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Background: The international Choosing Wisely campaign seeks to improve the appropriateness of care, notably through large campaigns among physicians and users designed to raise awareness of the risks inherent in overmedication.Methods: In deploying the Choosing Wisely campaign, the French Society of Geriatrics and Gerontology chose early operationalization via a tool for clinical audit over a limited area before progressive dissemination. This enabled validation of four consensual recommendations concerning the management of urinary tract infections, the prolonged use of anxiolytics, the use of neuroleptics in dementia syndromes, and the use of statins in primary prevention. The fifth recommendation concerns the importance of a dialogue on the level of care. It was written by patient representatives directly involved in the campaign.Results: The first cross-regional campaign in France involved 5337 chart screenings in 43 health facilities. Analysis of the results showed an important variability in practices between institutions and significant percentage of inappropriate prescriptions, notably of psychotropic medication.Discussion: The high rate of participation of target institutions shows that geriatrics professionals are interested in the evaluation and optimization of professional practices. Frequent overuse of psychotropic medication highlights the need of campaigns to raise awareness and encourage deprescribing. [ABSTRACT FROM AUTHOR]

Background: Persons over 80 represents 40% of patients in French emergency services. We assessed the appropriateness of these admissions and sought to identify risk factors for inappropriate hospital stays. Methods: The appropriateness of admission was assessed in a prospective, cross-sectional, multicenter study in eight hospitals in France by means of the Appropriateness Evaluation Protocol (French version, AEPf) during two non-consecutive periods of four weeks in 2010. We analyzed admission of patients aged 80 and over who were admitted to the hospital after a stay in the emergency department of the same hospital. Demographics and morbidity factors were recorded as were administrative hospitalization data to identify risk factors associated with inappropriate admissions. We also evaluated the economic impact of inappropriate admissions. For cost analysis, all variables were obtained from anonymized hospital reports of a diagnosis-related group system used for funding of the hospitals by health insurance. Results: During two different periods, 1577 patients were included. 139 (8.8%) hospital admissions were inappropriate according to explicit criteria of the AEPf, but 18 of these (1.1%) were in fact considered appropriate by the physician responsible for the admission, leading to 121 (7.7%) inappropriate admissions. Multivariate logistic regression showed that patients with heart disease were less often subject to inappropriate admission (odds ratio OR= 0.36 [0.23; 0.56], p < 0.001), as also were patients who usually lived in a nursing home (OR = 0.53 [0.30; 0.87], p = 0.018) and patients with higher Acute Physiology Scores (OR = 0.97 [0.95; 0.99], p < 0.001). Inappropriate admission increased when patients had a syndrome as the main diagnosis (OR = 1.81 [1.81; 2.83], p = 0.010). By contrast, cognitive functions, gait and balance disturbance or falls, behavioral disorders and method of transport to the emergency department did not change the probability of inappropriateness. The median cost of the hospital stay of an older patient was 3 606.5 [2 498.1; 4 994.2] euros for inappropriate admissions. Conclusion: Inappropriate emergency admissions of older patients were infrequent. None of the geriatric syndromes were linked with the phenomenon and principle causes were severity of illness, mention of a cardiac disease, unclear pattern of consultation and institutionalized way of life. [ABSTRACT FROM AUTHOR]

