Clinical Outcomes of Geriatric Care in Cipto Mangunkusumo Hospital, Before and After the Implementation of National Health Insurance Program

Background: the National Health Insurance (NIH/JKN) has been enacted since January 2014. Various outcomes of geriatric patient care, such as improved functional status and quality of life have not been evaluated. Prolonged hospitalization and re-hospitalization are potentially affecting the efficiency care of this vulnarable group. This study aimed to identify the differences of functional status improvement, quality of life improvement, length of stay, and hospitalization of geriatric patients admitted to CMH between prior to and after NHI implementation.Methods: a cohort study with historical control was conducted among geriatric patients admitted to Acute Geriatric Ward CMH Hospital on two periods of time: January-December 2013 (pre-NHI implementation) and June 2014-May 2015 (after NHI implementation). Patients who died within 24 hours of hospital admission, those with APPACHE II score >24, advance stage cancer, transfer to other wards before they were discharged or have incomplete record were excluded from the study. Data on demographical and clinical characteristics, functional status, quality of life, length of stay, and re-hospitalization were taken from patient’s medical record. The differences of studied outcomes were analyzed using t-test or Mann-Whitney test.Results: there were 102 subjects in pre-NHI and 135 subjects in NHI groups included in the study. Median lengths of stay were not different between two groups (12.5 days in pre-NHI and 10 days in NHI groups, p=0.087), although the proportion of patients with in-hospital stay less than 14 days was higher in NHI group. The difference of functional status of discharged patients in pre-NHI and NHI groups were 3 and 3 (p=0.149) respectively, whereas for health-related quality of life, although NHI group in the beginning showed a lower quality of life compared to the pre-NHI (0.163 [0.480] vs. 0.243 [0.550]; p=0.012). However, after incorporating comprehensive geriatric assessment (CGA) the quality of life improved significantly by the end of in-hospital care in both groups. Re-hospitalization incidence in NHI group was lower compared to pre-NHI (7 [5.2%] vs. 13 [12.7%]; p=0.038).Conclusion: our study shows that there was  no  significant difference regarding length of stay, functional status, and health-related quality of life between prior to and after national health insurance implementation on admitted geriatric patients. Rehospitalization incidence showed better results in NHI group and hence NHI implementation is favored

Polypharmacy and Drug Use Pattern among Indonesian Elderly Patients Visiting Emergency Unit

Background: polypharmacy is a major concern for elderly patients, as it links to high morbidity related to drug interaction and adverse drug effects. Not much is known about profile of polypharmacy among elderly subjects visiting emergency department (ED) for acute conditions. Methods: a cross sectional study conducted between July to December 2018 in ED of Cipto Mangunkusumo Hospital Jakarta Indonesia. All elderly patients admitted to ED were included. We evaluated drug use pattern using ATC system along with the association between polypharmacy with sex, age and number of comorbidities. Results: 475 geriatric patients visited EU 247 subjects were male (54.8%; mean age 67.69 (SD 6.58) years old). Polypharmacy was found in 57.6% subjects. The most frequently used of drug was that of alimentary tract and metabolism pharmacologic group, followed by drugs related to blood and blood forming organs, cardiovascular system, and anti-infectives for systemic use. Sex and age were not associated with polypharmacy, while more than 3 comorbidities was associated with polypharmacy. Conclusion: polypharmacy is prevalent among elderly visiting ED in Indonesia, requiring special attention from clinician to evaluate each drug and interaction among the drugs used

The Comparison of Survival, and Cost Effectiveness of Geriatric Patients Admitted in Dr. Cipto Mangunkusumo Hospital Before and During National Health Insurance Program Implementation

