Thierry Voisin

Incidence and main factors associated with early unplanned hospital readmission among French medical inpatients aged 75 and over admitted through emergency units

BACKGROUNDnamong elderly patients, readmission in the month following hospital discharge is a frequent occurrence which involves a risk of functional decline, particularly among frail subjects. While previous studies have identified risk factors of early readmission, geriatric syndromes, as markers of frailty have not been assessed as potential predictors.nnnOBJECTIVEnto evaluate the risk of early unplanned readmission, and to identify predictors in inpatients aged 75 and over, admitted to medical wards through emergency departments.nnnDESIGNnprospective multi-centre study.nnnSETTINGnnine French hospitals.nnnSUBJECTSnone thousand three hundred and six medical inpatients, aged 75 and older admitted through emergency departments (SAFES cohort).nnnMETHODSnusing logistic regressions, factors associated with early unplanned re-hospitalisation (defined as first unplanned readmission in the thirty days after discharge) were identified using data from the first week of hospital index stay obtained by comprehensive geriatric assessment.nnnRESULTSndata from a thousand out of 1,306 inpatients were analysed. Early unplanned readmission occurred in 14.2% of inpatients and was not related with sociodemographic characteristics, comorbidity burden or cognitive impairment. Pressure sores (OR = 2.05, 95% CI = 1.0-3.9), poor overall condition (OR = 2.01, 95% CI = 1.3-3.0), recent loss of ability for self-feeding (OR = 1.9, 95% CI = 1.2-2.9), prior hospitalisation during the last 3 months (OR = 1.6, 95% CI = 1.1-2.5) were found to be risk factors, while sight disorders appeared as negatively associated (OR = 0.5, 95% CI = 0.3--0.8).nnnCONCLUSIONSnmarkers of frailty (poor overall condition, pressure sores, prior hospitalisation) or severe disability (for self-feeding) were the most important predictors of early readmission among elderly medical inpatients. Early identification could facilitate preventive strategies in risk group.

Early Markers of Prolonged Hospital Stays in Older People: A Prospective, Multicenter Study of 908 Inpatients in French Acute Hospitals

OBJECTIVES: To identify early markers of prolonged hospital stays in older people in acute hospitals.

Derivation and validation of a mortality-risk index from a cohort of frail elderly patients hospitalised in medical wards via emergencies: the SAFES study

To identify predictive factors for 2-year mortality in frail elderly patients after acute hospitalisation, and from these to derive and validate a Mortality Risk Index (MRI). A prospective cohort of elderly patients was set up in nine teaching hospitals. This cohort was randomly split up into a derivation cohort (DC) of 870 subjects and a validation cohort (VC) of 436 subjects. Data obtained from a Comprehensive Geriatric Assessment were used in a Cox model to predict 2-year mortality and to identify risk groups for mortality. A ROC analysis was performed to explore the validity of the MRI. Five factors were identified and weighted using hazard ratios to construct the MRI: age 85 or over (1 point), dependence for the ADL (1 point), delirium (2 points), malnutrition risk (2 points), and co-morbidity level (2 points for medium level, 3 points for high level). Three risk groups were identified according to the MRI. Mortality rates increased significantly across risk groups in both cohorts. In the DC, mortality rates were: 20.8% in the low-risk group, 49.6% in the medium-risk group, and 62.1% in the high-risk group. In the VC, mortality rates were respectively 21.7, 48.5, and 65.4%. The area under the ROC curve for overall score was statistically the same in the DC (0.72) as in the VC (0.71). The proposed MRI appears as a simple and easy-to-use tool developed from relevant geriatric variables. Its accuracy is good and the validation procedure gives a good stability of results.

Predicting early mortality among elderly patients hospitalised in medical wards via emergency department: the SAFES cohort study.

