Priority setting in primary health care - dilemmas and opportunities: a focus group study

<p>Abstract</p> <p>Background</p> <p>Swedish health care authorities use three key criteria to produce national guidelines for local priority setting: severity of the health condition, expected patient benefit, and cost-effectiveness of medical intervention. Priority setting in primary health care (PHC) has significant implications for health costs and outcomes in the health care system. Nevertheless, these guidelines have been implemented to a very limited degree in PHC. The objective of the study was to qualitatively assess how general practitioners (GPs) and nurses perceive the application of the three key priority-setting criteria.</p> <p>Methods</p> <p>Focus groups were held with GPs and nurses at primary health care centres, where the staff had a short period of experience in using the criteria for prioritising in their daily work.</p> <p>Results</p> <p>The staff found the three key priority-setting criteria (severity, patient benefit, and cost-effectiveness) to be valuable for priority setting in PHC. However, when the criteria were applied in PHC, three additional dimensions were identified: 1) viewpoint (medical or patient's), 2) timeframe (now or later), and 3) evidence level (group or individual).</p> <p>Conclusions</p> <p>The three key priority-setting criteria were useful. Considering the three additional dimensions might enhance implementation of national guidelines in PHC and is probably a prerequisite for the criteria to be useful in priority setting for individual patients.</p

Canadian guidelines for clinical practice: an analysis of their quality and relevance to the care of adults with comorbidity

<p>Abstract</p> <p>Background</p> <p>Clinical guidelines have been the subject of much criticism in primary care literature partly due to potential conflicts in their implementation among patients with multiple chronic conditions. We assessed the relevance of selected Canadian clinical guidelines on chronic diseases for patients with comorbidity and examined their quality.</p> <p>Methods</p> <p>We selected 16 chronic medical conditions according to their frequency of occurrence, complexity of treatment, and pertinence to primary care. Recent Canadian clinical guidelines (2004 - 2009) on these conditions, published in English or French, were retrieved. We assessed guideline relevance to the care of patients with comorbidity with a tool developed by Boyd and colleagues. Quality was assessed using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument.</p> <p>Results</p> <p>Regarding relevance, 56.2% of guidelines addressed treatment for patients with multiple chronic conditions and 18.8% addressed the issue for older patients. Fifteen guidelines (93.8%) included specific recommendations for patients with one concurrent condition; only three guidelines (18.8%) addressed specific recommendations for patients with two comorbid conditions and one for more than two concurrent comorbid conditions. Quality of the evaluated guidelines was good to very good in four out of the six domains measured using the AGREE instrument. The domains with lower mean scores were Stakeholder Involvement and Applicability.</p> <p>Conclusions</p> <p>The quality of the Canadian guidelines examined is generally good, yet their relevance for patients with two or more chronic conditions is very limited and there is room for improvement in this respect.</p

Early rehospitalizations of frail elderly patients &ndash; the role of medications: a clinical, prospective, observational trial

Niklas Ekerstad,1,2 Kristoffer Bylin,3 Bj&ouml;rn W Karlson3,4 1Department of Cardiology, NU (N&Auml;L-Uddevalla) Hospital Group, Trollh&auml;ttan, 2Department of Medical and Health Sciences, Division of Health Care Analysis, Link&ouml;ping University, Link&ouml;ping, 3Department of Acute and Internal Medicine, NU (N&Auml;L-Uddevalla) Hospital Group, Trollh&auml;ttan, 4Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden Background and objective: Early readmissions of frail elderly patients after an episode of hospital care are common and constitute a crucial patient safety outcome. Our purpose was to study the impact of medications on such early rehospitalizations. Patients and methods: This is a clinical, prospective, observational study on rehospitalizations within 30&nbsp;days after an acute hospital episode for frail patients over the age of 75&nbsp;years. To identify adverse drug reactions (ADRs), underuse of evidence-based treatment and avoidability of rehospitalizations, the Naranjo score, the Hallas criteria and clinical judgment were used. Results: Of 390 evaluable patients, 96 (24.6%) were rehospitalized. The most frequent symptoms and conditions were dyspnea (n = 25) and worsened general condition (n = 18). The most frequent diagnoses were heart failure (n = 17) and pneumonia/acute bronchitis (n = 13). By logistic regression analysis, independent risk predictors for rehospitalization were heart failure (odds ratio [OR] = 1.8; 95% CI = 1.1&ndash;3.1) and anemia (OR = 2.3; 95% CI = 1.3&ndash;4.0). The number of rehospitalizations due to probable ADRs was 13, of which two were assessed as avoidable. The number of rehospitalizations probably due to underuse of evidence-based drug treatment was 19, all of which were assessed as avoidable. The number of rehospitalizations not due to ADRs or underuse of evidence-based drug treatment was 64, of which none was assessed as avoidable. Conclusion: One out of four frail elderly patients discharged from hospital was rehospitalized within 1 month. Although ADRs constituted an important cause of rehospitalization, underuse of evidence-based drug treatment might be an even more frequent cause. Potentially avoidable rehospitalizations were more frequently associated with underuse of evidence-based drug treatment than with ADRs. Efforts to avoid ADRs in frail elderly patients must be balanced and combined with evidence-based drug therapy, which can benefit these patients. Keywords: frail elderly, early rehospitalizations, causes, drugs, patient safet

