What Can Geriatrics Do for Your Hospital: Evidencebased Practice in Patientfocused Hospital Care.

1
What Can Geriatrics Do for Your Hospital?
Evidence-based Practice in Patientfocused
Hospital Care.

• John Puxty
• SERGP
• Queens University

2
Problems Facing Hospitals Regarding Services to
the Elderly

• Demographic pressures and hospital utilization
  patterns

3
Use of Emergency Department by Age in Canada
1996-97
4
Hospital Use by Age 1995-96
5
Demographic Pressures
6
Problems Facing Hospitals Regarding Services to
the Elderly

• Demographic pressures
• Budget constraints

7
Average Per Capita Expenditure on Health
N.B. Aging of pop. accounts for less 5 rise in
hospital cost 1961-90 (Angus et al 1995)
8
Per capita health expenditures, by use of funds
and by province/territory, 1996
other
other
Total
Hospitals instits Physicians Profess
Drugs Capital Other   Canada 2,512.72
862.93 251.23 358.52 294.54 340.58
74.11 330.81 Newfoundland 2,266.86
992.23 274.93 252.07 164.69 340.37
18.51 224.06 P. E. Island 2,465.77
915.37 347.56 245.74 256.39 400.09
40.29 260.34 Nova Scotia 2,273.71
890.86 310.20 268.48 218.74 357.98
19.36 208.08 New Brunswick 2,371.39
972.97 261.64 287.94 180.11 321.84
96.78 250.10 Quebec 2,309.01
896.18 207.03 304.82 245.24 333.97
62.86 258.90 Ontario 2,624.27
875.04 225.57 412.47 334.17 376.50
83.00 317.52 Manitoba 2,579.30
902.23 340.33 263.10 267.35 322.93
59.50 423.85 Saskatchewan 2,477.06
692.96 368.63 303.20 215.37 319.25
105.57 472.08 Alberta 2,380.35
722.38 280.48 288.82 310.12 297.83
50.36 430.36 British Columbia 2,728.32
830.59 309.91 453.75 354.86 287.21
88.78 403.22 Yukon 3,267.22
993.68 245.19 341.59 191.17 248.07
413.54 833.98 N. W. Territories 5,563.87
1,885.71 191.16 319.66 217.78 405.02
634.80 1,909.74   Sources Canadian Institute for
Health Information, National Health Expenditure
Trends, 1975-1998.  
9
Problems Facing Hospitals Regarding Services to
the Elderly

• Demographic pressures
• Budget constraints
• Acute and Complex Continuing Care cuts

10
HSRC Directed Hospital and LTC Changes
11
Problems Facing Hospitals Regarding Services to
the Elderly

• Demographic pressures
• Budget constraints
• Acute and complex continuing care cuts
• Systems change lacks synchronization

12
Problems Facing Hospitals Regarding Services to
the Elderly
13
Problems Facing Hospitals Regarding Services to
the Elderly

• Demographic pressures
• Budget constraints
• Acute and complex continuing care cuts
• Systems change lacks synchronization
• Hospitalization creates problems

14
Functional Decline Associated With Hospitalization
(Sager et al 1996)
15
Negative Consequences of Reduced LOS
Polypharmacy Less rehabilitation Multiple
admissions Community services stressed Crisis
admissions to LTC
16
Problems Facing Hospitals Regarding Services to
the Elderly

• Demographic pressures
• Budget constraints
• Acute and complex continuing care cuts
• Systems change lacks synchronization
• Hospitalization creates problems
• Lack of bench marks for geriatric services

17
Lack of Accepted Bench Marks

• BGS recommended 6-7 beds per 1000 over 75.
  Equivalent to 3,423-3,994 beds for Ontario
  compared to 310 within RGP services!
• HSRC declined to comment on specialized
  geriatric services

18
RGP Inpatient Services 1995/96
19
Specialized Geriatric Service Responding to the
Need

• Integration of the range of specialized geriatric
  services with extended follow up of high-risk
  groups (Hansen 1995)
• Preserve services during downsizing!
• Evidence based arguments for resources

20
Evidence for Improved Outcomes of GAU

• Reduce mortality 37 (Rubinstein LZ et al JAGS
  1991 3917s-18s)
• Increased likelihood of home discharge odds
  ratio 1.68 and functional outcome (stuck AE et
  al lancet 1993 3421032-6)
• Reduced LOS (Pawson G JAGS 1988)

21
Specialized Geriatric Service Responding to the
Need

• Integration with other specialized geriatric
  services and extended follow up (Hansen 1995)
• Maintain what works - inpatient services are well
  validated in terms of outcomes and
  cost-effectiveness
• Evidence based arguments for resources
• Target populations for service

22
Poor Outcome Prediction Following Hospitalization

• Age 80gt
• Recent CVA or
• Social isolation
• Admission from LTC
• Immobility, ADL impairment, incontinence,
  confusion or falls
• gt 2/52 in bed
• Depression
• Polypharmacy

23
Examples of Poor Outcome Prediction Tools
Following Hospitalization

• Hospital admission risk profile (HARP) functional
  decline associated with increased age, low MMSE
  and low pre-morbid IADL (sager et al JAGS
  251-257, 1996)
• Physical performance and mobility examination
  (PPME) and self-report of heath-related physical
  limitations (MOS-PFR) predicts further functional
  decline (Winograd et al JAGS 45604-609 1997)

24
Frailty Is a Dynamic State
25
Characteristics of Patients on Geriatric
Inpatient Units
26
Characteristics of Patients on Geriatric
Inpatient Units

• Primary diagnoses mobility problems (10),
  syncope falls (10), arthritis (9), ADL issues
  (9), CVA (8), PD (7), COPD (6), dementia (6)
• Medications 52 6-10, 22 gt10
• 41 develop in hospital complication

Knott C 1996
27
Variables Associated With Community Discharge

• Admission source 70 from community, 40.6 from
  acute care, 9.5 from LTC
• Cohabitation 39 alone, 66.2 with spouse, 56.7
  with other
• Transfers independent 64.4 vs dependent 38.4
• Toileting independent 63.8 vs dependent 41.2
• Dress lower independent 66.7 vs dependent 41.2
• Feeding independent 66.7 vs dependent 28.7

Knott C 1996
28
Specialized Geriatric Service Responding to the
Need

• Integration with other specialized geriatric
  services and extended follow up (Hansen 1995)
• Maintain what works - inpatient services are well
  validated in terms of outcomes and
  cost-effectiveness
• Evidence based arguments for resources
• Target populations for service
• Best practice models

29
Examples of Best Practice Models

• ACE Hospital units (Landerfield et al, NEJM 1997)
• Rehabilitation in sub-acute care units
• Case management of CCF in the elderly (Rich et
  al, NEJM 1995)
• Case identification in emergency dept using ISAR
  (McCusker et al JAGS 1999)

30
Small changes can result in major functional
gains!
Medications Foot wear Walking aides Surface
heights Chairs/bed Wall bars Lighting Flooring/mat
s
31
Conclusions

• Acute care hospitals are in the aging business
• Present care systems do not respond to needs of a
  significant subgroup of the ill elderly
• High-risk groups in emergency and hospital can be
  identified
• Specialized geriatric services through clincial,
  education and evaluation are cost-effective parts
  of the health care continuum