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Addressing frailty in the older cardiac patient population is an important step in further improving quality of care for this patient population.
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This study demonstrates that standard geriatric co-management in older patients with cardiac disease can reduce length of hospital stay without increasing hospital readmission rates
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Furthermore, more patients are discharged to geriatric rehabilitation facilities in the co-managed group, which demonstrates a greater effort to manage functional decline in the elderly after hospital admission.
Introduction
Methods
Study design and setting
Inclusion criteria
Intervention: standard geriatric co-management
Data collection
Baseline characteristics
Outcomes
Statistical analysis
Sample size calculation
Ethical considerations
Results
Overall (n = 1163) | Control group (n = 542) | Intervention group (n = 621) | P-value | ||
---|---|---|---|---|---|
Demographics | Age, median (IQR) † | 88 (4.0) | 88 (4.0) | 88 (4.0) | 0.31 |
Female, n (%)‡ | 695 (59.8) | 329 (60.7) | 366 (58.9) | 0.55 | |
Admission information | Admission diagnosis n (%)‡ | 0.30 | |||
– Congestive heart failure | 434 (37.3) | 216 (39.9) | 218 (35.1) | ||
– Arrhythmia | 230 (19.8) | 96 (17.7) | 134 (21.6) | ||
– Acute coronary syndrome | 214 (18.4) | 102 (18.8) | 112 (18.0) | ||
– Acute decompensated heart failure | 77 (6.6) | 41 (7.6) | 36 (5.8) | ||
– Syncope | 91 (7.8) | 35 (6.5) | 56 (9.0) | ||
– Chest pain | 71 (6.1) | 30 (5.5) | 41 (6.6) | ||
– Cardiac arrest | 10 (0.9) | 5 (0.9) | 5 (0.8) | ||
– Other | 36 (3.1) | 17 (3.1) | 19 (3.1) | ||
Previous hospital admission in last 12 months n = 1128, (%)‡ | 272 (24.1) | 129 (24.2) | 143 (24.0) | 0.94 | |
Patient history | CCI score, median (IQR) ‡ | 6 (2.0) | 6 (2.0) | 6 (2.0) | 0.05* |
Chronic heart disease, n (%)‡ | 858 (73.8) | 428 (79.0) | 430 (69.2) | < 0.01* | |
– Chronic heart failure‡ | 356 (30.6) | 185 (34.1) | 171 (27.5) | 0.02* | |
– Ischaemic heart disease‡ | 368 (31.6) | 194 (35.8) | 174 (28.0) | < 0.01* | |
– Heart valve dysfunction‡ | 301 (25.9) | 157 (29.0) | 144 (23.2) | 0.03* | |
– Arrhythmia‡ | 505 (43.4) | 246 (45.4) | 259 (41.7) | 0.21 | |
– Other‡ | 19 (1.6) | 8 (1.5) | 12 (1.9) | 0.49 | |
Peripheral vascular disease‡ | 151 (13.0) | 80 (14.8) | 71 (11.4) | 0.10 | |
Neurological disorder‡ | 359 (30.9) | 166 (30.6) | 193 (31.1) | 0.90 | |
Pulmonary disease‡ | 206 (17.7) | 94 (17.3) | 112 (18.0) | 0.82 | |
Body mass index, mean (SD) § | 26.2 (4.6) | 26.2 (4.5) | 26.2 (4.6) | 0.52 | |
Diabetes‡ | 280 (24.1) | 134 (24.7) | 146 (23.5) | 0.63 | |
Chronic kidney disease‡ | 538 (46.3) | 265 (48.9) | 273 (44.0) | 0.09 | |
