Is Hospital in the Home as safe and effective as inpatient care?

When Activity-Based Funding (ABF) for public hospitals begins on 1 July this year, it should make it easier for hospitals to establish Hospital in the Home (HITH) services. The pricing framework underpinning the ABF system stipulates that public hospital services should be priced in a way that facilitates the timely roll-out of evidence-based innovations in the most appropriate care setting. HITH services have been operating in some Australian hospitals for nearly 20 years. However before starting up a service of their own, many hospital managers will want to know if HITH is safe, and for which patients. This paper briefly outlines the evidence on the safety, quality and costs of HITH services. A list of resources is provided for those who want to know more. What does the evidence say? Many health services provide care in patients’ homes. To qualify as a HITH service it must provide active treatment by health care professionals in patients’ homes for conditions that otherwise would require hospital in-patient care. Examples of acute treatments delivered in the home include blood transfusions, intravenous antibiotic treatments for infections, and anticoagulation for patients with deep venous thrombosis and pulmonary emboli. Some HITH services (early - discharge HITH) also provide subacute treatment such as rehabilitation at home after orthopaedic injuries and procedures. The range of conditions that are treatable at home continues to expand as technology and confidence in HITH improves. Cochrane Reviews are generally regarded as an authoritative source of research evidence. A systematic review of the evidence on HITH was conducted by the Cochrane Collaboration in 2008 (it was updated in 2011 and no changes were made to the conclusions). After searching the main medical databases, the Cochrane reviewers found 10 randomised controlled trials (RCTs) that compared HITH with inpatient care; RCTs are generally thought to produce high quality evidence. Data from five of the RCTs on admission - substitution HITH services were broadly comparable, so they were pooled and used to conduct a more high-powered statistical analysis, a meta-analysis

Alternatives to standard in-hospital care

The accompanying published articles submitted for the degree of Doctor of Medicine by publication locus on the rigorous evaluation of health services. They present the results of three non-randomized controlled trials and four randomized controlled trials that I initiated, conceived the ideas for, designed the hypotheses, employed a variety of people to carry out the data collection, and usually analysed and wrote up myself. The papers examine various aspects of alternatives to standard in-hospital care. including providing Hospital in the Home: acute subacute or post-acute care at home and in residential aged care facilities; chronic care at home to prevent readmission: implementing Comprehensive Geriatric Assessment in the Emergency Department: and adding to the hospital workforce, using a team of volunteers to improve the care on the ward, thereby covering a large variety of older peoples' contacts with the hospital system. These studies have had a demonstrable major impact on the delivery of health services across Australia, and the ideas have been taken up overseas. There has been direct transfer of services based on these trials to other hospitals through the Australian Commonwealth Department of Health's National Demonstration Hospitals Program, as well as systemic roll out by the NSW Department of Health. These studies have advanced the field of health services research by demonstrating that improving the delivery of health services not only affects administrative outcomes by reducing length of stay and cost, but also has a measurable effect on health outcomes, such as reduced mortality and reduced complications, including delirium and wound infections, as well as increased patient satisfaction. Combining the two sets of data, health outcomes and economic evaluation, has assisted with more rapid dissemination

Toward best practice methods for delirium biomarker studies: An international modified Delphi study

Background: Delirium is a serious and distressing neurocognitive condition common in people with advanced illness. The understanding of delirium pathophysiology is limited and largely hypothetical. To accelerate empirical understanding of delirium pathophysiology, robust scientific methods for conducting and reporting delirium biomarker studies are urgently needed. The aim of this study was to develop international consensus on the core elements of high‐quality delirium biomarker studies. Methods: A three‐round modified Delphi survey was conducted from February to August 2019. Participants were international researchers experienced in conducting delirium studies from a range of settings (hospital, university, research centres). Round one commenced with open‐ended questions developed from results from a prior systematic review and the REMARK (REporting recommendations for tumour MARKer prognostic studies) checklist. Responses were qualitatively analysed, and closed statements were developed. Participants then ranked the importance of these statements using a 5‐point Likert scale in rounds 2 and 3. A priori consensus was defined as ≥70% participant agreement. Descriptive statistics for each item were computed including the mean Likert scores, SD and median participant scores. Results: Twenty-eight participants completed survey round one, 16 completed round two and 19 completed the final round. Consensus was achieved for a total of 60 items. Conclusion: The Delphi survey identified items that expert researchers agreed were important in the conduct of delirium biomarker studies. These reporting items provide a strong platform for improved methodological quality and opportunities to synthesise future delirium biomarker studies

