A new multimodal geriatric discharge-planning intervention to prevent emergency visits and rehospitalizations of older adults: the optimization of medication in AGEd multicenter randomized controlled trial.

To determine whether a new multimodal comprehensive discharge-planning intervention would reduce emergency rehospitalizations or emergency department (ED) visits for very old inpatients. Six-month prospective, randomized (Zelen design), parallel-group, open-label trial. Six acute geriatric units (AGUs) in Paris and its surroundings. Six hundred sixty-five consecutive inpatients aged 70 and older (intervention group (IG) n = 317; control group (CG) n = 348). Intervention-dedicated geriatricians different from those in the study centers implemented the intervention, which targeted three risk factors for preventable readmissions and consisted of three components: comprehensive chronic medication review, education on self-management of disease, and detailed transition-of-care communication with outpatient health professionals. Emergency hospitalization or ED visit 3 and 6 months after discharge, as assessed by telephone calls to the participant, the caregiver, and the general practitioner and confirmed with the hospital administrative database. Twenty-three percent of IG participants were readmitted to hospital or had an ED visit 3 months after discharge, compared with 30.5% of CG participants (P = .03); at 6 months, the proportions were 35.3% and 40.8%, respectively (P = .15). Event-free survival was significantly higher in the IG at 3 months (hazard ratio (HR) = 0.72, 95% confidence interval (CI) = 0.53-0.97, P = .03) but not at 6 months (HR = 0.81, 95% CI = 0.64-1.04, P = .10). This intervention was effective in reducing rehospitalizations and ED visits for very elderly participants 3 but not 6 months after their discharge from the AGU. Future research should investigate the effect of this intervention of transitional care in a larger population and in usual acute and subacute geriatric care.

Legrain S ，Tubach F ，Bonnet-Zamponi D ，Lemaire A ，Aquino JP ，Paillaud E ，Taillandier-Heriche E ，Thomas C ，Verny M ，Pasquet B ，Moutet AL ，Lieberherr D ，Lacaille S ... -  《-》

A randomized, controlled trial of comprehensive geriatric assessment and multidisciplinary intervention after discharge of elderly from the emergency department--the DEED II study.

To study the effects of comprehensive geriatric assessment (CGA) and multidisciplinary intervention on elderly patients sent home from the emergency department (ED). Prospective, randomized, controlled trial with 18 months of follow-up. Large medical school-affiliated public hospital in an urban setting in Sydney, Australia. A total of 739 patients aged 75 and older discharged home from the ED were randomized into two groups. Patients randomized to the treatment group underwent initial CGA and were followed at home for up to 28 days by a hospital-based multidisciplinary outreach team. The team implemented or coordinated recommendations. The control group received usual care. The primary outcome measure was all admissions, to the hospital within 30 days of the initial ED visit. Secondary outcome measures were elective and emergency admissions, and nursing home admissions and mortality. Additional outcomes included physical function (Barthel Index (total possible score=20) and instrumental activities of daily living (/12) and cognitive function (mental status questionnaire (/10)). Intervention patients had a lower rate of all admissions to the hospital during the first 30 days after the initial ED visit (16.5% vs 22.2%; P=.048), a lower rate of emergency admissions during the 18-month follow-up (44.4% vs 54.3%; P=.007), and longer time to first emergency admission (382 vs 348 days; P=.011). There was no difference in admission to nursing homes or mortality. Patients randomized to the intervention group maintained a greater degree of physical and mental function (Barthel Index change from baseline at 6 months: -0.25 vs -0.75; P<.001; mental status questionnaire change from baseline at 12 months: -0.21 vs -0.64; P<.001). CGA and multidisciplinary intervention can improve health outcomes of older people at risk of deteriorating health and admission to hospital. Patients aged 75 and older should be referred for CGA after an ED visit.

