Interface Geriatrics - a focussed, evidence based approach to the management of frail older people

1. Interface Geriatrics- a focussed, evidence based approach to the management of frail older people Simon Conroy Head of Service/Senior Lecturer University Hospital of Leicester

2. Population ageing - UK • By 2030 • 50% more 65+ (6.2 million) • 100% more 80+ (2.8 million) • Disease prevalence increasing • Arthritis, CHD, stroke, dementia, diabetes

3. Preventing (managing) frailty • Primary prevention • Healthy lifestyle • Secondary prevention • Disease management • Tertiary prevention • Comprehensive geriatric assessment

4. Primary prevention • Healthy lifestyle initiatives • Difficult to evaluate (no RCTs) • Limited effect size, but potentially important impact at population level • Challenge of lifelong health & wellbeing • Falls related population level intervention • 9% reduction in falls rate (Tinetti 2008)

5. Secondary prevention (disease management) • Hypertension • Uncertain • HYVET? • Hyperlipidaemia • Limited evidence in frail older people • Diabetes • Evidence base mainly for middle age (ACCORD, ADVANCE) • Evidence in frail mainly related to CGA interventions (EUGMS 2004) • Smoking • Smoking cessation therapy recommended for all (UK NICE 2006)

6. Compressing morbidity

9. UK context

10. Dying is expensive Proximity to death >>> age Care home use influential Seshamani , M & Gray, A. Ageing and health-care expenditure: the red herring argument revisited. Health Economics 2004;13(4):303-14.

11. Dying is difficult to predict End of life care + dementia + disability + resource use = geriatric medicine

12. A perfect storm • Increasing numbers of oldest old • Minimal compression of morbidity • Final years of life characterised by • Disability • Uncertainty • High resource use • QIPP gap

13. Solutions?

14. Screening & intervening • MRC trial of multidimensional assessment (1995-1998) • Multicentre cluster RCT, factorial design • 106 general practices • 43,219 eligible patients ≥75 years • 78% participation • 81 years old, 2/3 female, 45% living alone, 30% dependant for ≥1 ADL, mean 2.6 medications • Excluded patients in long term care • Few patients with major cognitive impairment

15. Control group??

16. MRC trial - results • 36 month FU • Universal vs. targeted approach • No difference in: • Mortality • Hospital admissions • Trend towards reduced institutionalisation • Adjusted risk ratio 0.83, 99% CI 0.66-1.04 • Increase in QoL

17. MRC trial results • Geriatric vs. primary care • No difference in: • Mortality • Hospital admissions • Institutionalisation • Slight increase in QoL

18. Risk stratification approach • UK Evercare evaluation • Population based risk stratification approach, focussing on preventing hospital admissions • Nurse led case management – community based • Controlled before/after evaluation • No difference in emergency admissions • No difference in hospital bed-days • Trend to increased mortality (34.4%, 95% CI −1.7% to 70.3%)

19. Case finding/screening • Screening for falls risk in primary care • 54% response rate • 35% falls prevalence • 52% high risk of future fall • Randomised to falls programme • IRR 0.73 (95% CI 0.51-1.03), p=0.07 • ICER per fall averted £3200

21. Tertiary prevention- picking up the pieces • Crisis management • Falls • Fractures • Hospital admissions

22. Falls • Unifactorial (RR 0.65) & multifactorial (RR 0.78) falls programmes work • Cost-effectiveness • Some evidence, targeted groups (Cochrane 2009)

23. Hospital admissions • Prime area of interest in England & Wales • 4 hour wait • Emergency department staffing issues • Primary/secondary care divide (also social care & mental health care) • Community matron scheme – ineffective • Intermediate care – grave concerns

24. Hospital at home • Admission avoidance hospital at home • Outcomes • 3 month readmissions HR 1.49, 95% CI 0.96-2.33 • 3 month mortality adjusted HR 0.77, 95% CI 0.54-1.09 • 6 month mortality adjusted HR 0.62, 95% CI 0.45-0.87 • Other health outcomes similar • Potentially effective alternative to inpatient care • Small selected group of older patients

25. Intermediate care schemes • Home based schemes • Good at early discharge • Equivalent outcomes • Increase patient satisfaction • Probably cost-effective • Residential schemes • Equivalent outcomes • Increase patient satisfaction • Diversionary – increase length of stay • Not cost saving

26. Community hospitals • One trial, 2005 • Step down service • Multidisciplinary assessment • Individualised care plan • Home assessments before discharge • Discharge coordinated • Consultant geriatrician visited twice a week • Hospital practitioner visited daily • Local GPs provided out of hours cover • LOS equal (15 days) • Independence greater in CH group • Satisfaction and carer burden similar

27. Back in the real world…

28. Frail older people and urgent care- Leicester experience • 3% of all ED attendees • 90% admitted • >10% of admissions to the acute medical unit • 90% admitted to ward • LOS 9 vs 5 days for non-frail older people • 30% vs. 22% readmitted post-discharge • Of those going home from AMU • 16% vs. 12% readmitted within 90 days • Mortality within 90 days 30% vs. 6%

29. Any readmission over time Hazard ratio 2.2

30. Deaths occurring early on Hazard ratio 4.2 Adjusted (age & gender) 3.6

31. Meta-analysis of consultant level discharge rates (AMU) Older people

32. What is going wrong? • Frail older people are different • Managing frail older people is not taught very well • Managing frail older people is not sexy (for some)