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Objectives: To evaluate the predictive ability of four clinical frailty indexes as regards one-year rapid cognitive decline (RCD - defined as the loss of at least 3 points on the MMSE score), and one-year institutional admission (IA) and mortality respectively; and to measure their agreement for identifying groups at risk of these severe outcomes. Design: One-year follow-up and multicentre study of old patients participating in the SAFEs cohort study. Setting: Nine university hospitals in France. Participants: 1,306 patients aged 75 or older (mean age 85±6 years; 65% female) hospitalized in medical divisions through an Emergency department. Measurements: Four frailty indexes (Winograd; Rockwood; Donini; and Schoevaerdts) reflecting the multidimensionality of the frailty concept, using an ordinal scoring system able to discriminate different grades of frailty, and constructed based on the accumulation of identified deficits after comprehensive geriatric assessment conducted during the first week of hospital stay, were used to categorize participants into three different grades of frailty: Gl - not frail; G2 - moderately frail; and G3 - severely frail. Comparisons between groups were performed using Fisher's exact test. Agreement between indexes was evaluated using Cohen's Kappa coefficient. Results: All patients were classified as frail by at least one of the four indexes. The Winograd and Rockwood indexes mainly classified subjects as G2 (85% and 96%), and the Donini and Schoevaerdts indexes mainly as G3 (71% and 67%). Among the SAFEs cohort population, 250, 1047 and 1,306 subjects were eligible for analyses of predictability for RCD, 1-year IA and 1-year mortality respectively. At 1 year, 84 subjects (34%) experienced RCD, 377 (36%) were admitted into an institutional setting, and 445 (34%) had died With the Rockwood index, all subjects who expenenced RCD were classified in G2; and in G2 and G3 when the Donini and Schoevaerdts indexes were used No significant difference was found between frailty grade and RCD, whereas frailty grade was significantly associated with an increased risk of IA and death, whatever the frailty index considered. Agreement between the different indexes of frailty was poor with Kappa coefficients ranging from −0.02 to 0.15. Conclusion: These findings confirm the poor clinimetric properties of these current indexes to measure frailty, underlining the fact that further work is needed to develop a better and more widely-accepted definition of frailty and therefore a better understanding of its pathophysiology. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To identify factors predictive of rapid cognitive decline (RCD) among elderly subjects aged 75 or over suffering from dementia. METHODS: The analysis concerned 250 patients drawn from the 'Sujet Agé Fragile--Evaluation et Suivi' (SAFES) cohort, presenting a dementia syndrome at inclusion and followed-up for at least 1 year. RCD was defined as the loss of at least 3 points on the Mini-Mental State Examination (MMSE) in the follow-up period of 12 months. All patients underwent a standardised geriatric evaluation. Logistic regression was used to identify factors predictive of RCD. RESULTS: In the study sample, 84 patients (33.6%) presented RCD. The factors identified in multivariate analysis as predictive of RCD were: high level of education (OR = 7.8, 95% CI = [1.9-31.2], p = 0.004), risk of depression (OR = 1.8, 95% CI = [1.02-3.18], p = 0.048, and the initial MMSE score (OR = 1.1, 95% CI = [1.0-1.2], p = 0.002). Among subjects with a main caregiver (n = 177), the predictive factors were malnutrition or risk thereof (OR = 4.2, 95% CI = [1.3-14.1], p = 0.02), risk of a fall (OR = 2.6, 95% CI = [1.1-6.1], p = 0.03, caregiver burden (OR = 2.6, 95% CI = [1.1-6.4], p = 0.04) and initial MMSE score (OR = 1.1, 95% CI = [1.0-1.3], p = 0.004). CONCLUSIONS: As soon as dementia is diagnosed in elderly subjects, information should be collected about the subject's socioeconomic status, nutritional status, risk of falling, mood state, and caregiver burden. This would enable the provision of appropriate therapeutic care, and make it possible to adapt follow-up in case of a risk of accelerated cognitive deterioration. [ABSTRACT FROM AUTHOR]

Objectives: The aim of the study was, by early identification of deleterious prognostic factors that are open to remediation, to be in a position to assign elderly patients to different mortality risk groups to improve management. Design: Prospective multicentre cohort. Setting: Nine French teaching hospitals. Participants: One thousand three hundred and six (1 306) patients aged 75 and over, hospitalised after having passed through Emergency Department (ED). Measurements: Patients were assessed using Comprehensive Geriatric Assessment (CGA) tools. A Cox survival analysis was performed to identify prognostic variables for six-week mortality. Receiver Operating Characteristics analysis was used to study the discriminant power of the model. A mortality risk score is proposed to define three risk groups for six-week mortality. Results: Crude mortality rate after a six-week follow-up was 10.6% (n=135). Prognostic factors identified were: malnutrition risk (HR=2.1; 95% CI: 1.1-3.8; p=.02), delirium (HR=1.7; 95% CI: 1.21-2.5; p=.006), and dependency: moderate dependency (HR=4.9; 95% CI: 1.5-16.5; p=.01) or severe dependency (HR=10.3; 95% CI: 3.2-33.1; p<.001). The discriminant power of the model was good: the c-statistic representing the area under the curve was 0.71 (95% IC: 0.67 - 0.75; p<.001). The six-week mortality rate increased significantly (p<.001) across the three risk groups: 1.1% (n=269; 95% CI=0.5-1.7) in the lowest risk group, 11.1% (n=854; 95% CI=9.4-12.9) in the intermediate risk group and 22.4% (n=125; 95% CI=20.1-24.7) in the highest risk group. Conclusions: A simple score has been calculated (using only three variables from the CGA) and practical schedule proposed to characterise patients according to the degree of mortality risk. Each of these three variables (malnutrition risk, delirium, and dependency) identified as independent prognostic factors can lead to a targeted therapeutic option to prevent early mortality. [ABSTRACT FROM AUTHOR]

