Development of a hospital electronic record frailty index (HerFI): an enhanced care alert score to identify older patients likely to require enhanced care on discharge from hospital

This thesis explores the different methods that are currently used to define frailty and the development of a new frailty index using routinely collected hospital data. The increasing ageing population means that older people account for the majority of the UK healthcare usage and spend therefore if the need for intervention can be quantified, adverse outcomes could be prevented. Data were extracted from the local systems at the Queen Elizabeth Hospital Birmingham for patients over 65 who were admitted as an emergency. A combination of 31 routinely collected test results were extracted and used to calculate a frailty score called FI-QEHB, by taking the sum of deficits divided by the total number of measurements for each patient. Machine Learning techniques were then used to firstly perform multiple imputation on missing data and then Classification and Regression Tree Analysis to determine the most important variables that predict mortality. This technique reduced the number of variables required to calculate a frailty score down to 6 from 31, and the area under the receiving operating characteristic (ROC) curve was used to assess the performance when the frailty score was added into a multivariable logistic regression model to predict emergency readmissions, mortality and whether a patient was discharged to a care home

The role of adult social care in the prevention of intensive health and care needs: a scoping review

Context: Despite the strong emphasis on prevention in social care policy, there is a lack of evidence on the effectiveness of preventive social care interventions to delay escalation of intensive care needs. Objective(s): We reviewed the literature relating to the role of Adult Social Care to prevent escalation of care needs. We aimed to identify mechanisms in service delivery that prevent development of long-term care needs. Method(s): We used the PRISMA-ScR framework to review papers reporting the (cost)effectiveness of preventative services. Findings were qualitatively synthesised using elements of realist synthesis. Findings: Thirty-one papers were included covering: integrated care, intermediate care, rehabilitation, post-discharge services, community-based care, and domiciliary care. Overall, we found few studies with conclusive results to inform policy and practice. Moreover, the evidence was mostly concerned with the impact of social care on health care utilisation, with relatively few studies addressing the impact on social care utilisation. There was some preliminary evidence for the effectiveness of multi-faceted support set within the community, and improvements were observed for patients’ Quality of Life. Limitations: The variety of papers we included reflects the complexity of the social care landscape but prevents robust assessment of the impact of services to delay advancing care needs. Implications: Greater investment in research in this field will help policy makers and families target scarce resources and invest in the most effective prevention services. We emphasise the impact of prevention services can take several years to realise, which must be reflected in research design and social care funding

Optimising drug therapy in older patients. Exploring different approaches across the patient pathway

Background - Drug therapy contributes to healthy aging but has a key duality: It prolongs and can improve quality of life, but drugs can also cause serious harm. Harm from drugs include falls, cognitive decline, lowered quality of life, hospitalisation, and death. Older patients are especially at risk for harm from drug therapy, therefore optimising drug therapy is imperative for this group. Aim - To generate new knowledge of drug therapy optimisation for older patients by exploring the impact of drug burden and investigating different approaches to optimise drug therapy across the patient pathway. Methods - This thesis used data from The Norwegian patient registry, The Norwegian Prescription Database and data collected in a randomised controlled trial (RCT). Observational data of the delivery of the RCT-intervention was included. In Paper I the association between anticholinergic (AC) and sedative (SED) drug burden and post-discharge institutionalisation (PDI) was assessed using multiple regression. Paper II described an RCT investigating the effect of an in-hospital pharmacist intervention. Paper III presented the fidelity and process outcomes of the intervention (Paper II). In Paper IV, an observational tool was developed and time distribution for the pharmacists running the RCT examined. Results - Number of drugs used before hospitalisation was mean 7.11 (SD 4.09) and at hospitalisation median 6.0 (range 4-9). Prevalence of AC/SED drugs was 45.5%. All measures of AC/SED drug burden was significantly associated with PDI. The number of AC drugs were most sensitive (OR 1.13, per AC drug), and the DBI most challenging to apply. The clinical pharmacist contributed to identify and solve discrepancies for 72% of the patients (median 1) and DRPs for 94.6% of the patients (median 4), and the acceptance rate was 67%. Intervention fidelity at admission was 100%, and 57% overall. The pharmacists advanced communication of drug therapy across the patient pathway. About 41% of pharmacist time was spent on administrative RCT-tasks and the estimated intervention time was >3.5 hours/patient. Conclusions - The drug burden is high in older patients acutely admitted to hospital in Norway and assessing AC/SED drug use can reduce the risk of PDI. The in-hospital pharmacist intervention contributed to drug therapy optimisation and facilitated communication across the patient pathway. These measures can contribute to optimisation of drug therapy but are time consuming and costly. It is essential to establish models for drug therapy optimisation across the pathway, including primary care

