Analyzing risk factors, resource utilization, and health outcomes of hospital-acquired delirium In elderly emergency department patients

BACKGROUND: Delirium is a disorder that is characterized by an acute change in cognitive functioning including inattention, and disordered thinking. Delirium disproportionately affects the population over the age of 65, and is associated with increased costs, worse outcomes and longer lengths of stay. Although delirium is estimated to affect approximately 10% of elderly patients in the emergency department (ED) and 42% of elderly inpatients, it often goes unrecognized by the clinical staff. There is evidence that delirium can be prevented through non-pharmacologic prevention strategies, however it is less clear which patients should be targeted for these measures. OBJECTIVES: The objective of this study is to identify risk factors for development of hospital-acquired delirium during the most proximal aspect of a patient’s hospital course, namely the ED. Secondary objectives of this study are to analyze resource utilization and outcomes associated with the development of hospital-acquired delirium. METHODS: This study is a secondary analysis of a prospective observational study conducted over 3 years at a single urban university hospital. Patients over the age of 65, who could complete a structured cognitive assessment interview, were screened for delirium by a trained research assistant. Patients that were judged to be not delirious in the ED, and who were then admitted to an inpatient unit were included in the final cohort. A validated chart review method was used to determine if patients developed delirium during the course of their hospitalization. Potential predictors of hospital-acquired delirium, including demographics, laboratory values, comorbidities and outcomes, were also abstracted from the medical chart. We performed a univariate analysis of these predictors and included those covariates with a p values ≤0.2 in multivariate analysis. We allowed 1 predictor per 10 outcomes in the final model to avoid over-fitting and evaluated the discriminatory ability and calibration of the model using the c-statistic and Hosmer-Lemeshow goodness-of-fit test. RESULTS: Of the 520 patients included in our cohort, 77 developed delirium over the course of their inpatient visit. Multivariate analysis identified 7 risk factors to predict delirium in elderly emergency department patients admitted to the hospital. Patients were more likely to develop delirium during their stay if they were age 80 or older, had a history of dementia, had a history of stroke or transient ischemic attack, were hypoxic or hyponatremic in the ED, or had an ED admitting diagnosis of acute stroke/transient ischemic attack or fall. The model had a c-statistic of 0.73 and a non-significant p-value of 0.7 in the Hosmer-Lemeshow goodness-of-fit test. CONCLUSION: The predictive model that we created may help identify a population to target for delirium prevention strategies in elderly emergency department patients, thereby reducing delirium incidence in hospitalized patients, and the associated morbidity, mortality, and healthcare utilization

An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging in patients with transient ischaemic attack and minor stroke : a systematic review, meta-analysis and economic evaluation

Erratum issued September 2015 Erratum DOI: 10.3310/hta18270-c201509Peer reviewedPublisher PD

Anticoagulation control in patients with atrial fibrillation

To examine self-reported depression, anxiety, beliefs about medication, knowledge of AF, and quality of life in newly anticoagulated atrial fibrillation (AF) patients and to investigate anticoagulation control, measured by time in therapeutic range (TTR) in AF patients and operated valvular heart disease (VHD) patients, prescribed long-term VKA therapy. Study I: AF patients have low levels of depression and anxiety, and positive beliefs about medication. AF knowledge and quality of life was poor. Results were unchanged at 6 months but AF symptoms and awareness of AF consequences improved. Study 2: TTR was significantly lower in South-Asians (60.5%) and Afro-Caribbeans (61.3%) compared to Whites (67.9%; p<0.00 1] despite similar INR monitoring intensity. TTR was similar among elderly (≥80 vs. <80 years) patients and those with/without chronic kidney disease. Non-white ethnicity was the strongest independent predictor of poor TTR. Study 3: TTR was significantly poorer in operated VHD patients with AF (55.7%) compared to those without AF (60.1 %; p=0.002). Independent predictors of poor TTR: female sex. AF and anaemia/bleeding history. Conclusion: Newly anticoagulated AF patients had poor quality of life and limited AF knowledge. 1TR was sub-optimal (TTR<70%) among non-white AF patients and operated VHD patients with AF

Is the time of calling helpful for differentiating transient ischaemic attack and stroke from mimics in primary care out-of-hours services?: A cross-sectional study