Caplan GA ，Williams AJ ，Daly B ，Abraham K ... -  《JOURNAL OF THE AMERICAN GERIATRICS SOCIETY》

Drug-related readmissions to medical units of older adults discharged from acute geriatric units: results of the Optimization of Medication in AGEd multicenter randomized controlled trial.

To assess the effect of an intervention on drug-related problem (DRP; adverse drug reactions, adherence problems, underuse)-related readmission rates in older adults. Ancillary study from a 6-month, prospective, randomized, parallel-group, open-label trial. Six acute geriatric units in Paris and suburbs. Six hundred sixty-five consecutively admitted individuals were included: 317 in the intervention group (IG) and 348 in the control group (CG) (aged 86.1 ± 6.2, 66% female). Discharge-planning intervention combining chronic drug review, education, and enhanced transition-of-care communication. Chronic drugs at discharge of the two groups were compared. An expert committee blinded to group assignment adjudicated whether 6-month readmission to the study hospitals was related to drugs. Six hundred thirty-nine individuals were discharged and followed up (300 IG, 339 CG). The intervention had no significant effect on drug regimen at discharge, characterized by prescriptions that are mostly appropriate but increase iatrogenic risk. Three hundred eleven readmissions occurred during follow-up (180 CG, 131 IG), of which 185 (59.5%) were adjudicated (102 CG, 83 IG). For 16, DRP imputability was doubtful. Of the remaining 169, DRPs were the most frequent cause for readmission, with 38 (40.4%) readmissions in the CG and 26 (34.7%) in the IG (relative risk reduction = 14.3%, 95% confidence interval = 14.0-14.5%, P = .54). The intervention was associated with 39.7% fewer readmissions related to adverse drug reactions (P = .12) despite the study's lack of power. Drug-related problem prevention in older people discharged from the hospital should be a priority, with a focus on improving the monitoring of drugs with high iatrogenic risk.

Bonnet-Zamponi D ，d'Arailh L ，Konrat C ，Delpierre S ，Lieberherr D ，Lemaire A ，Tubach F ，Lacaille S ，Legrain S ，Optimization of Medication in AGEd study group ... -  《-》

Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: a randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program.

Courtney M ，Edwards H ，Chang A ，Parker A ，Finlayson K ，Hamilton K ... -  《-》

Effectiveness of a national transitional care program in reducing acute care use.

This study evaluated the effectiveness of a national transitional care program for elderly adults with complex care needs and limited social support. The Aged Care Transition (ACTION) Program was designed to improve coordination and continuity of care and reduce rehospitalizations and visits to emergency departments (EDs). Dedicated care coordinators provided coaching to help individuals and families understand the individuals' conditions, effectively articulate their preferences, and enable self-management and care planning. Participants were individuals aged 65 and older hospitalized and enrolled from five public general hospitals in Singapore between February 2009 and July 2010 (N = 4,132). The coordinators worked with participants during hospitalization and followed up with telephone calls and home visits for 1 to 2 months after discharge and coordinated placements with appropriate community service providers. Unplanned rehospitalization and ED visit (up to 6 months after discharge) rates were compared with those of a comparator group of individuals who did not receive care coordination using propensity score-based weighting. Participant and caregiver surveys on quality of life and self-rated health were also administered. Recipients of the ACTION program had fewer unplanned rehospitalizations and ED visits after discharge. Propensity score-adjusted odds ratios of participants versus control for number of unplanned rehospitalization and ED visits were 0.5 (95% confidence interval (CI) = 0.5-0.6) and 0.81 (95% CI = 0.72-0.90) 30 days after discharge and 0.6 (95% CI = 0.6-0.7) and 0.90 (95% CI = 0.82-0.99) 180 days after discharge. Quality of life and self-rated health were better 4 to 6 weeks after discharge than 1 week after discharge. These findings confirm the effectiveness of the ACTION program in improving the transition of vulnerable older adults from hospital to community. Such transitional care should be considered as an integral part of care integration.

Wee SL ，Loke CK ，Liang C ，Ganesan G ，Wong LM ，Cheah J ... -  《-》