Making difficult decisions with older patients on medical wards

Khizar, Bushra; Harwood, Rowan H.

doi:10.7861/clinmedicine.17-4-353

Cited by 17 publications

(18 citation statements)

References 3 publications

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“…Findings suggest that a task-focused approach might limit engagement with patients and caregivers, in particular the integration of patients' and caregivers' knowledge within a CGA. The current analysis also highlights a need for a CGA that accommodates the complexities of patient and caregiver interpersonal factors to facilitate inclusive decision-making, 107,108 which encompasses supports for continuity after discharge and that acknowledges the ethical complexities that can arise. 110 defined the CGA as a 'multidisciplinary evaluation in which the multiple problems of older persons are uncovered, described, and explained, if possible, and in which the resources and strengths of the person are catalogued, need for services assessed, and a coordinated care plan developed to focus interventions on the person's problems'.…”

Section: Discussionmentioning

confidence: 99%

Comprehensive Geriatric Assessment in hospital and hospital-at-home settings: a mixed-methods study

Gardner

Shepperd

Godfrey

et al. 2019

Health Serv Deliv Res

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BackgroundThe Comprehensive Geriatric Assessment (CGA) is a multidisciplinary process that determines a frail older person’s medical, functional, psychological and social capability to ensure that they have a co-ordinated plan for treatment and follow-up.ObjectivesTo improve our understanding of the effectiveness, cost-effectiveness and implementation of the CGA across hospital and hospital-at-home settings.MethodsWe used a variety of methods. We updated a Cochrane review of randomised trials of the CGA in hospital for older people aged ≥ 65 years, conducted a national survey of community CGA, analysed data from three health boards using propensity score matching (PSM) and regression analysis, conducted a qualitative study and used a modified Delphi method.ResultsWe included 29 trials recruiting 13,766 participants in the Cochrane review of the CGA. Older people admitted to hospital who receive the CGA are more likely to be living at home at 3–12 months’ follow-up [relative risk (RR) 1.06, 95% confidence interval (CI) 1.01 to 1.10] (high certainty). The probability that the CGA would be cost-effective at a £20,000 ceiling ratio for quality-adjusted life-years (QALYs), life-years (LYs) and LYs living at home was 0.50, 0.89, and 0.47, respectively (low-certainty evidence). After PSM and regression analysis comparing CGA hospital with CGA hospital at home, we found that the health-care cost (from admission to 6 months after discharge) in site 1 was lower in hospital at home (ratio of means 0.82, 95% CI 0.76 to 0.89), in site 2 there was little difference (ratio of means 1.00, 95% CI 0.92 to 1.09) and in site 3 it was higher (ratio of means 1.15, 95% CI 0.99 to 1.33). Six months after discharge (excluding the index admission), the ratio of means cost in site 1 was 1.27 (95% CI 1.14 to 1.41), in site 2 was 1.09 (95% CI 0.95 to 1.24) and in site 3 was 1.70 (95% CI 1.40 to 2.07). At 6 months’ follow-up (excluding the index admission), there may be an increased risk of mortality (adjusted) in the three hospital-at-home cohorts (site 1: RR 1.09, 95% CI 1.00 to 1.19; site 2: RR 1.29, 95% CI 1.15 to 1.44; site 3: RR 1.27, 95% CI 1.06 to 1.54). The qualitative research indicates the importance of relational aspects of health care, incorporating caregivers’ knowledge in care planning, and a lack of clarity about the end of an episode of health care. Core components that should be included in CGA focus on functional, physical and mental well-being, medication review and a caregiver’s ability to care.LimitationsThe risk of residual confounding limits the certainty of the findings from the PSM analysis; a second major limitation is that the research plan did not include an investigation of social care or primary care.ConclusionsThe CGA is an effective way to organise health care for older people in hospital and may lead to a small increase in costs. There may be an increase in cost and the risk of mortality in the population who received the CGA hospital at home compared with those who received the CGA in hospital; randomised evidence is required to confirm or refute this. Caregiver involvement in the CGA process could be strengthened.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Section: Discussionmentioning

confidence: 99%

Comprehensive Geriatric Assessment in hospital and hospital-at-home settings: a mixed-methods study

