S. Nicole Hastings

Frailty Predicts Some but Not All Adverse Outcomes in Older Adults Discharged from the Emergency Department

OBJECTIVES: To determine whether frail older adults, based on a deficit accumulation index (DAI), are at greater risk of adverse outcomes after discharge from the emergency department (ED).

Frequency and predictors of adverse health outcomes in older Medicare beneficiaries discharged from the emergency department.

Background:Older adults who are discharged from the emergency department (ED) may be at risk for subsequent adverse outcomes; however, this has not been fully investigated in national, population-based samples. The goal of this study was to determine the frequency and predictors of adverse outcomes among older adults discharged from the ED. Design:Secondary analysis of data from the Medicare Current Beneficiary Survey. Subjects:A total of 1851 community-dwelling, Medicare fee-for-service enrollees, ≥65 years old who were discharged from the ED between January 2000 and September 2002. Measures:The primary dependent variable was time to first adverse outcome defined as any repeat outpatient ED visit, hospital admission, nursing home admission or death within 90 days of the index ED visit. Results:Six hundred twenty-three of 1851 subjects (32.9%) discharged from the ED experienced an adverse outcome within 90 days of the index visit; 17.2% returned to the ED but were not admitted, 18.3% were hospitalized, 2.6% were admitted to a nursing home, and 4.1% died. Patients who were older [hazard ratios (HR), 1.01; confidence interval (CI), 1.00–1.02], with more chronic health conditions (HR, 1.12; CI, 1.07–1.19), Medicaid insurance (HR, 1.42; CI, 1.11–1.82), and recent ED (HR, 1.46; CI, 1.17–1.82) or hospital use (HR, 1.80; CI, 1.50–2.17) were at particularly high risk. Conclusions:A substantial proportion of older Medicare beneficiaries in this study experienced an adverse outcome after ED discharge. Further study is needed to determine whether simple prediction tools based on these identified risk factors may be useful in predicting adverse outcomes in this vulnerable population.

Emergency Department Discharge Diagnosis and Adverse Health Outcomes in Older Adults

OBJECTIVES: To determine the relationship between the reason for an emergency department (ED) visit and subsequent risk of adverse health outcomes in older adults discharged from the ED.

Black–White Disparity in Disability: The Role of Medical Conditions

OBJECTIVES: To describe the independent contributions of selected medical conditions to the disparity between black and white people in disability rates, controlling for demographic and socioeconomic factors.

Quality of Pharmacotherapy and Outcomes for Older Veterans Discharged from the Emergency Department

OBJECTIVES: To determine whether suboptimal pharmacotherapy increases the risk of adverse outcomes in older adults discharged from the emergency department (ED).

Exploring Patterns of Health Service Use in Older Emergency Department Patients

OBJECTIVES Study objectives were to identify groups of older patients with similar patterns of health care use in the 12 months preceding an index outpatient emergency department (ED) visit and to identify patient-level predictors of group membership. METHODS   Subjects were adults ≥ 65 years of age treated and released from an academic medical center ED. Latent cluster analysis (LCA) models were estimated to identify groups with similar numbers of primary care (PC), specialist, and outpatient ED visits and hospital days within 12 months preceding the index ED visit. RESULTS   In this sample (n = 308), five groups with distinct patterns of health service use emerged. Low Users (35%) had fewer visits of all types and fewer hospital days compared to sample means. Low Users were more likely to be female and had fewer chronic health conditions relative to the overall sample (p < 0.05). The ED to Supplement Primary Care Provider (PCP) (23%) group had more PCP visits, but also significantly more ED visits. Specialist Heavy (22%) group members had twice as many specialist visits, but no difference in PCP visits. Members of this class were more likely to be white and male (p < 0.05). High Users (15%) received more care in all categories and had more chronic baseline health conditions (p < 0.05) but no differences in demographic characteristics relative to the whole sample. The ED and Hospital as Substitution Care (6%) group had fewer PC and specialist visits, but more ED visits and hospital days. CONCLUSIONS   In this sample of older ED patients, five groups with distinct patterns of health service use were identified. Further study is needed to determine whether identification of these patient groups can add important information to existing risk-assessment methods.

A Quality Improvement Program to Enhance After-Hours Telephone Communication Between Nurses and Physicians in a Long-Term Care Facility

OBJECTIVES: To determine whether satisfaction of on‐site nurses with after‐hours telephone communication with off‐site physicians improved in one long‐term care (LTC) facility after a nurse‐oriented intervention.

Assisted Early Mobility for Hospitalized Older Veterans: Preliminary Data from the STRIDE Program

An important contributor to hospital‐associated disability is immobility during hospitalization. Preliminary results from STRIDE, a clinical demonstration program of supervised walking for older adults admitted to the hospital with medical illness, are reported. The STRIDE program consisted of a targeted gait and balance assessment by a physical therapist, followed by daily walks supervised by a recreation therapy assistant for the duration of the hospital stay. To examine program effectiveness, STRIDE participants (n = 92) were compared with individuals referred but not enrolled (because of refusal or because program was at capacity, n = 35). Median length of stay was 4.7 days for STRIDE participants and 5.7 days for individuals receiving usual care (P = .31). There was one inpatient fall in each group (not associated with a STRIDE walk). Overall, 92% of STRIDE participants were discharged to home (rather than a skilled nursing facility (SNF)) compared to 74% of individuals receiving usual care (P = .007). Thirty‐day emergency department visit rates and readmission rates were not significantly different between the two groups. STRIDE, a supervised walking program for hospitalized older adults, was feasible and safe, and program participants were less likely to be discharged to a SNF than a demographically similar comparison group. STRIDE is a promising interdisciplinary approach to promoting mobility and improving outcomes in hospitalized older adults.

The Junior Faculty Laboratory: an innovative model of peer mentoring.

Mentoring in academic medicine has been shown to contribute to the success of junior faculty, resulting in increased productivity, career satisfaction, and opportunities for networking. Although traditional dyadic mentoring, involving one senior faculty member and one junior protégé, is the dominant model for mentoring in the academic environment, there is increasing recognition that the sharing of knowledge, skills, and experiences among peers may also contribute to the career development of junior faculty. The authors describe the structure, activities, and outcomes of the Junior Faculty Laboratory (JFL), a self-organized, flexible, and dynamic peer-mentoring model within the Duke University Center for the Study of Aging and Human Development. As an innovative mentoring model, JFL is entirely peer driven, and its activities are determined by the real-time needs of members. In contrast to some other peer-mentoring models, JFL lacks senior faculty input or a structured curriculum, members are multidisciplinary, meeting times are project driven rather than preset, and participation in collaborative projects is optional based on the interests and needs of group members. Additionally, JFL was not formed as a substitute for, but as a complement to, the dyadic mentoring relationships enjoyed by its members. The model, now in its fifth year, has demonstrated success and sustainability. The authors present the JFL as an innovative, mentoring model that can be reproduced by other junior faculty seeking to foster collegial relationships with peers while simultaneously enhancing their career development.

Identifying risk of readmission in hospitalized elderly adults through inpatient medication exposure.

To use electronic health record (EHR) data to examine the association between inpatient medication exposure and risk of hospital readmission.