Persistent delirium in older hospital patients: an updated systematic review and meta-analysis

Introduction: Delirium is associated with future dementia progression. Yet whether this occurs subclinically over months and years, or persistent delirium merges into worsened dementia is not understood. Our objective was to estimate the prevalence of persistent delirium and understand variation in its duration. Methods: We adopted an identical search strategy to a previous systematic review, only including studies using a recognised diagnostic framework for ascertaining delirium at follow-up (persistent delirium). Studies included hospitalised older patients outside critical and palliative care settings. We searched MEDLINE, EMBASE, PsycINFO and the Cochrane Database of Systematic Reviews on 11th January 2022. We applied risk of bias assessments based on Standards of Reporting of Neurological Disorders criteria and assessed strength of recommendations using the grading of recommendation, assessment, development and evaluation (GRADE) approach. Estimates were pooled across studies using random-effects meta-analysis, and we estimated associations with follow-up duration using robust error meta-regression. Results: We identified 13 new cohorts, which we added to 10 from the previous systematic review (23 relevant studies, with 39 reports of persistent delirium at 7 time-points in 3186 individuals admitted to hospital care (mean age 82 years and 41% dementia prevalence). Studies were mainly at moderate risk of bias. Pooled delirium prevalence estimates at discharge were 36% (95% CI 22% to 51%, 13 studies). Robust error meta-regression did not show variation in prevalence of persistent delirium over time (-1.6% per month, 95% CI -4.8 to 1.6, p=0.08). Margins estimates for this model indicate a prevalence of persistent delirium of 16% (95% CI 6% to 25%) at 12 months. Conclusions: This systematic review emphasises the importance of delirium as a persistent and extensive problem (GRADE certainty = moderate), raising questions on chronic delirium as a clinical entity and how it might evolve into dementia. Addressing persistent delirium will require a whole-system, integrated approach to detect, follow-up and implement opportunities for recovery across all healthcare settings

Optimising skill-mix in the primary health care workforce for the care of older Australians: a systematic review

Australia has an ageing population resulting in demand for extensive and comprehensive care of chronic disease. This demand has required new thinking about primary health care workforce re-modelling to meet the health care needs of community dwelling older Australians. Sibbald and others have developed a model of skill-mix change to discuss workforce redesign. We conducted a systematic literature review to identify skill-mix changes needed in the primary health care workforce to successfully meet the health care needs of older Australians. Sibbald's concept that skill-mix changes could be obtained through task substitution, enhancement, delegation and innovation formed the conceptual framework for the review.The research reported in this paper is a project of the Australian Primary Health Care Research Institute, which is supported by a grant from the Australian Government Department of Health and Ageing under the Primary Health Care Research, Evaluation and Development Strategy

Clinicians\u27 delirium treatment practice, practice change, and influences: A national online survey

Background: Recent studies cast doubt on the net effect of antipsychotics for delirium. Aim: To investigate the influence of these studies and other factors on clinicians’ delirium treatment practice and practice change in palliative care and other specialties using the Theoretical Domains Framework. Design: Australia-wide online survey of relevant clinicians. Setting/participants: Registered nurses (72%), doctors (16%), nurse practitioners (6%) and pharmacists (5%) who cared for patients with delirium in diverse settings, recruited through health professionals’ organisations. Results: Most of the sample (n=475): worked in geriatrics/aged (31%) or palliative care (30%); in hospitals (64%); and saw a new patient with delirium at least weekly (61%). More (59%) reported delirium practice change since 2016, mostly by increased non-pharmacological interventions (53%). Fifty-five percent reported current antipsychotic use for delirium, primarily for patient distress (79%) and unsafe behaviour (67%). Common Theoretical Domains Framework categories of influences on respondents’ delirium practice were: emotion (54%); knowledge (53%) and physical (43%) and social (21%) opportunities. Palliative care respondents more often reported: awareness of any named key study of antipsychotics for delirium (73% vs 39%, p\u3c0.001); decreased pharmacological interventions (60% vs 15%, p\u3c0.001); off-label medication use (86% vs 51%, p\u3c0.001); antipsychotics 79% vs 44%, p\u3c0.001); benzodiazepines 61% vs 26%, p\u3c0.001); and emotion as an influence (82% vs 39%, p\u3c0.001). Conclusion: Clinicians’ use of antipsychotic during delirium remains common and is primarily motivated by distress and safety concerns for the patient and others nearby. Supporting clinicians to achieve evidence-based delirium practice requires further work

