liu.seSearch for publications in DiVA
Change search
Link to record
Permanent link

Direct link
BETA
Ekerstad, Niklas
Publications (10 of 20) Show all publications
Ekerstad, N., Karlsson, B., Andersson, D., Husberg, M., Carlsson, P., Heintz, E. & Alwin, J. (2018). Short-term Resource Utilization and Cost-Effectiveness of Comprehensive Geriatric Assessment in Acute Hospital Care for Severely Frail Elderly Patients. Journal of the American Medical Directors Association, 19(10), 871-878.e2
Open this publication in new window or tab >>Short-term Resource Utilization and Cost-Effectiveness of Comprehensive Geriatric Assessment in Acute Hospital Care for Severely Frail Elderly Patients
Show others...
2018 (English)In: Journal of the American Medical Directors Association, ISSN 1525-8610, E-ISSN 1538-9375, Vol. 19, no 10, p. 871-878.e2Article in journal (Refereed) Published
Abstract [en]

Objective

The objective of this study was to estimate the 3-month within-trial cost-effectiveness of comprehensive geriatric assessment (CGA) in acute medical care for frail elderly patients compared to usual medical care, by estimating health-related quality of life and costs from a societal perspective.

Design

Clinical, prospective, controlled, 1-center intervention trial with 2 parallel groups.

Intervention

Structured, systematic interdisciplinary CGA-based care in an acute elderly care unit. If the patient fulfilled the inclusion criteria, and there was a bed available at the CGA unit, the patient was included in the intervention group. If no bed was available at the CGA unit, the patient was included in the control group and admitted to a conventional acute medical care unit.

Setting and Participants

A large county hospital in western Sweden. The trial included 408 frail elderly patients, 75 years or older, in need of acute in-hospital treatment. The patients were allocated to the intervention group (n = 206) or control group (n = 202). Mean age of the patients was 85.7 years, and 56% were female.

Measures

The primary outcome was the adjusted incremental cost-effectiveness ratio associated with the intervention compared to the control at the 3-month follow-up.

Results

We undertook cost-effectiveness analysis, adjusted by regression analyses, including hospital, primary, and municipal care costs and effects. The difference in the mean adjusted quality-adjusted life years gained between groups at 3 months was 0.0252 [95% confidence interval (CI): 0.0082-0.0422]. The incremental cost, that is, the difference between the groups, was −3226 US dollars (95% CI: −6167 to −285).

Conclusion

The results indicate that the care in a CGA unit for acutely ill frail elderly patients is likely to be cost-effective compared to conventional care after 3 months.

Place, publisher, year, edition, pages
Elsevier, 2018
Keywords
Comprehensive Geriatric Assessment (CGA), frailty, elderly patients, cost-effectiveness, emergency care
National Category
Geriatrics
Identifiers
urn:nbn:se:liu:diva-154797 (URN)10.1016/j.jamda.2018.04.003 (DOI)000445790500011 ()29784592 (PubMedID)2-s2.0-85047081533 (Scopus ID)
Available from: 2019-02-27 Created: 2019-02-27 Last updated: 2019-03-06Bibliographically approved
Ekerstad, N., Bylin, K. & Karlson, B. W. (2017). Early rehospitalizations of frail elderly patients - the role of medications: a clinical, prospective, observational trial. Drug, Healthcare and Patient Safety, 9, 77-88
Open this publication in new window or tab >>Early rehospitalizations of frail elderly patients - the role of medications: a clinical, prospective, observational trial
2017 (English)In: Drug, Healthcare and Patient Safety, ISSN 1179-1365, E-ISSN 1179-1365, Vol. 9, p. 77-88Article in journal (Refereed) Published
Abstract [en]

Early readmissions of frail elderly patients after an episode of hospital care are common and constitute a crucial patient safety outcome. Our purpose was to study the impact of medications on such early rehospitalizations.

Place, publisher, year, edition, pages
Dove Medical Press, 2017
Keywords
causes; drugs; early rehospitalizations; frail elderly; patient safety
National Category
Nursing
Identifiers
urn:nbn:se:liu:diva-145047 (URN)10.2147/DHPS.S139237 (DOI)28860862 (PubMedID)
Available from: 2018-02-08 Created: 2018-02-08 Last updated: 2018-03-05
Ekerstad, N., Karlson, B. W., Dahlin Ivanoff, S., Landahl, S., Andersson, D., Heintz, E., . . . Alwin, J. (2017). Is the acute care of frail elderly patients in a comprehensive geriatric assessment unit superior to conventional acute medical care?. Clinical Interventions in Aging, 12
Open this publication in new window or tab >>Is the acute care of frail elderly patients in a comprehensive geriatric assessment unit superior to conventional acute medical care?
Show others...
2017 (English)In: Clinical Interventions in Aging, ISSN 1176-9092, E-ISSN 1178-1998, Vol. 12Article in journal (Refereed) Published
Abstract [en]

