using linked hospital, ED, and death registration data. Index ED visits were identified for patients who left without being seen (LWBS) and for those who completed ED treatment and were discharged home. Statistical analyses included a general description and univariate analysis of patient, ED visit, temporal, and hospital-level factors. Logistic regression models were developed to assess risk factors associated with LWBS status compared to patients who completed treatment, to assess 48 hour re-presentations to ED; 48-hour hospital admissions; and 2-,7-, and 30-day mortality among those who LWBS compared to those who completed treatment. Adjusted odds ratios (ORs) and 99% confidence intervals (CIs) are presented. RESULTS There were 239,305 LWBS episodes, for 205,500 patients over the 5-year period. Independent factors associated with LWBS patients in comparison to those who completed treatment include patients who are younger (15 to 24 years, OR = 2.46, 99% CI = 2.37 to 2.56), male (OR = 1.07, 99% CI = 1.05 to 1.08), of Australian indigenous background (OR = 1.63, 99% CI = 1.53 to 1.73), of non-English-speaking background (OR = 1.08, 99% CI = 1.06 to 1.10), noncompensable status (OR = 1.73, 99% CI = 1.68 to 1.79), self-referring (OR = 1.46, 99% CI = 1.43 to 1.49), nonassisted arrival mode (OR = 1.35, 99% CI = 1.30 to 1.40), and those with a hospital admission in the 12 months before the ED presentation (OR = 1.53, 99% CI = 1.51 to 1.55). Patients who LWBS had triage categories of lower urgency (nonurgent, OR = 8.21, 99% CI = 8.00 to 8.43), attended during the evening (OR = 1.10, 99% CI = 1.08 to 1.12), on either Sunday (OR = 1.20, 99% CI = 1.18 to 1.23) or Monday (OR = 1.20, 99% CI = 1.17 to 1.23), in winter (OR = 1.14, 99% CI = 1.12 to 1.16), with higher rates occurring in higher volume EDs (OR = 2.20, 99% CI = 2.15 to 2.26). There was no greater risk of mortality for LWBS patients compared to patients who completed treatment. The risk of hospital admission within 48 hours of discharge was lower for LWBS patients (OR = 0.60, 99% CI = 0.58 to 0.62); however, ED re-presentation risk was higher (OR = 1.63, 99% CI = 1.60 to 1.67). CONCLUSIONS Patients who leave EDs in Victoria, Australia, without being seen are at lower risk of hospital admission and at no greater risk of mortality, but are at higher risk of re-presenting to an ED compared to patients who complete treatment and are discharged home.

Use of antipsychotic medications for the management of delirium: an audit of current practice in the acute care setting

OBJECTIVE Despite delirium being common in older hospitalized people, little is known about its management. The aims of this study are (1) to describe the pharmacological management of delirium in an acute care setting as a baseline measure prior to the implementation of newly developed Australian guidelines; and (2) to determine what areas of delirium pharmacological management need to be targeted for future practical guideline implementation and quality improvement activities. METHODS A medical record audit was conducted using a structured audit form. All patients aged 65 years and over who were admitted to a general medical or orthopaedic unit of the Royal Melbourne Hospital between 1 March 2006 and 28 February 2007 and coded with delirium were included. Data on the use of antipsychotic medications for the management of delirium in relation to best practice recommendations were assessed. RESULTS Overall 174 episodes of care were included in the analysis. Antipsychotic medications were used for the management of most patients with severe behavioral and or emotional disturbance associated with delirium. There was variation in the prescribing patterns of antipsychotic agents and the documentation of medication management plans. Less than a quarter of patients prescribed antipsychotic medication were started on a low dose and very few were reviewed on a regular basis. CONCLUSION A wide range of practice is seen in the use of antipsychotic agents to manage older patients with severe symptoms associated with delirium. The findings highlight the need to implement evidence-based guideline recommendations with a focus on improving the consistency in the pharmacological management and documentation processes.

Poorer outcomes and greater healthcare costs for hospitalised older people with dementia and delirium: a retrospective cohort study

To compare healthcare utilisation outcomes among older hospitalised patients with and without cognitive impairment, and to compare the costs associated with these outcomes.