Objectives: The aim of the study was, by early identification of deleterious prognostic factors that are open to remediation, to be in a position to assign elderly patients to different mortality risk groups to improve management.Design: Prospective multicentre cohort.Setting: Nine French teaching hospitals.Participants: One thousand three hundred and six (1 306) patients aged 75 and over, hospitalised after having passed through Emergency Department (ED).Measurements: Patients were assessed using Comprehensive Geriatric Assessment (CGA) tools. A Cox survival analysis was performed to identify prognostic variables for six-week mortality. Receiver Operating Characteristics analysis was used to study the discriminant power of the model. A mortality risk score is proposed to define three risk groups for six-week mortality.Results: Crude mortality rate after a six-week follow-up was 10.6% (n=135). Prognostic factors identified were: malnutrition risk (HR=2.1; 95% CI: 1.1–3.8; p=.02), delirium (HR=1.7; 95% CI: 1.2-2.5; p=.006), and dependency: moderate dependency (HR=4.9; 95% CI: 1.5–16.5; p=.01) or severe dependency (HR=10.3; 95% CI: 3.2–33.1; p< .001). The discriminant power of the model was good: the c-statistic representing the area under the curve was 0.71 (95% IC: 0.67 – 0.75; p< .001). The six-week mortality rate increased significantly (p< .001) across the three risk groups: 1.1% (n=269; 95% CI=0.5–1.7) in the lowest risk group, 11.1% (n=854; 95% CI=9.4–12.9) in the intermediate risk group, and 22.4% (n=125; 95% CI=20.1–24.7) in the highest risk group.Conclusions: A simple score has been calculated (using only three variables from the CGA) and a practical schedule proposed to characterise patients according to the degree of mortality risk. Each of these three variables (malnutrition risk, delirium, and dependency) identified as independent prognostic factors can lead to a targeted therapeutic option to prevent early mortality.

Loss of independence in Katz’s ADL ability in connection with an acute hospitalization: early clinical markers in French older people

BackgroundThe preservation of autonomy and the ability of elderly to carry out the basic activities of daily living, beyond the therapeutic care of any pathologies, appears as one of the main objectives of care during hospitalization.ObjectivesTo identify early clinical markers associated with the loss of independence in elderly people in short stay hospitals.MethodsAmong the 1,306 subjects making up the prospective and multicenter SAFEs cohort study (Sujet Agé Fragile: Évolution et suivi—Frail elderly subjects, evaluation and follow-up), 619 medical inpatients, not disabled at baseline and hospitalized through an emergency department were considered. Data used in a multinomial logistic regression were obtained through a comprehensive geriatric assessment (CGA) conducted in the first week of hospitalization. Dependency levels were assessed at baseline, at inclusion and at 30xa0days using Katz’s ADL index. Baseline was defined as the dependence level before occurrence of the event motivating hospitalization. To limit the influence of rehabilitation on the level of dependence, only stays shorter than 30xa0days were considered.ResultsAbout 514 patients were eligible, 15 died and 90 were still hospitalized at end point (nxa0=xa0619). Two-thirds of subjects were women, with a mean age of 83. At day 30 162 patients (31%) were not disabled; 61 (12%) were moderately disabled and 291 severely disabled (57%). No socio-demographic variables seemed to influence the day 30 dependence level. Lack of autonomy (odds ratio (OR)xa0=xa01.9, 95% confidence interval (CI)xa0=xa01.2–3.6), walking difficulties (ORxa0=xa02.7, 95% CIxa0=xa01.3–5.6), fall risk (ORxa0=xa02.1, 95% CIxa0=xa01.3–6.8) and malnutrition risk (ORxa0=xa02.2, 95% CIxa0=xa01.5–7.6) were found in multifactorial analysis to be clinical markers for loss of independence.ConclusionsBeyond considerations on the designing of preventive policies targeting the populations at risk that have been identified here, the identification of functional factors (lack of autonomy, walking difficulties, risk of falling) suggests above all that consideration needs to be given to the organization per se of the French geriatric hospital care system, and in particular to the relevance of maintaining sector-type segregation between wards for care of acute care and those involved in rehabilitation

The geriatric patient: Use of acute geriatrics units in the emergency care of elderly patients in France