Objective: The aim of this study was to investigate whether the acute care of frail elderly patients in a comprehensive geriatric assessment (CGA) unit is superior to the care in a conventional acute medical care unit. Design: This is a clinical, prospective, randomized, controlled, one-center intervention study. Setting: This study was conducted in a large county hospital in western Sweden. Participants: The study included 408 frail elderly patients, aged amp;gt;= 75 years, in need of acute in-hospital treatment. The patients were allocated to the intervention group (n=206) or control group (n=202). Mean age of the patients was 85.7 years, and 56% were female. Intervention: This organizational form of care is characterized by a structured, systematic interdisciplinary CGA-based care at an acute elderly care unit. Measurements: The primary outcome was the change in health-related quality of life (HRQoL) 3 months after discharge from hospital, measured by the Health Utilities Index-3 (HUI-3). Secondary outcomes were all-cause mortality, rehospitalizations, and hospital care costs. Results: After adjustment by regression analysis, patients in the intervention group were less likely to present with decline in HRQoL after 3 months for the following dimensions: vision (odds ratio [OR] = 0.33, 95% confidence interval [CI] = 0.14-0.79), ambulation (OR =0.19, 95% CI = 0.1-0.37), dexterity (OR =0.38, 95% CI =0.19-0.75), emotion (OR =0.43, 95% CI =0.22-0.84), cognition (OR =0.076, 95% CI =0.033-0.18) and pain (OR =0.28, 95% CI =0.15-0.50). Treatment in a CGA unit was independently associated with lower 3-month mortality adjusted by Cox regression analysis (hazard ratio [HR] = 0.55, 95% CI = 0.32-0.96), and the two groups did not differ significantly in terms of hospital care costs (Pamp;gt;0.05). Conclusion: Patients in an acute CGA unit were less likely to present with decline in HRQoL after 3 months, and the care in a CGA unit was also independently associated with lower mortality, at no higher cost.

Place, publisher, year, edition, pages
DOVE MEDICAL PRESS LTD, 2017
Keywords
frailty; elderly; acute care; intervention; comprehensive geriatric assessment
National Category
Geriatrics
Identifiers
urn:nbn:se:liu:diva-133878 (URN)10.2147/CIA.S124003 (DOI)000390471100001 ()28031704 (PubMedID)
Note

Funding Agencies|Health Care Subcommittee, Region Vastra Gotaland; Department of Research and Development, NU Hospital Group; Fyrbodal Research and Development Council, Region Vastra Gotaland, Sweden

Available from: 2017-01-13 Created: 2017-01-13 Last updated: 2018-04-18
Ekerstad, N., Swahn, E., Janzon, M., Alfredsson, J., Löfmark, R., Lindenberger, M., . . . Carlsson, P. (2014). Frailty is independently associated with 1-year mortality for elderly patients with non-ST-segment elevation myocardial infarction. European Journal of Preventive Cardiology, 21(10), 1216-1224
Open this publication in new window or tab >>Frailty is independently associated with 1-year mortality for elderly patients with non-ST-segment elevation myocardial infarction
Show others...
2014 (English)In: European Journal of Preventive Cardiology, ISSN 2047-4873, E-ISSN 2047-4881, Vol. 21, no 10, p. 1216-1224Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: For the large population of elderly patients with cardiovascular disease, it is crucial to identify clinically relevant measures of biological age and their contribution to risk. Frailty is denoting decreased physiological reserves and increased vulnerability. We analysed the manner in which the variable frailty is associated with 1-year outcomes for elderly non-ST-segment elevation myocardial infarction (NSTEMI) patients. METHODS AND RESULTS: Patients aged 75 years or older, with diagnosed NSTEMI were included at three centres, and clinical data including judgment of frailty were collected prospectively. Frailty was defined according to the Canadian Study of Health and Aging Clinical Frailty Scale. Of 307 patients, 149 (48.5%) were considered frail. By Cox regression analyses, frailty was found to be independently associated with 1-year mortality after adjusting for cardiovascular risk and comorbid conditions (hazard ratio 4.3, 95% CI 2.4-7.8). The time to the first event was significantly shorter for frail patients than for nonfrail (34 days, 95% CI 10-58, p = 0.005). CONCLUSIONS: Frailty is strongly and independently associated with 1-year mortality. The combined use of frailty and comorbidity may constitute an important risk prediction concept in regard to cardiovascular patients with complex needs.

