The purpose of the research was to determine the effectiveness of care for seniors in the acute phase of illness or injury admitted to acute geriatric units compared to seniors not admitted to these specialized centres.

“It is the first study to quantify the effectiveness of an innovative function-focused approach to older adults' acute hospital care,” says 91��ɫ Professor Mary Fox of the graduate program in nursing in 91��ɫ's School of Nursing, Faculty of Health. She is the first author of the article, “”, published online Friday in the . It will also be published in an upcoming print version of the journal.

Mary Fox

As the principal investigator of the Canadian Institutes of Health Research-funded study, Fox conducted a systematic review and meta-analysis of 13 trials involving 6,839 acutely ill or injured octogenarians. Acute geriatric units are those with at least one Acute Care for Elders (ACE) component, either patient-centred care, frequent medical review, early rehabilitation, early discharge planning or prepared environment. The goal of ACE components is to prevent hospital-acquired complications and functional deterioration associated with common hospital medications, treatments and procedures for older adults.

The researchers also found that seniors admitted to acute geriatric units had less delirium and were more likely to be discharged home as opposed to a nursing facility.

“It demonstrated that this approach has significant beneficial effects in improving both patient- and system-level outcomes over usual care,” says Fox. “Hospital administrators may anticipate cost savings of approximately $246 per person, per length of hospital stay (in US dollars, standardized to year 2000) and a reduced length of hospital stay by more than half a day, when compared to usual care.”

Seniors aged 65 and older are considered the “core business” of hospitals. They account for 40 per cent of all hospital care days even though they comprise only 14 per cent of the Canadian population.

“As older adults account for 50 per cent of Canadian hospital expenditures,” says Fox, "this cost difference may represent a significant future source of financial saving to Canada's health-care system while improving patient outcomes.”

It is known that older adults face a higher risk of functional decline, falls, pressure ulcers and delirium when hospitalized, which is associated with increased hospital costs, institutionalization and death. “These poor outcomes are more often not related to their illness, but to other things, like not getting up and walking around while in the hospital or receiving treatments, such as drugs and catheters that make it difficult to move around. There are things that fall through the cracks,” says Fox. Early intervention is crucial in helping to circumvent these risks.

The goal is to develop senior-friendly hospitals by informing and engaging decision makers – clinicians, hospital administrators, policymakers and funders – about the best interventions to prevent physical, cognitive and psychosocial functional decline. Acute geriatric care units would not only save hospitals money, but provide the most beneficial care for seniors.

91��ɫ nursing Professors Malini Persaud, Deborah Tregunno and Ellen Schraa, along with 91��ɫ librarian IIo-Katryn Maimets, were co-authors of the study, which included a team of researchers from 91��ɫ, Ryerson University and the University of Toronto.

The study was also supported by a 91��ɫ Faculty of Health Junior Faculty award.

By Sandra McLean, YFile deputy editor

Republished courtesy of YFile– 91��ɫ’s daily e-bulletin to research stories on the research website.

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Published in the current issue of the , the study reports that despite guidelines encouraging physicians to recommend heart failure clinics, few patients recently hospitalized with heart failure receive referrals or use one.

“Given the demonstrated benefits of these services, the rates of referral and enrollment in our study are discouragingly low,” says lead investigator Shannon Gravely (PhD ’11) of 91��ɫ, the University Health Network and the Toronto Rehabilitation Institute. 91��ɫ Professor Sherry Grace and Professor Liane Ginsburg both of 91��ɫ’s Faculty of Health were also involved with the study.

Shannon Gravely

The investigators recruited 474 heart failure inpatients from 11 hospitals across Ontario. The patients completed a survey that evaluated environmental and individual factors affecting heart failure clinic use. Environmental factors included hospital type, whether the hospital had an onsite heart failure clinic and whether the patient had been referred to other outpatient disease management programs (DMP), such as smoking cessation clinics or diabetes education. Individual factors included socio-demographic information, whether the patient lived in a rural area, marital status, perceived stress and depressive symptoms. Clinical indicators of the need for rehabilitative services were gathered from patient charts.

A year after the first survey, the patients received a second survey. The 270 patients who completed the follow-up survey reported on whether they had been referred to a heart failure clinic and if they had attended.

Results showed that 15 per cent of study participants were referred to a heart failure clinic and 13 per cent reported using one. Patients with higher education were five times more likely to use an outpatient heart failure clinic compared to those with lower education. Lower stress levels and more serious health conditions were also associated with heart failure clinic use. Patients who received a referral to another DMP were nearly five times more likely to use a heart failure clinic. The most important factor in determining whether a patient used a heart failure clinic was the presence of an established program at the patient’s original hospital.

