Re: Preventing admission of older people to hospital
Sir,
Souza and Guptha provide a provocative overview of admission prevention strategies in the elderly. There needs however to be some clarity of language and definition in this complex area as well as a little care in some of the common assumptions.
There is a widely held belief that chronic disease management strategies are a suitable proxy for the prevention of acute crisis related to frailty. Long term conditions management may be a key to better health but are not synonymous with frailty. We have also learned that the crisis that confronts an older adult with frailty can be quicker, more profound and more prolonged as a consequence (2). For this reason it may in its nature be unpredictable.
Secondly there is a danger in assuming that all community approaches are comparable and this may not be the case.
Thirdly there needs to be clarity regarding the definition of comprehensive geriatric assessment (CGA). It is in fact not a tool but a complex intervention composed of personnel and key processes to deliver multidimensional care across multiple domains. It cannot therefore be compared with a screening tool. It is also not of equal effectiveness in all situations as recent reviews have demonstrated (3).
Fourthly the assumption that the key to preventing admission is the identification of frailty still assumes you can predict sudden decompensation and avoid it. This as we have seen has yet to be proven.
In fact the prevention of frailty and multiple comorbidity will not rest on a single intervention. It is likely to require a multifactorial approach. This might include the promotion of activity, changing societal attitudes to dementia, the prevention and management of chronic diseases, anticipatory care planning, responsive community services, tackling polypharmacy and alternatives to hospital admission. Such multifaceted approaches are as much about public health, public policy and media influences as they are about integration, and health and social care interventions. Further such a broad range of initiatives may not deliver dividends rapidly.
It is right to ask for a critical evaluation of policy direction and to question the assumptions or even the confidence on which health care management decisions are based. Nevertheless there are reasons to be positive. The prevention of admission to long-term residential care may be more important to patients and their carers than admission to a hospital. Not only that but community rehabilitation programmes also appear to prevent decline and dependence (4). Importantly however some alternatives to admission have suggested significant potential benefits to mortality, patient acceptability and cost that need to be explored further (5).
Necessity requires us to innovate and evaluate. This area of public health needs focus now more than ever before. Certainly the current economic climate brings inevitable change, however we need to be able to address these challenges head on or face being condemned to push rocks uphill forever.
1) D’Souza S, Guptha S. Preventing admission of older people to hospital
BMJ 2013; 346:f3186
2) Clegg A, Young J, Illiffe S, Rikkert MO, Rockwood K. Frailty in elderly people.
Lancet 2013;381:752-62
3) Ellis G, Whitehead MA, O'NeillD, Langhorne P, Robinson D. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No.: CD006211. DOI: 10.1002/14651858.CD006211.pub2.
4) Beswick AD, Rees K, Dieppe P, Ayis S, Gooberman-Hill R, Horwood J, Ebrahim S. Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis. Lancet. 2008 Mar 1;371(9614):725-35. doi: 10.1016/S0140-6736(08)60342-6.
5) Shepperd S, Doll H, Angus RM, Clarke MJ, Iliffe S, Kalra L, Ricauda
NA, Wilson AD. Hospital at home admission avoidance. Cochrane Database
of Systematic Reviews 2008, Issue 4. Art. No.: CD007491. DOI:
10.1002/14651858.CD007491
Rapid Response:
Re: Preventing admission of older people to hospital
Sir,
Souza and Guptha provide a provocative overview of admission prevention strategies in the elderly. There needs however to be some clarity of language and definition in this complex area as well as a little care in some of the common assumptions.
There is a widely held belief that chronic disease management strategies are a suitable proxy for the prevention of acute crisis related to frailty. Long term conditions management may be a key to better health but are not synonymous with frailty. We have also learned that the crisis that confronts an older adult with frailty can be quicker, more profound and more prolonged as a consequence (2). For this reason it may in its nature be unpredictable.
Secondly there is a danger in assuming that all community approaches are comparable and this may not be the case.
Thirdly there needs to be clarity regarding the definition of comprehensive geriatric assessment (CGA). It is in fact not a tool but a complex intervention composed of personnel and key processes to deliver multidimensional care across multiple domains. It cannot therefore be compared with a screening tool. It is also not of equal effectiveness in all situations as recent reviews have demonstrated (3).
Fourthly the assumption that the key to preventing admission is the identification of frailty still assumes you can predict sudden decompensation and avoid it. This as we have seen has yet to be proven.
In fact the prevention of frailty and multiple comorbidity will not rest on a single intervention. It is likely to require a multifactorial approach. This might include the promotion of activity, changing societal attitudes to dementia, the prevention and management of chronic diseases, anticipatory care planning, responsive community services, tackling polypharmacy and alternatives to hospital admission. Such multifaceted approaches are as much about public health, public policy and media influences as they are about integration, and health and social care interventions. Further such a broad range of initiatives may not deliver dividends rapidly.
It is right to ask for a critical evaluation of policy direction and to question the assumptions or even the confidence on which health care management decisions are based. Nevertheless there are reasons to be positive. The prevention of admission to long-term residential care may be more important to patients and their carers than admission to a hospital. Not only that but community rehabilitation programmes also appear to prevent decline and dependence (4). Importantly however some alternatives to admission have suggested significant potential benefits to mortality, patient acceptability and cost that need to be explored further (5).
Necessity requires us to innovate and evaluate. This area of public health needs focus now more than ever before. Certainly the current economic climate brings inevitable change, however we need to be able to address these challenges head on or face being condemned to push rocks uphill forever.
1) D’Souza S, Guptha S. Preventing admission of older people to hospital
BMJ 2013; 346:f3186
2) Clegg A, Young J, Illiffe S, Rikkert MO, Rockwood K. Frailty in elderly people.
Lancet 2013;381:752-62
3) Ellis G, Whitehead MA, O'NeillD, Langhorne P, Robinson D. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No.: CD006211. DOI: 10.1002/14651858.CD006211.pub2.
4) Beswick AD, Rees K, Dieppe P, Ayis S, Gooberman-Hill R, Horwood J, Ebrahim S. Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis. Lancet. 2008 Mar 1;371(9614):725-35. doi: 10.1016/S0140-6736(08)60342-6.
5) Shepperd S, Doll H, Angus RM, Clarke MJ, Iliffe S, Kalra L, Ricauda
NA, Wilson AD. Hospital at home admission avoidance. Cochrane Database
of Systematic Reviews 2008, Issue 4. Art. No.: CD007491. DOI:
10.1002/14651858.CD007491
Competing interests: No competing interests