33. Frail older people are different… • Non-specific presentations • Homeostatic failure • Multiple comorbidities → polypharmacy • Functional decline • Differential challenge

34. Patient Deemed Poor HistorianUnable to identify five causes of Pelopponesian Wars • Asthma/COPD sufferer Hank Lee Spencer was found to be an extremely poor historian by a team of admitting house staff late Thursday evening, according to hospital spokesman Gil Heredia. • Dr. Karen Filmer, a junior resident, was one of the first to evaluate Spencer in Franklin Medical Center's Emergency Department. • "He definitely knew a lot about post-Civil War American history, and that was a plus. But when it came down to the ancient civilizations of Egypt, Greece, and Rome, he simply didn't have a clear grasp of the basic principles underlying the important events in those eras." • Filmer cited her patient's inability to define at least five causes of the Pelopponesian Wars as indicative of his weakness in this area of World History. http://www.qfever.com/issues/20000906/historian.html

35. Interface geriatrics • DEED II • Discharge coordinator • Multidisciplinary input (including geriatrician) • 25% relative reduction in 30-day admissions • 18% relative reduction in 18 month emergency admissions • Mean 1.65 additional problems were identified per patient – the majority medical

36. Mortality

37. Readmissions

38. Institutionalisation

39. Evidence based service development Leicester, Leicestershire & Rutland

40. ED AMU CGA CGA ISAR or fall • Necessary conditions • Single point of access • Communication • Education • Teamwork • Shared goals • Continuity of care • Patient centred services • Financial levers • Positive attitude towards older people Primary care • Prevention • Falls prevention? • Care homes? • CGA on admission? • Pharmacist reviews (STOPP/START) • (Advance) care planning • Dementia awareness • Case management? • Advance care planning? Interface geriatrician • Locality based • Community hospital • Matrons • Intermediate care (post-acute can be nurse led) • Hospital at home/admission avoidance • Community geriatrician

41. Ambulatory ICAH GP EMAS DNs Matrons Informal support Adult social care SPA/BB/ED Residential Intermediate care and sub-acute care Frail Not frail Specialist or usual care MDT Triage Trajectory Transfer EFU In-patient CGA FOPAL Frail older person in crisis

42. Shared definition of target population Single point of access e-communication Education & training Multiagency working • Community hospitals • Community matrons • Intermediate care • Social care • Care homes • Mental health • Public support GPs

43. Key UHL developments • Emergency frailty unit (EFU) • Located in EDU • Consultant geriatrician & team 7/7 • Frail Older Peoples’ Advice & Liaison Service (FOPAL) • Located in AMU • Consultant geriatrician & team 5/7

44. EFU - aims • To improve the quality of care and decision making for frail older people attending the Emergency Department • To deliver multidisciplinary assessment from nurses, therapists and geriatricians in the Emergency Department – operationalised as the EFU • Objectives • To reduce the ED conversion rate for FOP from 90% to 80% • To reduce the LoS for admitted patients by 0.5 days

45. Snapshot May 2010 vs. May 2011 • Average number of people aged 85+ attending per month 760 (2011) vs. 692 (2010) (↑10%) • 42% of people aged 85+ discharged in May 2011 compared to 35% in May 2010 ((↑20%) • If sustained over 2011, with average 760 patients per month, 66 patients aged 85+ going homewho would have been admitted in 2010 • Assuming average LoS of 9 days for people aged 85+, this represents 66*9*12=7128 bed-daysor approximately £2153 per patient (total £1.7 million) • Average LoS in EDU for 85+ 0.4 days in 2011 vs. 0.3 days on 2010

46. Emergency Frailty Unit (EFU) & ED • Caveats • Confounding – there are differences with the ED from 2010 to 2011 (staffing levels, fewer locum staff) • Bias - not comparing like with like, e.g. more, possibly different patients attending in 2011 vs. 2010 • Data only on 85+ - not all will be frail, some who are frail will be <85 • Does not account for acute medicine contribution from EFU • Service still maturing and currently not running to full potential • Costs are unreliable – as extremely sensitive to LoS • No data yet on readmissions or other important outcomes • But the only major change in delivery that is likely to have impacted on frail older people is the EFU, with in-reach and enhanced education and training (‘Hawthorne effect’)

47. Potential impact of EFU - summary • Comparing May 2010 to May 2011 • Number aged 85+ attending ED has increased by 30% (relative increase) • Overall discharge rate from ED for people aged 85+ has increased by 20% (relative risk) • EDU specific discharge rate increased by 24% (relative risk) • 7128 bed-days saved or approximately £2153 per patient (total £1.7 million) • Performance against objectives • 10% reduction in ED conversion rate for FOP: data to date indicates 7% reduction • Length of stay reduction: not available

48. Frail Older Peoples’ Advice & Liaison Service (FOPAL) • Aims • To improve the quality of care and decision making for frail older people attending the acute medical unit • To deliver multidisciplinary assessment from nurses, therapists and geriatricians in the acute medical unit • Objectives • To increase AMU discharge rate from 8% to 10% • To reduce LoS for admitted patients by 0.5 days

49. FOPAL outcomes • In 69% of patients seen FOPAL recommendation different • In those discharged, readmission rate 19/264 (7%) • No deaths within 30 days in those discharged; • Length of stay for admitted patients median 10 days

50. FOPAL outcomes • In 69% of patients seen FOPAL recommendation different • In those discharged, readmission rate 19/264 (7%) • No deaths within 30 days in those discharged; • Length of stay for admitted patients median 10 days