Older persons’ and their caregivers’ perspectives and experiences of research participation with impaired decision-making capacity: A scoping review

Background and Objectives: Human research ethics statements support equitable inclusion of diverse groups. Yet older people are under-represented in clinical research, especially those with impaired decision-making capacity. The aim of this study was to identify perspectives and experiences of older persons and their caregivers of research participation with impaired decision-making capacity. Research Design and Methods: Scoping review of literature and online sources in January-February 2019 (updated June 2020) according to Joanna Briggs Institute methodology and PRISMA Extension for Scoping Reviews. English-language peer-reviewed research articles and Australian online narratives were included. Data were tabulated and narratively synthesized. Results: From 4171 database records and 93 online resources, 22 articles (2000-2019, 82% United States, 16 first authors) and one YouTube webinar (2018) were initially included; updated searches yielded an additional article (2020) and YouTube webinar (2020). Studies were heterogeneous in terminology, methods and foci, with hypothetical scenarios, quantitative analyses and examination of proxy consent predominating. Participants (n=7331) were older persons (71%), caregivers of older persons with dementia/cognitive impairment (23%) and older persons with dementia/cognitive impairment (6%). Synthesis identified two themes: willingness to participate and decision-making approaches. Discussion and Implications: Research participation by older persons with dementia may be optimized through reducing risks and burdens and increasing benefits for participants, greater consumer input into study development, and shared and supported decision-making. Older persons’ and caregivers’ perspectives and experiences of research participation with impaired decision-making capacity require investigation in a greater range of countries and conditions other than dementia, and dissemination through more varied media

A world-wide study on delirium assessments and presence of protocols

Acknowledgement of collaborative authors: The “WDAD Study Team” comprises of 158 non-author collaborators. They are listed in Appendix 1a in the Supplementary Data. The authors would like to gratefully acknowledge the many participating clinicians for supporting the 2023 WDAD Study Team and survey. They are named in Appendix 1b in the Supplementary Data.Peer reviewe

Advancing specificity in delirium: The delirium subtyping initiative

BACKGROUND: Delirium, a common syndrome with heterogeneous etiologies and clinical presentations, is associated with poor long-term outcomes. Recording and analyzing all delirium equally could be hindering the field's understanding of pathophysiology and identification of targeted treatments. Current delirium subtyping methods reflect clinically evident features but likely do not account for underlying biology. METHODS: The Delirium Subtyping Initiative (DSI) held three sessions with an international panel of 25 experts. RESULTS: Meeting participants suggest further characterization of delirium features to complement the existing Diagnostic and Statistical Manual of Mental Disorders Fifth Edition Text Revision diagnostic criteria. These should span the range of delirium-spectrum syndromes and be measured consistently across studies. Clinical features should be recorded in conjunction with biospecimen collection, where feasible, in a standardized way, to determine temporal associations of biology coincident with clinical fluctuations. DISCUSSION: The DSI made recommendations spanning the breadth of delirium research including clinical features, study planning, data collection, and data analysis for characterization of candidate delirium subtypes. HIGHLIGHTS: Delirium features must be clearly defined, standardized, and operationalized. Large datasets incorporating both clinical and biomarker variables should be analyzed together. Delirium screening should incorporate communication and reasoning

The Delphi Delirium Management Algorithms. A practical tool for clinicians, the result of a modified Delphi expert consensus approach

Delirium is common in hospitalised patients, and there is currently no specific treatment. Identifying and treating underlying somatic causes of delirium is the first priority once delirium is diagnosed. Several international guidelines provide clinicians with an evidence-based approach to screening, diagnosis and symptomatic treatment. However, current guidelines do not offer a structured approach to identification of underlying causes. A panel of 37 internationally recognised delirium experts from diverse medical backgrounds worked together in a modified Delphi approach via an online platform. Consensus was reached after five voting rounds. The final product of this project is a set of three delirium management algorithms (the Delirium Delphi Algorithms), one for ward patients, one for patients after cardiac surgery and one for patients in the intensive care unit.</p