Comprehensive Geriatrics Assessment (CGA) has been proven to improve the overall outcome of geriatric patients care, and has been implemented in RSCM as the standard geriatric medical care. National Health Insurance Program (NHIP) was implemented in Indonesia in January 2014. It is unclear how NHI program will affect survival and cost effectiveness of geriatric patients receiving CGA. The aim of this study was to compare the survival and cost effectiveness between geriatric patients hospitalized during NHIP and before NHIP era in RSCM. This was a retrospective cohort study with historical control. The subjectswere geriatric inpatients aged ≥60 years old with one or more geriatric giants between July to December 2013 (non NHIP) and January to June 2014 (NHIP). A survival analysis and determination of incremental costeffectiveness ratio (ICER) was used to compare the survival and cost-effectiveness between the two groups. The clinical and demographic characteristics were relatively similar between the NHIP and non NHIP group. No difference in mortaliy rate during hospital care and 30 days survival rate between NHIP and non NHIP group (31.2% vs 28%, p=0.602; 65.2% vs 66.4%, p = 0.086, respectively).  No significant difference was found in the survival curve between the two groups. Calculation of ICER showed that NHIP was associated with an increased cost of 1.4 million rupiah and 1.2 % higher mortality rate. Further research is needed to evaluate this result when NHI Program has been implemented for a longer duration

The Difference in Length of Stay, Quality of Life, and Cost Effectiveness of Care for Geriatric Patients in Acute Care for Elderly Dr. Cipto Mangunkusumo National Hospital Before and After National Health Insurance Program Implementation

Geriatric population with special characteristics tend to have longer average length of stay. The aim of the study is to evaluate the implementation of NHIP (national health insurance program) system according to length of stay, quality adjusted life days (QALD) and cost effectiveness of care in Cipto Mangunkusumo National Hospital (CMNH). This is a retrospective cohort study with historical control. The subjects were geriatric patients with geriatrics giants on July to December 2013 (non NHIP) and January to June 2014 (NHIP). We used independent t-test to compare two means of length of stay and QALD. The characteristics were similar between 100 subjects in non NHIP group and 125 subjects in NHIP group. The median of age was 70 (60-86) dan 68 (60-85) years old respectively. There was no significant difference between length of stay in non NHIP, median 12(2-76) days and NHIP group, median 12(2-59) days, p= 0.974. As for QALD, there was also no significant difference between non NHIP, median 0.812 (-3.1–24.37) and NHIP group, median 0.000 (-7.37–22.43), p= 0.256. The median cost spent was Rp 19.961.000 (Rp2.57–Rp100 millions) in non NHIP and Rp 20.832.000 (Rp3.067-Rp100 millions) in NHIP group. Incremental cost effectiveness ratio (ICER) scheme showed NHIP is more expensive Rp1.500.000 to have 0.91 shorter days than non NHIP system. For QALD, the cost was cheaper Rp3.484.887 to have 0,25 QALD lower than non NHIP. There was no significant difference in length of stay and quality of life of patients who admitted in CMNH with CGA approach before and after NHIP implementation

Dementia Risk Reduction in Cognitively Normal Elderly Receiving Mediterranean Diet

Studies showed cognitive health improvement with mediterranean diet (MD). It is important to find out the benefit in dementia prevention. Relevant meta-analysis and randomised controlled trials pertaining to MD impact on dementia risk reduction in cognitively normal elderly were collected. The comprehensive search relied on databases Pubmed and Cochrane with keywords MD and dementia. Results of methodological quality assessment of three studies utilising Oxford Centre for Evidence Based Medicine year 2011 tools, showed that the studies were valid and applicable. Neuroprotective effect was different in group with the highest adherence to the diet in study 1 with adjusted hazard ratio (HR) of 0.67 (95% CI 0.52-0.88, p=0.004). In study 2 none were diagnosed with dementia in all three groups receiving MD with extravirgin olive oil (EVOO), diet with nuts, and control group. In comparison with the control group in study 3, number needed to treat (NNT) was 13.29 for group with EVOO (absolute risk reduction/ ARR = 7.5% [95%CI 1.09%-13.95%]) and was 10.79 for group with nuts (ARR = 9.2% [95%CI 2.88%-15.65%]). Long-term MD may be beneficial to reduce dementia rate. Neuroprotective effect is achievable only with the highest adherence (p=0.004). Gado-gado modification in Indonesian diet is desirable. Keywords: dementia, mediterranean diet, risk reduction, prevention.   Penurunan Risiko Demensia pada Usia Lanjut Berfungsi Luhur Normal dengan Diet Mediterania Abstrak Diet mediterania dapat mempertahankan fungsi kognitif berdasarkan beberapa penelitian. Manfaatnya terhadap pencegahan demensia perlu diketahui. Studi ini mengumpulkan meta-analisis dan uji acak dengan kontrol mengenai pengaruh diet mediterania terhadap penurunan risiko demensia pada usia lanjut (lansia) dengan fungsi luhur normal. Sumber data elektronik Pubmed dan Cochrane digunakan dengan kata kunci mediterranean diet dan dementia. Hasil dari penilaian kualitas studi dengan metode Oxford Centre for Evidence Based Medicine 2011 terhadap tiga studi terpilih menunjukkan bahwa studi tersebut valid dan dapat diterapkan. Efek neuroprotektif berbeda signifikan pada kelompok dengan tingkat ketaatan tertinggi pada diet mediterania dalam penelitian pertama dengan hazard ratio (HR) 0,67 (95% CI 0,52-0,88, p= 0,004). Pada penelitian kedua, tidak ada yang terdiagnosis demensia pada akhir penelitian pada ketiga kelompok, yakni kelompok diet dengan tambahan minyak zaitun ekstravirgin, kelompok dengan tambahan kacang-kacangan (kelompok 2), serta kelompok kontrol. Mekipun demikian penelitian ketiga menunjukkan number needed to treat (NNT) 13,29 pada kelompok minyak zaitun ekstravirgin (absolute risk reduction/ ARR = 7,5% [95%CI 1,09% - 13,95%]) dan pada kelompok 2 NNT 10,79 (ARR = 9,2% [95%CI 2,88%-15,65%]) dibandingkan kontrol. Diet mediterania jangka panjang dapat menurunkan angka demensia. Efek neuroprotektif hanya dapat dicapai dengan ketaatan tinggi terhadap diet (p=0,004). Pada diet Indonesia, modifikasi gado-gado dapat dipertimbangkan. Kata kunci: demensia, diet mediterania, penurunan risiko, pencegahan