Are frail elderly patients treated in a CGA unit more satisfied with their hospital care than those treated in conventional acute medical care?

Niklas Ekerstad,1,2 G&ouml;ran &Ouml;stberg,3 Maria Johansson,3 Bj&ouml;rn W Karlson3,4 1Department of Cardiology, NU (N&Auml;L-Uddevalla) Hospital Group, Trollh&auml;ttan-Uddevalla-V&auml;nersborg, 2Department of Medical and Health Sciences, Division of Health Care Analysis, Link&ouml;ping University, Link&ouml;ping, 3Division of Internal and Acute Medicine, NU Hospital Group, Trollh&auml;ttan-Uddevalla-V&auml;nersborg, 4Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden Objectives: Our aim was to study whether the acute care of frail elderly patients directly admitted to a comprehensive geriatric assessment (CGA) unit is superior to the care in a conventional acute medical care unit in terms of patient satisfaction.Design: TREEE (Is the TReatment of frail Elderly patients Effective in an Elderly care unit?) is a clinical, prospective, controlled, one-center intervention trial comparing acute treatment in CGA units and in conventional wards.Setting: This study was conducted in the N&Auml;L-Uddevalla county hospital in western Sweden.Participants: In this follow-up to the TREEE study, 229 frail patients, aged &ge;75 years, in need of acute in-hospital treatment, were eligible. Of these patients, 139 patients were included in the analysis, 72 allocated to the CGA unit group and 67 to the conventional care group. Mean age was 85 years and 65% were female.Intervention: Direct admittance to an acute elderly care unit with structured, systematic interdisciplinary CGA-based care, compared to conventional acute medical care via the emergency room.Measurements: The primary outcome was the satisfaction reported by the patients shortly after discharge from hospital. A four-item confidential questionnaire was used. Responses were given on a 4-graded scale.Results: The response rate was 61%. In unadjusted analyses, significantly more patients in the intervention group responded positively to the following three questions about the hospitalization: &ldquo;Did you get the nursing from the ward staff that you needed?&rdquo; (p=0.003), &ldquo;Are you satisfied with the information you received on your diseases and medication?&rdquo; (p=0.016), and &ldquo;Are you satisfied with the planning before discharge from the hospital?&rdquo; (p=0.032). After adjusted analyses by multiple regression, a significant difference in favor of the intervention remained for the first question (p=0.027).Conclusion: Acute care in a CGA unit with direct admission was associated with higher levels of patient satisfaction compared with conventional acute care via the emergency room. Keywords: frailty, elderly, comprehensive geriatric assessment, acute care, patient satisfaction, direct admissio

Hospitalized frail elderly patients &ndash; atrial fibrillation, anticoagulation and 12 months&rsquo; outcomes