Use of consensus methods to select clinical indicators to assess activities to minimise functional decline among older hospitalised patients

OBJECTIVES The study aimed to develop a set of clinical indicators to minimise the risk and adverse outcomes of functional decline in older hospitalised people. METHODS Existing Australian and international clinical indicators relevant to cognition and emotional health, mobility, vigour and self care, continence, nutrition, skin integrity, person-centred care, assessment and medication management were identified by literature and electronic website review. A multidisciplinary expert advisory group used modified Delphi methods, including two anonymous voting rounds and a group discussion, to gain consensus for a prioritised set of clinical indicators. For each indicator, experts voted on a scale of 1 (low level of prioritisation) to 9 (high level of prioritisation) based on measurement attributes and utility for use at the level of clinical teams, hospital managers and jurisdictional policy makers. RESULTS There were 55 existing clinical indicator sets identified, from which 63 relevant indicators were extracted. The final prioritised set covered all domains and included 19 indicators of which 17 were process indicators and 2 were outcome indicators. Scores for scientific measurement attributes and practicality for implementation were only moderate. CONCLUSION These clinical indicators offer a consistent basis for monitoring hospital performance and improving care of older people in Victoria and other jurisdictions.

People with dementia in the emergency department: Behavioural symptoms and use of restraint

Dear Editor, People living with dementia are high users of ED services, with up to 40% of older people in the ED estimated to have cognitive impairment or dementia. The unfamiliar and overstimulating ED environment along with the presenting acute illness can worsen behavioural symptoms associated with dementia. Behavioural and psychological symptoms of dementia (BPSD) include symptoms such as aggression and psychosis. BPSD is common, complex and multifactorial and can be associated with the environment and unmet needs such as hunger and pain. Guidelines recommend using non-pharmacological strategies as the first-line approach to manage BPSD, and reserve use of antipsychotic medications for severe symptoms where the behaviour is distressing to the person, or where there is a risk of harm to self or others. The aim of this retrospective audit was to assess the prevalence of BPSD, and the use of chemical and mechanical restraint, among people with dementia admitted to the ED of a metropolitan teaching hospital. A standardised form was used to review ED notes and collect data. All cases were audited by one reviewer who was an advanced trainee and medical registrar in aged care. The presence of a provisional principle diagnostic code for dementia was used to identify cases: total 142 cases during year 2014, of which 100 were randomly selected for review. The median age was 83 years, 55% were women, 60% living in the community and most arrived by ambulance. The median time in the ED was 6 h and 82% of cases were admitted to hospital. Thirty-nine per cent of cases experienced behavioural symptoms during their ED stay, with aggressiveness (35%) being the most common symptom – this included verbal and/or physical aggression and agitation (Table 1). It was difficult to determine severity of symptoms. Fifteen patients were administered antipsychotics during their ED stay, with one patient administered two types of antipsychotics. Two-thirds of those administered antipsychotics in the ED commenced above the recommended low start dose. Six patients received a benzodiazepine, with one patient receiving both antipsychotic and benzodiazepine medications. The medical notes recorded the following justifications for the application of chemical restraint: agitation (8, 40%), inability to provide care and perform investigations (7, 35%) or aggression towards others (5, 25%). Non-pharmacological strategies such as use of family and reorienting the patient were not well documented (Table 1).

HOSPITALISED OLDER PEOPLE WITH DEMENTIA AND DELIRIUM: MORE READMISSIONS AND IN-HOSPITAL COMPLICATIONS, GREATER LENGTH OF STAY AND ASSOCIATED HEALTHCARE COSTS

need for checkup” was the leading reason by 28.2%, followed by “other by 23.9% and “forgot the date” by 19.7%. The 45 subjects who answered “other” further reported the following reasons: 9 responded “there was no call from the center,” 3 responded “I was too busy,” 2 responded “I didn’t know I had to take a test,” 1 responded “personal reasons,” and 29 left the reason blank. Conclusions: Considering the low dementia detection rate of the group who revisited only after contact and the reasons they gave for noncompliance, there appears to be a need for ongoing outreach and education regarding the course and prognosis of MCI. Active publicity and detailed education for the public, along with secure personnel and budget may be crucial for detection improvement.