Frailty risk in hospitalised older adults with and without diabetes mellitus

Background: Research indicates that diabetes mellitus (DM) may be a risk factor for frailty and individuals with DM are more likely to be frail than individuals without DM; however, there is limited research in hospitalised older adults.Objectives: To determine the extent of frailty in hospitalised older adults with and without DM using a 16-item Frailty Risk Score (FRS) and assess the role of frailty in predicting 30-day rehospitalisation, discharge to an institution and in-hospital mortality.Methods: The study was a retrospective, cohort, correlational design and secondary analysis of a data set consisting of electronic health record data. The sample was older adults hospitalised on medicine units. Logistic regression was performed for 30-day rehospitalisation and discharge location. Cox proportional hazards regression was used to analyse time to in-hospital death and weighted using propensity scores.Results: Of 278 hospitalised older adults, 49% had DM, and the mean FRS was not significantly different by DM status (9.6 vs. 9.1, p = 0.07). For 30-day rehospitalisation, increased FRS was associated with significantly increased odds of rehospitalisation (AOR = 1.24, 95% CI [1.01, 1.51], p = 0.04). Although 81% were admitted from home, 57% were discharged home and 43% to an institution. An increased FRS was associated with increased odds of discharge to an institution (AOR = 1.48, 95% CI [1.26, 1.74], p Conclusion: Diabetes mellitus and frailty were highly prevalent; the mean FRS was not significantly different by DM status. Although increased frailty was significantly associated with rehospitalisation and discharge to an institution, only DM was significantly associated with in-hospital mortality.Relevance to clinical practice: Frailty assessment may augment clinical assessment and facilitate tailoring care and determining optimal outcomes in patients with and without DM

What role can local and national supportive services play in supporting independent and healthy living in individuals 65 and over?

Executive summary The UK population is ageing rapidly and the extent of comorbidities will continue to increase. This greater demand for support and care will need to be met within an environment of continued economic restraint. One policy response to mitigate such demand has been the reinvigorated focus on prevention and early intervention in health, social and third sector care. Prevention is broadly defined to include a wide range of services that promote independence; prevent or delay the deterioration of health and well-being resulting from ageing, illness or disability; and delay the need for more costly and intensive services. In exploring the existing evidence base around effective and cost-effective preventative services, our typology of prevention includes the accepted discourse of primary, second and tertiary prevention, while placing those ‘upstream’ well-being interventions at the core of any prevention strategy. Well-being preventative services across the continuum • In mitigating social isolation and loneliness, there is relatively good evidence that befriending interventions, social prescribing services, group activities and volunteer schemes can reduce loneliness and depressive symptomology, improve physical health, and result in differences in mortality. • A range of exercise provision is able to improve balance, cognition, well-being, mobility, core strength and cardio-metabolic health, and reduce fall or fracture risk, depressive symptomology and cognitive decline. Physical activity can be supported through community-based interventions (e.g. walking for health groups, peer-supported exercise programmes), resulting in improved health-related quality of life and reductions in the use of secondary health care. • Information, advice and signposting are seen as fundamental by individuals, as well as their families or carers, who need (or in the future may need), care and support to maintain independence. However, few studies concentrate on what works for older people, or whether timely and appropriate advice is able to maintain independence or improve quality of life. There is emerging evidence that care navigators (CNs) can provide effective practical and social support to older people, ensuring timely signposting to interventions and acting as a ‘link’ between community and statutory services. • There is a range of low-level practical interventions that can support older people to remain at home, e.g. minor housing repairs, assisted gardening and shopping. While the link between such services and the use of higher-intensity provision is little discussed in the literature, a timely and trusted response can improve quality of life and reduce service use. Gardening has been shown to improve physical strength, fitness and cognitive ability and to reduce depression and anxiety. Primary, secondary and tertiary prevention Available primary and secondary preventative services (e.g. health screening, vaccinations, care management, day services, reablement) should be delivered holistically, i.e. ‘making every contact count’. • Two national population health screening programmes – breast and bowel screening – demonstrate efficacy. In contrast, the level of uptake of the NHS Health Check has been lower than expected. While older people are more likely to attend, older individuals most likely to benefit (e.g. smokers, minority ethnic groups and those living in more deprived areas) seem less keen to engage. • Day services for older people are a contested area, often perceived as part of the ‘one-size-fits-all’ welfarist agenda. Where the evidence is available, day services improve social care and quality of life for users and carers, reduce social isolation, may delay institutionalisation for people with dementia, and provide a sense of purpose for the individual, but are unlikely to reduce health service use. • Care management, essential in supporting the individual to ‘age in place’, can reduce hospital admissions, lengths of stay and Accident and Emergency (A&E) attendances, although outcomes are dependent on the structure and processes adopted. Improved outcomes can be achieved by delivering well-being services alongside statutory provision. • While reablement improves independence, health-related quality of life and service use, there are continuing process difficulties in appropriately involving or transferring older people to further service provision. • In exploring tertiary prevention (minimising disability and deterioration from established diseases), the evidence base remains fragmented, with little clarity on the processes, structures or outcomes of, for example, rapid response teams (RRTs) or ambulatory emergency care (AEC) units. Fragmented evidence base? There is a wide range of available and effective well-being preventative services that can support older people to live independent and healthy lives. However, there are still gaps in the evidence base. Few evaluations explore whether reported changes in quality of life, service use, morbidity or mortality are maintained long term, with even fewer reporting cost-effectiveness. There is also little evidence that identifies the types of package of early interventions that should be provided, when these need to be offered, and to whom they would make the most difference. The evidence is non-existent on the structures and processes of effective preventative pathways. The future role of services to 2030 If appropriate management of future pressures on the health and social care environment is to be delivered, the system needs to be rebalanced toward well-being interventions, and primary, secondary and tertiary prevention. However, the budget for such care is continually under threat. There is an urgent need to apply a single health and social care budget, incorporating housing and transport and delivered through a single commissioning point. Perhaps the main challenge in reorienting provision toward preventative care is that there first needs to be an accepted clarity from all partners across the health and social care environment as to what is being prevented – unnecessary hospital admissions or morbidity (ill health). The rhetoric of prevention needs to be embedded into service provision with appropriate care strategies, processes and structures able to support the promotion of well-being and health, rather than the management of disease