Niklas Ekerstad,1,2 Thomas Karlsson,3 Sara S&ouml;derqvist,4 Bj&ouml;rn W Karlson4,5 1Department of Cardiology, NU (N&Auml;L-Uddevalla) Hospital Group, Trollh&auml;ttan-Uddevalla-V&auml;nersborg, Sweden; 2Department of Medical and Health Sciences, Division of Health Care Analysis, Link&ouml;ping University, Link&ouml;ping, Sweden; 3Health Metrics Unit, Institution of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; 4Department of Acute and Internal Medicine, NU (N&Auml;L-Uddevalla) Hospital Group, Trollh&auml;ttan-Uddevalla-V&auml;nersborg, Sweden; 5Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden Background and objective: Multiple chronic conditions and recurring acute illness are frequent among elderly people. One such condition is atrial fibrillation (AF), which increases the risk of stroke up to fivefold. The aim of this study was to investigate the prevalence of AF among hospitalized frail elderly patients, their use of anticoagulation and their 12-month outcomes. Patients and methods: This was a clinical observational study of acutely hospitalized frail patients over the age of 75 years. The CHA2DS2-VASc Score was used to evaluate ischemic stroke risk in patients with AF. Clinically relevant outcomes were the composite of ischemic stroke and/or bleeding within 12 months, which was considered as primary in the analysis, ischemic stroke/transient ischemic attack (TIA), mortality, bleeding and hospital care consumption. Student&rsquo;s t-test, Fisher&rsquo;s exact test, Mann&ndash;Whitney U test and a Cox proportional hazards model were used for the analyses. Results: The prevalence of AF was 47%, and 63% of them were prescribed an anticoagulant. AF patients without anticoagulation were older, more often females, more often in residential care, and they had worse Mini Nutritional Assessment and activities of daily living scores. Of the patients without anticoagulation, 56% had a documented contraindication. In univariate analysis, there were significantly more events among AF patients without anticoagulation regarding the composite outcome of ischemic stroke and/or bleeding (hazard ratio [HR] 3.65, 95% CI = 1.70&ndash;7.86; p &lt; 0.001). When adjusting for potential confounders in Cox regression analysis, the difference remained significant (HR 4.54, 95% CI = 1.83&ndash;11.25; p = 0.001). Conclusion: The prevalence of AF in a hospitalized frail elderly population was 47%. Of these, 63% were prescribed anticoagulation therapy. Almost half of the patients without stroke prophylaxis had no documented contraindication. At 1 year, there were significantly more events in terms of ischemic stroke and/or bleeding among AF patients without anticoagulation therapy than among those with. Keywords: frail elderly, atrial fibrillation, anticoagulants, outcomes, patient safet

Preserved physical fitness is associated with lower 1-year mortality in frail elderly patients with a severe comorbidity burden

Kristina &Aring;hlund,1,2 Niklas Ekerstad,3,4 Maria B&auml;ck,2,5 Bj&ouml;rn W Karlson,6,7 Birgitta &Ouml;berg2 1Department of Physiotherapy, NU Hospital Group, Trollh&auml;ttan, Sweden; 2Department of Medical and Health Sciences, Division of Physiotherapy, Link&ouml;ping University, Link&ouml;ping, Sweden; 3Department of Research and Development, NU Hospital Group, Trollh&auml;ttan, Sweden; 4Department of Medical and Health Sciences, Division of Health Care Analysis, Link&ouml;ping University, Link&ouml;ping, Sweden; 5Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Gothenburg, Sweden; 6Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; 7Department of Internal and Acute Medicine, NU Hospital Group, Trollh&auml;ttan-Uddevalla, Sweden Introduction: Physical deterioration in connection with a care episode is common. The aim of this study was, in frail elderly patients with a severe comorbidity burden, to analyze 1) the association between physical fitness measurements and 1-year mortality and 2) the association between preserved physical fitness during the first three months after discharge from emergency hospital care and 1-year prognosis. Methods: Frail elderly patients (&ge;75&nbsp;years) in need of inpatient emergency medical care were included. Aerobic capacity (six-minute walk test, 6MWT) and muscle strength (handgrip strength test, HS) were assessed during the hospital stay and at a three-month follow-up. The results were analyzed using multivariate Cox regression; 1) 0&ndash;12-month analysis and 2) 0&ndash;3-month change in physical fitness in relation to 1-year mortality. The analyses were adjusted for age, gender, comorbidity and frailty. Results: This study comprised 408 frail elderly hospitalized patients of whom 390 were evaluable (mean age 85.7&nbsp;years, Charlson&rsquo;s index mean 6.8). The three-month mortality was 11.5% and the 1-year mortality was 37.9%. After adjustments, the Cox-regression analysis showed that both 6MWT and HS were associated with 1-year mortality, HR6MWT 3.31 (95% CI 1.89&ndash;5.78, p&lt;0.001) and HRHS 2.39 (95% CI 1.33&ndash;4.27, p=0.003). The 0&ndash;3-month change in the 6MWT and the HS were associated with 1-year mortality, where patients who deteriorated had a poorer prognosis than those with improved fitness, HR6MWT 3.80 (95% CI 1.42&ndash;10.06, p=0.007) and HRHS 2.21 (95% CI 1.07&ndash;4.58, p=0.032). Conclusion: In frail elderly patients with a severe comorbidity burden, physical fitness in connection with emergency hospital care was independently associated with 1-year mortality. Moreover, a change in physical fitness during the first months after hospital care was important for the long-term prognosis. These results emphasize the importance of providing hospital care designed to prevent physical deterioration in frail elderly patients. Keywords: frail elderly, mortality, physical fitness, six-minute walk test, handgrip strength test, in-hospital rehabilitatio