“It’s likely that having an HR clinic on-site is related to greater awareness of the benefits of such services by physicians providing care,” says Gravely. “However, broader referral mechanisms are needed to ensure that all patients, regardless of where they receive care, have equitable access to heart failure clinics.”

In a related study published in the same issue, Gravely and colleagues examined more broadly the use of DMPs by patients with cardiovascular disease (CVD). The survey looked at factors that influenced DMP use and was completed by 1,803 hospitalized patients, along with a follow-up study a year later which assessed whether they had used any DMPs, such as cardiac rehabilitation, outpatient diabetes education, a heart failure clinic, stroke rehabilitation or a smoking cessation program.

Overall, roughly 40 per cent of patients did not access any post-acute DMPs, 50 per cent accessed one program and 10 per cent attended more than one. Among participants with a comorbid indication (diabetes, stroke, heart failure or smokers), 21 per cent of these participants reported that they used multiple programs. DMP participants were younger, more likely to be married and more highly educated than those who did not attend DMPs.

Overall, 53 per cent reported participating in cardiac rehabilitation, and among participants with a comorbid illness or risk, 41per cent of diabetics reported attending a diabetes education center, 26 per cent of stroke patients attended stroke rehabilitation, 13 per cent of patients with a heart failure diagnosis used a heart failure clinic and 12 per cent of smokers attended a smoking cessation program. Among all study participants these findings suggest a gross underuse of DMP services, particularly stroke rehabilitation, heart failure clinics, and most notably, smoking cessation programs.

“What is one of the most concerning findings is that only 12 per cent of current smokers reported taking part in a smoking cessation program,” says Gravely. “Participation in smoking cessation programs results in significantly higher cessation rates when compared with standard care.”

Gravely notes that future research is needed to explore not only patient-related factors, but also health-system factors, such as awareness and capacity that may be at play. “The appropriateness and cost repercussions of multiple DMP use should be investigated, as an integrated approach to vascular disease management may be warranted.”

Republished courtesy of YFile– 91��ɫ’s daily e-bulletin.

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A critical component of this health-care transformation is the move toward people-centred health that can be powerfully enabled by eHealth information and communication technology (ICT). As Canada faces a looming health-care crisis, today’s Faculty of Health summit is all about integrating health and health care to ensure accessible and sustainable health services for all.

Left: Faculty of Health Dean Harvey Skinner

Roberto Nuño Solinís, director of the Basque Institute for Healthcare Innovation, will talk about the problems and solutions of transformation in health care in the Basque Country, Spain. University of Toronto Professor , chief innovator and founder of the Centre for Global eHealth Innovation, will bring a global perspective to the discussion, while Daniele Zanotti, chief executive officer of the United Way of 91��ɫ Region, will bring the 91��ɫ Region perspective.

Right: U of T's Alex Jadad

Harvey Skinner, dean of the Faculty of Health, is co-chair of the summit with Jadad and , who is president of the Canadian Association of People-Centred Health. Skinner will talk about the mission to design and test ways to dramatically improve the capacity to keep more people and their communities healthier, longer.

To do that, he says, it is important to go beyond traditional boundaries in medicine and health care and to work together to create an integrated health system. That means addressing the social determinants of health, prevention and health promotion, as well as providing accessible, quality treatment and rehabilitation when needed.

Left: Co-chair Vaughan Glover

The summit will provide an opportunity for participants to share key learning about what works and what doesn’t in integrated health systems and an innovative network will be explored for linking academic, clinical, public health, community and private sector partners with potential chronic disease/injury initiatives.

In the second half of the summit, participants will have the opportunity to co-create a roadmap for accelerating innovation in chronic disease prevention and management that will support the design, testing and implementation of integrated systems in the culturally diverse community of the GTA, including 91��ɫ Region.

For more information, visit the Rethinking Health website.

Republished courtesy of YFile– 91��ɫ’s daily e-bulletin.

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It will not only ensure patients receive leading-edge care but help build a reputation for excellence at the hospital, the [91��ɫ Central] chief of emergency medicine says. And that's why he is participating in the initiative.

Knowledge translation, Ghosh explains, makes that important link between research and its application in health care. "We know there is good evidence-based, science-based research that has not been translated into clinical practice," he says. "A gap exists."

To narrow that gap, 91��ɫ Central Hospital made a decision to forge a collaborative effort with 91��ɫ about two years ago. Researchers with a specialty in two of YCH's areas of focus, seniors' health and chronic disease management, now have offices at the hospital.

For example, Dr. William Gage, whose research focuses on seniors' health, has connected 91��ɫ Central staff with a 91��ɫ researcher examining changes in motor performance among patients with mild cognitive impairment.