Clinical Outcomes of Geriatric Care in Cipto Mangunkusumo Hospital, Before and After the Implementation of National Health Insurance Program

Background: the National Health Insurance (NIH/JKN) has been enacted since January 2014. Various outcomes of geriatric patient care, such as improved functional status and quality of life have not been evaluated. Prolonged hospitalization and re-hospitalization are potentially affecting the efficiency care of this vulnarable group. This study aimed to identify the differences of functional status improvement, quality of life improvement, length of stay, and hospitalization of geriatric patients admitted to CMH between prior to and after NHI implementation. Methods: a cohort study with historical control was conducted among geriatric patients admitted to Acute Geriatric Ward CMH Hospital on two periods of time: January-December 2013 (pre-NHI implementation) and June 2014-May 2015 (after NHI implementation). Patients who died within 24 hours of hospital admission, those with APPACHE II score >24, advance stage cancer, transfer to other wards before they were discharged or have incomplete record were excluded from the study. Data on demographical and clinical characteristics, functional status, quality of life, length of stay, and re-hospitalization were taken from patient’s medical record. The differences of studied outcomes were analyzed using t-test or Mann-Whitney test. Results: there were 102 subjects in pre-NHI and 135 subjects in NHI groups included in the study. Median lengths of stay were not different between two groups (12.5 days in pre-NHI and 10 days in NHI groups, p=0.087), although the proportion of patients with in-hospital stay less than 14 days was higher in NHI group. The difference of functional status of discharged patients in pre-NHI and NHI groups were 3 and 3 (p=0.149) respectively, whereas for health-related quality of life, although NHI group in the beginning showed a lower quality of life compared to the pre-NHI (0.163 [0.480] vs. 0.243 [0.550]; p=0.012). However, after incorporating comprehensive geriatric assessment (CGA) the quality of life improved significantly by the end of in-hospital care in both groups. Re-hospitalization incidence in NHI group was lower compared to pre-NHI (7 [5.2%] vs. 13 [12.7%]; p=0.038). Conclusion: our study shows that there was  no  significant difference regarding length of stay, functional status, and health-related quality of life between prior to and after national health insurance implementation on admitted geriatric patients. Rehospitalization incidence showed better results in NHI group and hence NHI implementation is favored

Pengaruh Status Nutrisi terhadap Kesintasan 30 Hari Pasien Geriatri yang Dirawat di Rumah Sakit