To identify predictive factors for 2-year mortality in frail elderly patients after acute hospitalisation, and from these to derive and validate a Mortality Risk Index (MRI). A prospective cohort of elderly patients was set up in nine teaching hospitals. This cohort was randomly split up into a derivation cohort (DC) of 870 subjects and a validation cohort (VC) of 436 subjects. Data obtained from a Comprehensive Geriatric Assessment were used in a Cox model to predict 2-year mortality and to identify risk groups for mortality. A ROC analysis was performed to explore the validity of the MRI. Five factors were identified and weighted using hazard ratios to construct the MRI: age 85 or over (1 point), dependence for the ADL (1 point), delirium (2 points), malnutrition risk (2 points), and co-morbidity level (2 points for medium level, 3 points for high level). Three risk groups were identified according to the MRI. Mortality rates increased significantly across risk groups in both cohorts. In the DC, mortality rates were: 20.8% in the low-risk group, 49.6% in the medium-risk group, and 62.1% in the high-risk group. In the VC, mortality rates were respectively 21.7, 48.5, and 65.4%. The area under the ROC curve for overall score was statistically the same in the DC (0.72) as in the VC (0.71). The proposed MRI appears as a simple and easy-to-use tool developed from relevant geriatric variables. Its accuracy is good and the validation procedure gives a good stability of results. [ABSTRACT FROM AUTHOR]

BACKGROUND: In France, there is evidence to suggest that 50% of elderly individuals are prescribed psychotropic medications. However, it is known that use of these agents increases the risk of falls, fractures and delirium in older people. OBJECTIVE: To study the consumption of 'potentially inappropriate medication' (PIM) among patients aged >/=75 years, paying particular attention to psychotropic drugs and the factors influencing the use of 'potentially inappropriate psychotropics' (PIPs). METHOD: This was a cross-sectional analysis of a prospective multicentre cohort of 1306 hospitalized French patients aged >/=75 years (the SAFEs [Sujet Agé Fragile: Evaluation et suivi (Frail Elderly Subjects: Evaluation and follow-up)] cohort). The present analysis involved the 1176 patients for whom there was information on the usual treatments being taken in the 2 weeks before hospitalization. The drugs were coded according to the Anatomical Therapeutic Chemical classification; the Beers list as updated in 2003 defined which medications were considered PIPs. Standardized geriatric assessment variables were recorded on inclusion in the study. Logistic regression analysis was performed to identify factors linked to use of psychotropics and PIPs. RESULTS: The mean number of drugs taken was 5.7 +/- 2.9 per patient. Twenty-eight percent of patients took at least one PIM. The number of patients who had taken at least one psychotropic drug in the 2 weeks before hospitalization (mean 1.6 +/- 0.9 psychotropics per patient) was 589 (50.1%). More than half of both the 510 patients with a depressive syndrome and the 543 patients affected by dementia were treated with psychotropics. Multivariate analysis showed that prescription of psychotropics was linked to the presence of a dementia syndrome (odds ratio [OR] = 1.4; 95% CI 1.1, 1.9; p = 0.03), the presence of a depressive syndrome (OR = 1.7; 95% CI 1.3, 2.1; p < 0.001), living in an institution (OR = 2.2; 95% CI 1.5, 3.4; p < 0.001), use of more than five drugs (OR = 3.2; 95% CI 2.5, 4.2; p < 0.001) and Charlson's co-morbidity score >1 (OR = 0.6; 95% CI 0.5, 0.8; p = 0.001). Nineteen percent of all psychotropics prescribed were PIPs. Of these PIPs, 66.5% were anxiolytics, 28.4% were antidepressants and 5.1% were antipsychotics. Use of PIPs in the multivariate analysis was associated only with consumption of more than five drugs (OR = 1.7; 95% CI 1.1, 2.5; p = 0.01). CONCLUSION : PIM use is common among hospitalized older adults in France. The most important determinant of risk of receiving a psychotropic medication or a PIP was the number of drugs being taken. The elderly, who have multiple co-morbidities, complex chronic conditions and are usually receiving polypharmacy, are at increased risk for adverse drug events. These adverse events are often linked to problems that could be preventable such as delirium, depression and falls. Regular review of prescriptions would help optimize prescription of psychotropics in the elderly. The Beers list is a good tool for evaluating PIMs but is too restrictive with respect to psychotropics; in the latter respect, the list could usefully be widened. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To identify early markers of prolonged hospital stays in older people in acute hospitals. DESIGN: A prospective, multicenter study. SETTING: Nine hospitals in France. PARTICIPANTS: One thousand three hundred six patients aged 75 and older were hospitalized through an emergency department (Sujet Agé Fragile: Evaluation et suivi (SAFEs)--Frail Elderly Subjects: Evaluation and follow-up). MEASUREMENTS: Data used in a logistic regression were obtained through a gerontological evaluation of inpatients, conducted in the first week of hospitalization. The center effect was considered in two models as a random and fixed effect. Two limits were used to define a prolonged hospital stay. The first was fixed at 30 days. The second was adjusted for Diagnosis Related Groups according to the French classification (f-DRG). RESULTS: Nine hundred eight of the 1,306 hospital stays that made up the cohort were analyzed. Two centers (n=298) were excluded because of a large volume of missing f-DRGs. Two-thirds of subjects in the cohort analyzed were women (64%), with a mean age of 84. One hundred thirty-eight stays (15%) lasted more than 30 days; 46 (5%) were prolonged beyond the f-DRG-adjusted limit. No sociodemographic variables seemed to influence the length of stay, regardless of the limit used. For the 30-day limit, only cognitive impairment (odds ratio (OR)=2.2, 95% confidence interval (CI)=1.2-4.0) was identified as a marker for prolongation. f-DRG adjustment revealed other clinical markers. Walking difficulties (OR=2.6, 95% CI=1.2-16.7), fall risk (OR=2.5, 95% CI=1.7-5.3), cognitive impairment (OR=7.1, 95% CI=2.3-49.9), and malnutrition risk (OR=2.5, 95% CI=1.7-19.6) were found to be early markers for prolonged stays, although dependence level and its evolution, estimated using the Katz activity of daily living (ADL) index, were not identified as risk factors. CONCLUSION: When the generally recognized parameters of frailty are taken into account, a set of simple items (walking difficulties, risk of fall, risk of malnutrition, and cognitive impairment) enables a predictive approach to the length of stay of elderly patients hospitalized under emergency circumstances. Katz ADLs were not among the early markers identified. [ABSTRACT FROM AUTHOR]