Researcher Sherry Grace [] worked with Tiziana Rivera, chief practice officer at 91��ɫ Central and others on publishing a review of studies on women and cardiac rehabilitation, program adherence and preference for alternative models of care. YCH staff can use the information when setting rehabilitation programs for their female cardiac patients.

Republished courtesy of YFile – 91��ɫ’s daily e-bulletin

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People who have had chest pain or angina could also benefit, she says, and congenital heart patients are being tested to see how much rehab can help them, too.

"Rehab itself costs only $1,500 per patient, whereas a bypass surgery, for example, can cost $40,000 and up," said Grace, director of research for the cardiovascular rehabilitation and prevention program at Peter Munk Cardiac Centre. "So if we are by this $1,500 preventing a lot more bypass surgeries and re-hospitalizations down the road, it's a real win-win in terms of the cost benefit and the health-economics of chronic disease management and cardiac rehab."

The team studied 2,635 patients with coronary artery disease at 11 Ontario hospitals. The patients filled out surveys while in the hospital, their medical charts were studied, and more than 1,800 patients completed a follow-up survey a year later.

The about the study is available in the Research News section.

Posted by Elizabeth Monier-Williams, research communications officer, with files courtesy of YFile – 91��ɫ’s daily e-bulletin.

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Researchers explored multiple strategies to increase referrals to cardiac rehabilitation programs at 11 hospitals across Ontario, including using a discharge checklist for doctors, electronic referral in medical records and talking with patients at the bedside.

According to the study, “Effect of Cardiac Rehabilitation Referral Strategies on Utilization Rates”, published in the Feb. 14 edition of the journal , a combined approach – a checklist or electronic referral and talking with patients – can increase referrals by 45 per cent. By targeting both health care providers and patients, more than 70 per cent of patients enrol in cardiac rehab.

“Every patient discharged from the hospital with a heart condition should be referred to a cardiac rehab program,” says 91��ɫ kinesiology & health science Professor Sherry Grace, principal investigator and director of research for the Cardiovascular Rehabilitation & Prevention Program at the Peter Munk Cardiac Centre, which is part of the University Health Network in Toronto.

“Cardiac rehab is a key component of the continuum of cardiac care. We shouldn’t just discharge patients from the hospital without ensuring there is a link to these proven rehab services to support patients in their recovery,” says Grace.

Cardiac rehabilitation offers a comprehensive approach to health by combining medical treatments and lifestyle modification. Patients are able to benefit from a variety of services, including: education sessions, nutritional assessment with a dietitian, risk factor treatment (hypertension, cholesterol and smoking cessation) by physicians and nurse practitioners, medication review with a pharmacist, targeted exercise prescription by an exercise physiologist, nurse or kinesiologist and supervised exercise.

indicate that participating in cardiac rehab after a cardiac illness, such as a heart attack, can reduce the risk of death by approximately 25 per cent, a reduction similar to that of other standard therapies such as cholesterol-lowering medications (statins) and aspirin. In spite of this evidence, only 20 to 30 per cent of patients are referred to a cardiac rehabilitation program after hospital discharge, a phenomenon observed in many countries.

Joe Walters, 55, lost 30 pounds through the centre’s Cardiac Rehabilitation Program at Toronto Western Hospital (TWH) after having being diagnosed with an irregular heartbeat in August 2009.

“The cardiac rehab program was truly motivational. It opened my eyes to the number of people who have heart problems like me, and it was refreshing to know it came with a built-in support network,” says Walters, who notes work-related stress contributed to his weight gain and heart trouble. “I highly recommend a cardiac rehab program for anyone with a heart condition.”

Walters graduated from the program in April 2010, but continues to attend classes to keep the weight off.

Dr. Caroline Chessex, medical doctor and clinical director of the Cardiovascular Rehabilitation & Prevention Program at the centre, is part of a multidisciplinary team who treats patients like Walters by developing a personalized exercise program tailored to each patient's cardiac risk profile.

“Our goal is to develop strategies for patients to reduce or eliminate their risk of coronary artery disease, prevent or minimize hospitalization, decrease mortality and improve quality of life,” says Chessex, noting that patients can prolong their life and reduce their risk of having a second heart attack, or needing a second heart surgery.

Beyond the physical and psychological benefits, cardiac rehabilitation saves money. Cardiac bypass surgery, the most common type of open-heart surgery, costs approximately $23,000 for each patient, but rehabilitation costs $1,000 to 1,500 per patient.

“The return on investment is obvious. Focusing on expensive cardiac interventions and then discharging patients without a systematic approach for support just doesn’t make sense,” says Grace.  “Cardiac rehab is the right step towards prevention and it saves money.”

The (CIHR) and the   funded this study.

Republished courtesy of YFile– 91��ɫ’s daily e-bulletin

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