Predictors of short- and long-term mortality in critically ill, older adults admitted to the emergency department : an observational study

Background In the future, we can expect an increase in older patients in emergency departments (ED) and acute wards. The main purpose of this study was to identify predictors of short- and long-term mortality in the ED and at hospital discharge. Methods This is a retrospective, observational, single-center, cohort study, involving critically ill older adults, recruited consecutively in an ED. The primary outcome was mortality. All patients were followed for 6.5-7.5 years. The Cox proportional hazards model was used. Results Regarding all critically ill patients aged &gt;= 70 years and identified in the ED (n = 402), there was a significant association between mortality at 30 days after ED admission and unconsciousness on admission (HR 3.14, 95% CI 2.09-4.74), hypoxia on admission (HR 2.51, 95% CI 1.69-3.74) and age (HR 1.06 per year, 95% CI 1.03-1.09), (all p &lt; 0.001). Of 402 critically ill patients aged &gt;= 70 years and identified in the ED, 303 were discharged alive from hospital. There was a significant association between long-term mortality and the Charlson Comorbidity Index (CCI) &gt; 2 (HR 1.90, 95% CI 1.46-2.48), length of stay (LOS) &gt; 7 days (HR 1.72, 95% CI 1.32-2.23), discharge diagnosis of pneumonia (HR 1.65, 95% CI 1.24-2.21) and age (HR 1.08 per year, 95% CI 1.05-1.10), (all p &lt; 0.001). The only symptom or vital sign associated with long-term mortality was hypoxia on admission (HR 1.70, 05% CI 1.30-2.22). Conclusions Among critically ill older adults admitted to an ED and discharged alive the following factors were predictive of long-term mortality: CCI &gt; 2, LOS &gt; 7 days, hypoxia on admission, discharge diagnosis of pneumonia and age. The following factors were predictive of mortality at 30 days after ED admission: unconsciousness on admission, hypoxia and age. These data might be clinically relevant when it comes to individualized care planning, which should take account of risk prediction and estimated prognosis

Is the acute care of frail elderly patients in a comprehensive geriatric assessment unit superior to conventional acute medical care?

Niklas Ekerstad,1,2 Bj&ouml;rn W Karlson,3 Synneve Dahlin Ivanoff,4 Sten Landahl,5 David Andersson,6 Emelie Heintz,7 Magnus Husberg,2 Jenny Alwin2 1Department of Cardiology, NU (N&Auml;L-Uddevalla) Hospital Group, Trollhattan, 2Division of Health Care Analysis, Department of Medical and Health Sciences, Link&ouml;ping University, Link&ouml;ping, 3Department of Molecular and Clinical Medicine, Institute of Medicine, 4Centre for Ageing and Health, AGECAP, Department of Health and Rehabilitation, 5Department of Geriatrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, 6Division of Economics, Department of Management and Engineering, Link&ouml;ping University, Link&ouml;ping, 7Health Outcomes and Economic Evaluation Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden Objective: The aim of this study was to investigate whether the acute care of frail elderly patients in a comprehensive geriatric assessment (CGA) unit is superior to the care in a conventional acute medical care unit. Design: This is a clinical, prospective, randomized, controlled, one-center intervention study. Setting: This study was conducted in a large county hospital in western Sweden. Participants: The study included 408 frail elderly patients, aged&nbsp;&ge;75&nbsp;years, in need of acute in-hospital treatment. The patients were allocated to the intervention group (n=206) or control group (n=202). Mean age of the patients was 85.7&nbsp;years, and 56% were female. Intervention: This organizational form of care is characterized by a structured, systematic interdisciplinary CGA-based care at an acute elderly care unit. Measurements: The primary outcome was the change in health-related quality of life (HRQoL) 3 months after discharge from hospital, measured by the Health Utilities Index-3 (HUI-3). Secondary outcomes were all-cause mortality, rehospitalizations, and hospital care costs. Results: After adjustment by regression analysis, patients in the intervention group were less likely to present with decline in HRQoL after 3 months for the following dimensions: vision (odds ratio [OR] =0.33, 95% confidence interval [CI] =0.14&ndash;0.79), ambulation (OR =0.19, 95% CI =0.1&ndash;0.37), dexterity (OR =0.38, 95% CI =0.19&ndash;0.75), emotion (OR =0.43, 95% CI =0.22&ndash;0.84), cognition (OR = 0.076, 95% CI =0.033&ndash;0.18) and pain (OR =0.28, 95% CI =0.15&ndash;0.50). Treatment in a CGA unit was independently associated with lower 3-month mortality adjusted by Cox regression analysis (hazard ratio [HR] =0.55, 95% CI =0.32&ndash;0.96), and the two groups did not differ significantly in terms of hospital care costs (P&gt;0.05). Conclusion: Patients in an acute CGA unit were less likely to present with decline in HRQoL after 3 months, and the care in a CGA unit was also independently associated with lower mortality, at no higher cost. Keywords: frailty, elderly, acute care, intervention, comprehensive geriatric assessmen