OBJECTIVES: Telephone triage of patients suspected of transient ischaemic attack (TIA) or stroke is challenging. Both TIA and stroke more likely occur during daytime, with a peak in the morning hours. Thus, the time of calling might be a helpful determinant during telephone triage. We assessed the time of calling in patients with stroke-like symptoms who called the out-of-hours services in primary care (OHS-PC), and evaluated whether the time of calling differed between patients with TIA or stroke compared with those with mimics. DESIGN: Cross-sectional study. SETTING: Six OHS-PC locations in the Netherlands. PARTICIPANTS: 1269 telephone triage recordings of patients calling the OHS-PC because of stroke-like symptoms. We collected information on patient characteristics, symptoms, time of calling and urgency allocation. The final diagnosis related to each triage call was based on letters from the neurologist (retrieved from the patient's general practitioner). PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measures were the time of calling hourly and 4 hourly, and the risk of TIA or stroke/hour. The secondary outcome measure was the risk ratio of TIA or stroke in the morning (08:00-12:00h) versus other hours. RESULTS: Mean age was 68.6 (SD±18.5) years, 56.9% were women and 50.0% had a TIA or stroke. The risk ratio of TIA or stroke among people calling with stroke-like symptoms between 08:00-12:00h versus other hours was 1.13 (95% CI 1.00 to 1.28, p=0.070). After correction for age and sex, the adjusted risk ratio was 0.94 (95% CI 0.80 to 1.10, p=0.434). CONCLUSION: In patients who called the OHS-PC because of stroke-like symptoms, the time of calling did not differ between patients with TIA or stroke and patients with mimics. TRIAL REGISTRATION NUMBER: The Netherlands National Trial Registry (NTR7331)

Added value of acute multimodal CT-based imaging (MCTI) : a comprehensive analysis

Introduction: MCTI is used to assess acute ischemic stroke (AIS) patients.We postulated that use of MCTI improves patient outcome regardingindependence and mortality.Methods: From the ASTRAL registry, all patients with an AIS and a non-contrast-CT (NCCT), angio-CT (CTA) or perfusion-CT (CTP) within24 h from onset were included. Demographic, clinical, biological, radio-logical, and follow-up caracteristics were collected. Significant predictorsof MCTI use were fitted in a multivariate analysis. Patients undergoingCTA or CTA&amp;CTP were compared with NCCT patients with regards tofavourable outcome (mRS ≤ 2) at 3 months, 12 months mortality, strokemechanism, short-term renal function, use of ancillary diagnostic tests,duration of hospitalization and 12 months stroke recurrence

Validation of self-reported hypertension status and predictors of uncontrolled blood pressure levels in the Community initiative to eliminate stroke (CITIES) project

Few studies have comprehensively investigated the validity of self-reported hypertension (HT) and assessed predictors of HT status in the stroke belt. The purpose of phase I of this study aims to evaluate self-reporting as a valid tool to screen large study populations and determine predictors of congruency between self-reported HT and clinical measures. Community Initiative to Eliminate Stroke project (n=16,598) was conducted in two counties of North Carolina in 2004-2007, which included collection of self-reported data and clinical data of stroke-related risk factors. Congruency between self-reported hypertension status and clinical measures was based on epidemiological parameters of sensitivity, specificity and predictive values. McNemar's test and Kappa agreement levels assessed differences in congruency, while unadjusted odds ratios and logistic regression determined significant correlates of congruency. Sensitivity of self-reported HT was low (33.3%), but specificity was high (89.5%). Prevalence of self-reported HT was 16.15%. Kappa agreement between self-report and clinical measures for BP was fair (&amp;#312; = 0.25). Females, whites and young adults were most likely to be positively congruent, whereas individuals in high risk categories for total blood cholesterol, LDL, triglycerides and diabetes were least likely to be accurate about their HT status. Self-report HT information should be used with caution for epidemiological investigations. The purpose of phase II of this study was to evaluate demographic sub-groups, self-reported health information and clinical measures as predictors of uncontrolled systolic and diastolic hypertension among individuals taking blood pressure lowering medications. Systolic hypertension is the most common form of hypertension among older individuals. Inadequate controls of systolic blood pressure have been largely attributable for poor control of overall hypertension rates. The National Heart Blood Pressure Education Program's guidelines for management of hypertension emphasize the importance of controlling isolated systolic hypertension in older individuals. The Community Initiative to Eliminate Stroke was a stroke risk-factor screening and reduction/prevention project conducted in two North Carolina counties. The initiative collected self-reported information such as personal history of atrial fibrillation and clinical measures, such as blood pressure levels, among other cardiovascular and stroke risk factors. Statistical modeling of predictors was based on odds ratios and logistic regression analyses. Of the 2,663 participants, 43.5% and 22.8% had uncontrolled systolic and diastolic hypertension, respectively. African Americans were more likely to have uncontrolled systolic or diastolic hypertension as compared to whites. Similarly, participants older than 55 years of age were more likely to have uncontrolled systolic hypertension compared to younger individuals. Regression analyses indicated that race (OR = 1.239, p = 0.00), age (OR = 1.683, p = 0.00) and non-adherence with medications (OR = 2.593, p = 0.00) were significant predictors of uncontrolled systolic blood pressure levels. Based on the recommendations made by national guidelines and our findings, future interventions should focus on management of systolic hypertension among older individuals and African Americans to increase the overall control of hypertension