We studied the factors influencing the choice of admission to Geriatrics units, instead of other acute hospital units after an emergency visit. We report the results from a cohort of 1283 randomly selected patients aged >75 years hospitalized in emergency and representative of the French University hospital system. All patients underwent geriatric assessment. Baseline characteristics of patients admitted to Geriatrics and other units were compared. A center effect influencing the use of Geriatrics units during emergencies was also investigated. Admission to a Geriatrics unit during the acute care episode occurred in 499 cases (40.3%). By multivariate analysis, 4 factors were related to admission to a Geriatrics unit: cognitive disorder: odds ratio (OR)=1.79 (1.38-2.32) (95% confidence interval=95% CI); failure to thrive syndrome OR=1.54 (1.01-2.35), depression: OR=1.42 (1.12-1.83) or loss of Activities of Daily Living (ADL): OR=1.35 (1.04-1.75). The emergency volume of the hospital was inversely related to the use of Geriatrics units, with high variation that could be explained by other unstudied factors. In the French University Emergency Healthcare system, the geriatrics patient is defined by the existence of cognitive disorder, psychological symptoms or installed loss of autonomy. Nevertheless, considerable nation-wide variation was observed underlining the need to clarify and reinforce this discipline in the emergency healthcare system.

Indicateurs précoces de durée de séjour prolongée chez les sujets âgés: Étude pilote réalisée au CHRU de Strasbourg

Summary Objectives The aim of this study was to identify early indicators of prolonged hospital stays by elderly patients. Methods This prospective pilot study, conducted at Strasbourg University Hospital, included patients aged 75 years or older who were hospitalized via the emergency department (SAFES cohort: Sujet Âge Fragile: Evaluation et suivi, that is, Frail Elderly Subjects: Evaluation and Follow-up). A gerontologic evaluation of these patients during the first week of their hospitalization furnished the data for an exact logistic regression. Two definitions were used for prolonged hospitalization: 30 days and a composite number adjusted for diagnosis-related group according to the French classification (f-DRG). Results The analysis examined 137 hospitalizations. More than two thirds of the patients were women (73%), with a mean age of 84 years. Twenty-four hospitalizations (17%) lasted more than 30 days, but only 6 (4%) lasted beyond the DRG-adjusted limit. No social or demographic variables appeared to affect the length of stay, regardless of the definition of prolonged stay. No indicator was associated with the 30-day limit, but clinical markers were linked to prolongation assessed by f-DRG adjustment. A “risk of malnutrition” (ORxa0=xa014.07) and “mood disorders” (ORxa0=xa02,5) were both early markers for prolonged hospitalization. Although not statistically significant, “walking difficulties” (ORxa0=xa02.72) and “cognitive impairment” (ORxa0=xa05.03) appeared to be associated with prolonged stays. No association was seen with either the variables measured by Katzs Activities of Daily Living Index or its course during hospitalization. Conclusion Our study shows that when generally recognized indicators of frailty are taken into account, a set of simple items enables a predictive approach to the prolongation of emergency hospitalizations of the elderly.

Indicateurs précoces de durée de séjour prolongée chez les sujets âgés

Summary Objectives The aim of this study was to identify early indicators of prolonged hospital stays by elderly patients. Methods This prospective pilot study, conducted at Strasbourg University Hospital, included patients aged 75 years or older who were hospitalized via the emergency department (SAFES cohort: Sujet Âge Fragile: Evaluation et suivi, that is, Frail Elderly Subjects: Evaluation and Follow-up). A gerontologic evaluation of these patients during the first week of their hospitalization furnished the data for an exact logistic regression. Two definitions were used for prolonged hospitalization: 30 days and a composite number adjusted for diagnosis-related group according to the French classification (f-DRG). Results The analysis examined 137 hospitalizations. More than two thirds of the patients were women (73%), with a mean age of 84 years. Twenty-four hospitalizations (17%) lasted more than 30 days, but only 6 (4%) lasted beyond the DRG-adjusted limit. No social or demographic variables appeared to affect the length of stay, regardless of the definition of prolonged stay. No indicator was associated with the 30-day limit, but clinical markers were linked to prolongation assessed by f-DRG adjustment. A “risk of malnutrition” (ORxa0=xa014.07) and “mood disorders” (ORxa0=xa02,5) were both early markers for prolonged hospitalization. Although not statistically significant, “walking difficulties” (ORxa0=xa02.72) and “cognitive impairment” (ORxa0=xa05.03) appeared to be associated with prolonged stays. No association was seen with either the variables measured by Katzs Activities of Daily Living Index or its course during hospitalization. Conclusion Our study shows that when generally recognized indicators of frailty are taken into account, a set of simple items enables a predictive approach to the prolongation of emergency hospitalizations of the elderly.