Acute care of severely frail elderly patients in a CGA-unit is associated with less functional decline than conventional acute care

Niklas Ekerstad,1,2 Synneve Dahlin Ivanoff,3 Sten Landahl,4 G&ouml;ran &Ouml;stberg,5 Maria Johansson,5 David Andersson,6 Magnus Husberg,2 Jenny Alwin,2 Bj&ouml;rn W Karlson7 1Department of Cardiology, NU (N&Auml;L-Uddevalla) Hospital Group, Trollh&auml;ttan-Uddevalla-V&auml;nersborg, 2Department of Medical and Health Sciences, Division of Health Care Analysis, Link&ouml;ping University, 3Center of Aging and Health (AGECAP), Section of Health and Rehabilitation, 4Department of Geriatrics, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, 5Division of Internal and Acute Medicine, NU Hospital Group, Trollh&auml;ttan-Uddevalla-V&auml;nersborg, 6Department of Management and Engineering, Division of Economics, 7Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden Background: A high percentage of individuals treated in specialized acute care wards are frail and elderly. Our aim was to study whether the acute care of such patients in a comprehensive geriatric assessment (CGA) unit is superior to care in a conventional acute medical care unit when it comes to activities of daily living (ADLs), frailty, and use of municipal help services.Patients and methods: A clinical, prospective, controlled trial with two parallel groups was conducted in a large county hospital in West Sweden and included 408 frail elderly patients, age 75 or older (mean age 85.7 years; 56% female). Patients were assigned to the intervention group (n=206) or control group (n=202). Primary outcome was decline in functional activity ADLs assessed by the ADL Staircase 3 months after discharge from hospital. Secondary outcomes were degree of frailty and use of municipal help services.Results: After adjustment by regression analyses, treatment in a CGA unit was independently associated with lower risk of decline in ADLs [odds ratio (OR) 0.093; 95% confidence interval (CI) 0.052&ndash;0.164; P&lt;0.0001], and with a less prevalent increase in the degree of frailty (OR 0.229; 95% CI 0.131&ndash;0.400; P&lt;0.0001). When ADLs were classified into three strata (independence, instrumental ADL-dependence, and personal ADL-dependence), changes to a more dependence-associated stratum were less prevalent in the intervention group (OR 0.194; 95% CI 0.085&ndash;0.444; P=0.0001). There was no significant difference between the groups in increased use of municipal help services (OR 0.682; 95% CI&nbsp;0.395&ndash;1.178; P=0.170).Conclusion: Acute care of frail elderly patients in a CGA unit was independently associated with lesser loss of functional ability and lesser increase in frailty after 3 months. Keywords: frail elderly, comprehensive geriatric assessment, acute care, functional outcome

Comprehensive Geriatric Assessment for Frail Older People in Swedish Acute Care Settings (CGA-Swed) : A Randomised Controlled Study

The aim of the study is to evaluate the effects of the Comprehensive Geriatric Assessment (CGA) for frail older people in Swedish acute hospital settings - the CGA-Swed study. In this study protocol, we present the study design, the intervention and the outcome measures as well as the baseline characteristics of the study participants. The study is a randomised controlled trial with an intervention group receiving the CGA and a control group receiving medical assessment without the CGA. Follow-ups were conducted after 1, 6 and 12 months, with dependence in activities of daily living (ADL) as the primary outcome measure. The study group consisted of frail older people (75 years and older) in need of acute medical hospital care. The study design, randomisation and process evaluation carried out were intended to ensure the quality of the study. Baseline data show that the randomisation was successful and that the sample included frail older people with high dependence in ADL and with a high comorbidity. The CGA contributed to early recognition of frail older people's needs and ensured a care plan and follow-up. This study is expected to show positive effects on frail older people's dependence in ADL, life satisfaction and satisfaction with health and social care.This article belongs to the Special Issue: Geriatric Assessment: Multidimensional, Multidisciplinary and Comprehensive</p