Mean eGFR (SD) § | 52 (19.6) | 49.7 (19.2) | 54 (19.8) | 0.46 | |
History of malignancy‡ | 271 (23.3) | 113 (20.8) | 158 (25.4) | 0.07 | |
Mean haemoglobin (SD) § | 8.0 (2.4) | 8.1 (3.3) | 7.9 (1.1) | 0.29 | |
CGA components | Number of medications, median (IQR) † | 7 (5.0) | 7 (4.0) | 7 (5.0) | 0.67 |
SNAQ score, median (IQR) † | 0 (1.0) | 0 (1.0) | 0 (1.0) | 0.54 | |
History of dementia‡ | 127 (10.9) | 61 (11.3) | 66 (10.6) | 0.53 | |
History of delirium, n = 990 n (%)‡ | 181 (18.3) | 79 (19.0) | 103 (17.8) | 0.68 | |
Fall history, n = 1030 n (%)‡ | 295 (28.6) | 129 (29.8) | 166 (27.8) | 0.49 | |
Katz ADL score, n = 1056, median (IQR) † | 0 (2.0) | 0 (2.0) | 0 (3.0) | 0.54 | |
Residential situation n = 1157 n (%)‡ | 0.74 | ||||
– Community | 994 (85.9) | 460 (85.5) | 534 (86.3) | ||
– Other | 163 (14.1) | 78 (14.5) | 85 (13.7) |
Implementation of geriatric co-management
Hospital readmission rate
Cumulative number of readmissions | Cumulative number of person days | Readmission incidence rate per PY | IRR* | 95% CI | ||
---|---|---|---|---|---|---|
Total follow-up | Intervention group | 406 | 238,062 | 0.62 | 1.08 | 0.86–1.23 |
Control group | 619 | 364,931 | 0.62 | 1.00 | ||
12-month follow-up | Intervention group | 290 | 158,196 | 0.67 | 0.99 | 0.83–1.16 |
Control group | 279 | 141,796 | 0.72 | 1.00 | ||
6‑month follow-up | Intervention group | 186 | 88,691 | 0.77 | 1.08 | 0.87–1.35 |
Control group | 155 | 75,590 | 0.75 | 1.00 | ||
1‑month follow-up | Intervention group | 74 | 16,293 | 1.66 | 0.87 | 0.63–1.21 |
Control group | 77 | 13,808 | 2.04 | 1.00 |
Secondary outcomes
Univariate analysis | Multivariate analysis | |||||||
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Control group n = 542 | Intervention group n = 621 | Effect size | 95% CI | p-value | Effect size | 95% CI | p-value | |
LOS in days median (range) | 6 (72) | 5 (51) | −0.08† | 0.01* | −0.11¶ | −0.21–−0.003 | 0.04* | |
In-hospital mortality n = 1151 n (%) | 60 (11.0) | 55 (8.9) | 0.78‡ | 0.53–1.15 | 0.21 | 0.82 | 0.55–1.22 | 0.34 |
3‑month mortality n = 1151 n (%) | 120 (22.3) | 125 (20.4) | 0.90‡ | 0.68–1.19 | 0.45 | 0.93 | 0.6–1.24 | 0.61 |
Change in residence situation n = 1048 n (%) | 49 (10.2) | 64 (11.3) | 1.13‡ | 0.76–1.67 | 0.55 | 1.10 | 0.72–1.67 | 0.65 |
Discharge to geriatric rehabilitation n = 1048 n (%) | 17 (3.5) | 38 (7.2) | 1.97‡ | 1.10–3.54 | 0.02* | 2.02§ | 1.11–3.66 | 0.02* |
Number of fallers n (%) | 10 (1.8) | 12 (1.9) | 1.14‡ | 0.50–2.62 | 0.76 | 1.19 | 0.51–2.76 | 0.69 |
Patients with delirium n (%) | 57 (10.5) | 68 (11.0) | 1.05‡ | 0.72–1.52 | 0.81 | 1.02 | 0.70–1.50 | 0.90 |
Number of consults mean (SD) | 0.3 (0.6) | 0.34(0.75) | −0.004† | 0.88 | 0.98** | 0.03–1.18 | 0.81 |