What does it take to make integrated care work? A ‘cookbook’ for large-scale deployment of coordinated care and telehealth

The Advancing Care Coordination & Telehealth Deployment (ACT) Programme is the first to explore the organisational and structural processes needed to successfully implement care coordination and telehealth (CC&TH) services on a large scale. A number of insights and conclusions were identified by the ACT programme. These will prove useful and valuable in supporting the large-scale deployment of CC&TH. Targeted at populations of chronic patients and elderly people, these insights and conclusions are a useful benchmark for implementing and exchanging best practices across the EU. Examples are: Perceptions between managers, frontline staff and patients do not always match; Organisational structure does influence the views and experiences of patients: a dedicated contact person is considered both important and helpful; Successful patient adherence happens when staff are engaged; There is a willingness by patients to participate in healthcare programmes; Patients overestimate their level of knowledge and adherence behaviour; The responsibility for adherence must be shared between patients and health care providers; Awareness of the adherence concept is an important factor for adherence promotion; The ability to track the use of resources is a useful feature of a stratification strategy, however, current regional case finding tools are difficult to benchmark and evaluate; Data availability and homogeneity are the biggest challenges when evaluating the performance of the programmes

Addressing the Health Needs of an Aging America: New Opportunities for Evidence-Based Policy Solutions

This report systematically maps research findings to policy proposals intended to improve the health of the elderly. The study identified promising evidence-based policies, like those supporting prevention and care coordination, as well as areas where the research evidence is strong but policy activity is low, such as patient self-management and palliative care. Future work of the Stern Center will focus on these topics as well as long-term care financing, the health care workforce, and the role of family caregivers

Bringing the pieces together:Integrating cardiac and geriatric care in older patients with heart disease

Due to the increasing aging population, the number of older cardiac patients is also expected to rise in the next decades. The treatment of older cardiac patients is complex due to the simultaneously presence of comorbidities and polypharmacy, and geriatric conditions such as functional impairment, fall risk and malnutrition. However, the assessment of geriatric conditions is not part of the medical routine in cardiology and therefore these conditions are frequently unrecognized although they have a significant impact on treatment and on outcomes. In addition, treatments are mostly based on single-disease oriented guidelines and inadequately take other conditions into account. This may lead to conflicting recommendations and treatments that do not address important outcomes for older patients such as daily functioning, symptom relief and quality of life. Thus, the care of older cardiac patients is currently suboptimal which increases the risk of functional loss, readmission and mortality. The overall aim of the work described in this thesis is to explore the integration of cardiac and geriatric care for older patients with heart disease. First, by examining how hospitalized older cardiac patients at high risk for adverse events could be identified. Second, by investigating lifestyle-related secondary prevention of cardiovascular complications in older cardiac patients. And third, by developing a transitional care intervention for older cardiac patients and evaluating the effect on unplanned hospital readmission and mortality