Introduction: The PRISMA implementation research has used an innovative tool: the penetration rate of integrated model in the system. The experimentation in France of the PRISMA adopts and adapts this methodology. Aims and objective: This measurement relates to the functions of the 6 tools and mechanisms of the model: coordination boards, single entry point, case-management, single assessment instrument, individualised services plan and information system. In contrast with Quebec, no public policy in France incites to move towards this model of integration. In addition, in the French system the construction of coordination boards is complex because there is as much as ten supervision authorities and about fifteen organisation managers involved in each experimental site. Methods of adaptation of the tool in France: The measurement was not only the absence, partial existence or existence of the 6 components but takes into account the appropriation process for each one, the administrative time and the new definition of thresholds to reach as compared to the model. Results: This research tool presents two advantages. The measurement scale enables also the partners to appropriate the function of each model component and more precisely the global model of the integration. Actors do not feel evaluated but accompanied. [ABSTRACT FROM AUTHOR]

Introduction: The fragmentation of the French health and services system has a negative impact on the quality of the services offered because dependant community-dwelling older persons receive services from a mean of three interveners, and 25% of the most dependent ones perceive assistance from at least 6 interveners. In 2006, the Ministry of Health funded an experimentation of implantation of an evidence-based model of integration based on case management: PRISMA. Aims and objective: An implementation evaluative research was associated with the experimentation undertaken by an international (France, Quebec) and multidisciplinary (medical doctors, sociologists, economists) group of research. Methods: This evaluation is carried out continuously all along the implementation process. It is essentially based on research-action framework. A multi-case qualitative analysis is performed on three sites contrasted in regard of the health and services local organisation: rural, urban and megalopolitan. Results: Initial implementation seems to be low during the first 18 months. First objective signs of integration after 12 months were the emergence of a coordination process on a strategic level, the adoption of a unique assessment tools by all the partners and the project of constituting a multi-professional team of case managers. Sociological and political identified barriers will be discussed. [ABSTRACT FROM AUTHOR]

Purpose: Recent work on diffusion of innovation insists on the importance of the processual dimensions of an innovation's adoption. Context: In the course of a pilot-project aiming to implement three service integration networks for people losing their autonomy, we performed an analysis of the prior conceptions the various actors held of two founding principals: integration and coordination. This research aims to identify the prior conceptions held by the actors and to elucidate the adjustments they do to sustain the adoption of the innovation. Data sources: We conducted 32 interviews with the various key actors pertaining, as well to the strategic, tactical and operational levels of the three different sites. Case description: A content analysis of the conflicts of conception and adjustments elaborated by the adoptants during the course of the interviews was conducted. Conclusion: We notice differences in regards to the operational conceptions of the actors about the founding principles of the innovation. The capacity of working out compromises between these different conceptions is considered as predictive of the adoption of the innovation. Discussion: The adjustments they have elaborated favour a progressive adoption of the innovation and found the next step of the process of diffusion of innovation, which is local appropriation. [ABSTRACT FROM AUTHOR]