Pendahuluan. Dengan meningkatnya jumlah populasi usia lanjut, masalah kesehatan yang dialami juga semakin banyak, salah satunya malnutrisi. Studi di luar negeri menunjukkan malnutrisi pada pasien geriatri yang dirawat di rumah sakit menurunkan kesintasan. Pasien usia lanjut di Indonesia mempunyai karakteristik yang berbeda dengan pasien usia lanjut di luar negeri. Di Indonesia belum ada studi tentang status nutrisi pasien usia lanjut yang dirawat di rumah sakit dan pengaruhnya terhadap kesintasan. Penelitian ini bertujuan mengetahui pengaruh status nutrisi terhadap kesintasan 30 hari pasien usia lanjut yang dirawat di ruang rawat akut geriatri dan ruang rawat penyakit dalam rumah sakit. Metode. Penelitian kohort retrospektif, dengan pendekatan analisis kesintasan, dilakukan terhadap 177 pasien geriatri yang dirawat di ruang rawat akut geriatri dan ruang rawat penyakit dalam Rumah Sakit Cipto Mangunkusumo selama bulan April–September 2011. Data demografis, diagnosis medis, kadar albumin, indeks ADL Barthel, geriatric depression scale, status nutrisi dengan mini nutritional assessment (MNA) dikumpulkan, dan diamati selama 30 hari sejak mulai dirawat untuk melihat ada tidaknya mortalitas. Perbedaan kesintasan kelompok pasien dengan status nutrisi baik, berisiko malnutrisi dan malnutrisi ditampilkan dalam kurva Kaplan-Meier, diuji dengan uji Log-rank, serta analisis multivariat dengan Cox proportional hazard regression model untuk menghitung adjusted Hazard Ratio dan interval kepercayaan 95% terjadinya mortalitas 30 hari dengan memasukkan variabel-variabel perancu sebagai kovariat. Hasil. Kesintasan antara subyek yang status nutrisinya baik, berisiko malnutrisi dan malnutrisi ialah 94,7% dengan 89,0% dan 80,7%, namun perbedaan kesintasan 30 hari tak bermakna dengan uji Log-rank (p=0,106). Pada analisis multivariat didapatkan adjusted HR setelah penambahan variabel perancu sebesar 1,49 (IK 95% 0,29 – 7,77) untuk kelompok berisiko malnutrisi dan 2,65 (IK 95% 0,47 – 14,99) untuk kelompok malnutrisi dibandingkan dengan pasien nutrisi baik Simpulan. Perbedaan kesintasan 30 hari pasien geriatri yang dirawat di rumah sakit yang menderita malnutrisi dan berisiko malnutrisi dibandingkan dengan status nutrisi baik pada awal perawatan belum dapat dibuktikan

Palliative Screening Tools to Identify Palliative Care Consultation at Tertiary Hospital

Background: The need of palliative care is increasing, but it is not all achievable. It is necessary to identify palliative patients in order to provide the proper care according to the needs of the patients. Cipto Mangunkusumo Hospital has been making the identification using a palliative-patient screening questionnaire, but no performance assessment has been carried out on the screening tool. This study aimed to evaluate the performance of the screening-tool questionnaire used on palliative-care patients at Cipto Mangunkusumo Hospital in order to assess the need of palliative-care consultation and to find out the optimal cut-off point of palliative care screening tools. Methods: The design of this study is cross-sectional and was conducted at Cipto Mangunkusumo National Central Public Hospital in July – October 2019. The sampling was collected by consecutive sampling. The reliability test was performed by the intraclass correlation coefficient (ICC). The internal consistency was measured by the Cronbach’s-Alpha coefficient. The criterion-validity test was run by an evaluation using the Pearson test. Results: There were 64 subjects collected, the largest age group was 51-70 years (50%). Cancer was the main disease found in most of the subjects (56 people / 87.5%). The most common comorbidity was kidney disease (11 people). The most common palliative score distribution was 6 (15 people). The average score was 7.51. The mortality rate at the hospital was 51.6%, 33 patients from a total of 64 patients. From the palliative score distribution curve, the AUC value was 0.687 with a 95% CI (0.557-0.818). The optimal cut-off point was 8. All patients were palliative according to expert opinion based on WHO criteria. Conclusion: The performance of this tool is sufficient to screen palliative patients in a terminal and complex condition, but requires improvements to screen for patients who need early palliative care. The optimal cut-off point to determine the limit of consultation on palliative patients is found at score 8