Gardner

Shepperd

Godfrey

et al. 2019

Health Serv Deliv Res

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“…Different opinions in arriving appropriate course of action have been the subject of controversy in decision-making. The challenge is further complicated by medical complexity [ 1 , 2 ] and exponentially expanding clinical knowledge [ 3 ]. The use of predictive models is likely to improve clinical decision process and achieve better outcome without increasing costs.…”

Section: Introductionmentioning

confidence: 99%

“…e challenge is further complicated by medical complexity [1,2] and exponentially expanding clinical knowledge [3]. e use of predictive models is likely to improve clinical decision process and achieve better outcome without increasing costs.…”

Section: Introductionmentioning

confidence: 99%

The Promise for Reducing Healthcare Cost with Predictive Model: An Analysis with Quantized Evaluation Metric on Readmission

Teo

Yong

Muhamad

et al. 2021

Journal of Healthcare Engineering

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Quality of care data has gained transparency captured through various measurements and reporting. Readmission measure is especially related to unfavorable patient outcomes that directly bends the curve of healthcare cost. Under the Hospital Readmission Reduction Program, payments to hospitals were reduced for those with excessive 30-day rehospitalization rates. These penalties have intensified efforts from hospital stakeholders to implement strategies to reduce readmission rates. One of the key strategies is the deployment of predictive analytics stratified by patient population. The recent research in readmission model is focused on making its prediction more accurate. As cost-saving improvements through artificial intelligent-based health solutions are expected, the broad economic impact of such digital tool remains unknown. Meanwhile, reducing readmission rate is associated with increased operating expenses due to targeted interventions. The increase in operating margin can surpass native readmission cost. In this paper, we propose a quantized evaluation metric to provide a methodological mean in assessing whether a predictive model represents cost-effective way of delivering healthcare. Herein, we evaluate the impact machine learning has had on transitional care and readmission with proposed metric. The final model was estimated to produce net healthcare savings at over $1 million given a 50% rate of successfully preventing a readmission.

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“…Five of the articles were from Europe, three from the United States, and one from Australia. The articles primarily included narratives expressed as expert opinion (n=3) (Appel, 2012;Appelbaum, 2007;Kabelka, 2017) and discussion (n=2) (Khizar & Harwood, 2017;Nazarko, 2008). One qualitative research study was included, which focused on the views of carers of people living with dementia in hospital (Bloomer et al, 2016).…”

Section: Resultsmentioning

confidence: 99%

“…The discourse across the articles on decision-making with people living with dementia focused on whether the patient had capacity (or not) to make the decision. Capacity was considered in the process of making a decision (Appelbaum, 2007;Khizar & Harwood, 2017;Nazarko, 2008;Volicer & Ganzini, 2003). A person's capacity was most often queried when the person disagreed with the clinician's treatment decision (e.g., Eisemann et al, 1999;Khizar & Harwood, 2017).…”

Section: Capacity For Decision-making Is Conceptualised As 'All or No...mentioning

confidence: 99%

Making clinical care decisions with people living with dementia in hospital: An integrative literature review

Todd

Lawson

Grealish

2021

International Journal of Nursing Studies

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Making difficult decisions with older patients on medical wards

Cited by 17 publications

References 3 publications

Comprehensive Geriatric Assessment in hospital and hospital-at-home settings: a mixed-methods study

Comprehensive Geriatric Assessment in hospital and hospital-at-home settings: a mixed-methods study

The Promise for Reducing Healthcare Cost with Predictive Model: An Analysis with Quantized Evaluation Metric on Readmission

Making clinical care decisions with people living with dementia in hospital: An integrative literature review

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