Value of home assessment after hospitalization in the elderly - includes editor's note - adapted fro

Date: May 15, 1995

Various strategies have been considered to reduce the rate of readmission and mortality in recently discharged elderly hospital patients. Kravitz and colleagues prospectively studied frail elderly patients to evaluate the impact of a geriatric home assessment after hospitalization.

Of 1,369 patients screened before discharge, 357 (26 percent) had one or more risk factors (see the accompanying table) indicative of frailty or instability. A total of 177 patients were randomly assigned to the intervention group, and 152 completed the full home assessment. One hundred eighty patients did not receive home assessment.

An average of three new or worsening problems were identified in 150 (99 percent) of the 152 patients. Half of the study subjects had hypovolemia, impaction, infection or other medical problems, 58 percent had gait instability, visual and hearing impairment, and other functional problems, and 53 percent had a need for assistance with activities of daily living, financial and transportation problems, and other social needs. An additional 22 percent had medication-related problems. Ninety percent had some problem understanding follow-up instructions, such as future appointments and home safety issues. Sixty-eight percent had no living will or durable power-of-attorney.

The authors conclude that 61 of the 558 problems identified in the 152 patients were judged by the physician reviewer to have required urgent attention. Twenty-three patients had potentially life-threatening disorders of fluids and electrolytes. (Journal of the American Geriatrics Society, December 1994, vol. 42, p. 1229.)

List of Specific Inclusion Criteria

Indicative of Frailty or Instability

Age 85 years or older Unplanned admission (other than index admission) in the past 3 months Recent or previously unevaluated incontinence Current diagnosis of pneumonia or dehydration Fever (greater than 38[degrees]C[100.4[degrees]F]) in the past 48 hours Confusion noted during hospitalization Decubitus ulcer Discharged on parenteral antibiotics Chest pain during past 48 hours (except in patients ruled out for myocardial infarction) Shortness of breath in the past 48 hours Recorded pulse of 110 per minute or greater, or less than 50 per minute, in the past 48 hours Recorded respiratory rate 30 or more per minute in the past 48 hours Diastolic blood pressure of 105 mm Hg or more or systolic blood pressure of 90 mm Hg or less in the past 48 hours Weight increase greater than 3 lb since admission in presence of congestive heart failure or renal failure Fall within the past three months New fracture this hospitalization Requires personal assistance to ambulate or transfer Malnutrition (albumin less than 3.5 mg per dL, or by history and examination) Electrolyte disturbances (potassium: 3.4 mEq per dL or less, or 5.5 mEq per dL or greater; sodium: 129 mEq per dL or less, or 150 mEq per dL or greater) Creatinine 5.0 mg per dL or greater, or steadily rising Hematocrit less than 25%, or 25% to 305 and fallen at least 5% in past week Leukocytosis greater than 12,000 in the absence of leukemia

From Kravitz RL, Reuben DB, Davis JW, Mitchell A, Hemmerling K, Kington RS, et al. Geriatric home assessment after hospital discharge. J Am Geriatr Soc 1994;42:1229. Used with permission.

EDITOR'S NOTE: The data indicate that home assessment after hospital discharge may identify a large number of important and potentially correctable clinical and social problems. The generalizability of the study findings (i.e., the significant number of serious problems detected) is limited by the study's focus on one teaching hospital. The ultimate effect of this intervention on health outcomes and costs compared with the 180 frail elderly control subjects who did not receive home assessment will be reported in a future article.

COPYRIGHT 1995 American Academy of Family PhysiciansCOPYRIGHT 2004 Gale Group

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