Place, publisher, year, edition, pages
Sage Publications, 2014
Keywords
Elderly, frailty, mortality, myocardial infarction
National Category
Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-99008 (URN)10.1177/2047487313490257 (DOI)000342818000003 ()23644488 (PubMedID)
Available from: 2013-10-15 Created: 2013-10-15 Last updated: 2017-12-06
Sandman, L., Broqvist, M., Gustavsson, E., Arvidsson, E., Ekerstad, N. & Carlsson, P. (2014). Vård som inte kan anstå: Tolkning i relation till den etiska plattformen och nationella modellen för öppna prioriteringar. Linköping: Linköping University Electronic Press
Open this publication in new window or tab >>Vård som inte kan anstå: Tolkning i relation till den etiska plattformen och nationella modellen för öppna prioriteringar
Show others...
2014 (Swedish)Report (Other academic)
Abstract [sv]

Metod

Uppdraget från Socialstyrelsen består av tre sammanhängande delar. I den första delen presenteras olika tolkningar av begreppet vård som inte kan anstå utifrån en analys av hur begreppet används i den aktuella propositionen och lagtexten. Dessa tolkningar specificeras i ett antal kriterier. I den andra delen analyseras dessa tolkningar utifrån den etiska plattformen. Den tredje delen syftar till att analysera hur begreppet vård som inte kan anstå förhåller sig till den nationella modellen för öppna prioriteringar inom hälso- och sjukvård och diskutera om denna kan användas för att ge stöd vid prioritering och ransonering. Den teoretiska analysen kompletteras med några exempel på praktiskabeslutssituationer avseende vård av papperslösa hämtade från kliniskt verksamma personer.

Analys

I rapporten har vi formulerat ett antal kriterier som tillämpningen av  begreppet vård som inte kan anstå behöver uppfylla i enlighet med lag 2012/13:407. Dessa kriterier är:

Vårdbehovskriteriet: Personen har ett vårdbehov – d.v.s. det finns en diskrepans mellan önskvärt och aktuellt tillstånd som kan påverkas med en vårdåtgärd.

Begränsningskriteriet: Vårdgivaren får begränsa vården till vård som inte kan anstå för personer som inte är folkbokförda i Sverige och är fyllda 18 år. En sådan begränsning bör baseras på överväganden kring:

  • Svårighetsgraden hos tillståndet (aktuell ohälsa, risk för framtida ohälsa eller särskilda behov utifrån tidigare övergrepp och trauma).
  • Effekten av åtgärden om den ges i nuläget jämfört med om den fördröjs.
  • Kostnadseffektiviteten hos åtgärden om den ges i nuläget jämfört med om den fördröjs.

Begränsade ansvarskriteriet: När begreppet vård som inte kan anstå tillämpas bör vårdgivaren utgå från att personen förväntas vara en begränsad tid i Sverige men behöver inte väga in vad som kommer att hända med personens möjlighet att få vård efter att hen inte längre befinner sig i Sverige.

Alternativt:

Utökade ansvarskriteriet: När begreppet vård som inte kan anstå tillämpas bör vårdgivaren utgå från att personen förväntas vara en begränsad tid i Sverige men bör samtidigt väga in vad som kommer att hända med personens möjlighet att få vård efter att hen inte längre befinner sig i Sverige.

Slutsatser

Utifrån vårdbehovskriteriet drar vi slutsatsen att papperslösa personer som söker vård bör bedömas på ett adekvat sätt vid varje sådant tillfälle för att vårdgivaren ska kunna ta ställning till om det föreligger ett vårdbehov.

Vi drar slutsatsen att begränsningskriteriet strider mot människovärdesprincipen när det gäller begränsning av vård utifrån kronologisk ålder och folkbokföring. Vi drar även slutsatsen att den ransonering av vård som impliceras av begränsningskriteriet inte förefaller baseras på en resursbegränsning, utan på att papperslösa inte har samma rätt till hälso- och sjukvård som den folkbokförda befolkningen.

Vi drar slutsatsen att i valet mellan det begränsade och utökade ansvarskriteriet så är det utökade ansvarskriteriet att föredra. Detta utifrån hänsyn till den etiska plattformen eftersom detta utökade kriterium i större utsträckning tillåter hänsyn till relevanta aspekter som svårighetsgrad, effekt av åtgärd och kostnadseffektivitet på ett sätt som är i linje med hur den folkbokförda befolkningen behandlas. Samtidigt drar vi slutsatsen att ansvarskriteriets tidsbegränsning är svår att förhålla sig till eftersom det i många fall är ytterst osäkert hur länge en person kan befinna sig i Sverige utan nödvändiga tillstånd.

Vi drar slutsatsen att de faktorer som lyfts fram för att avgöra hur vård som inte kan anstå ska avgränsas är i sak desamma som förekommer i den nationella modellen för öppna prioriteringar – d.v.s. svårighetsgraden hos tillståndet (aktuellt och potentiellt), effekten av åtgärden (och hur den utvecklas över tid) samt kostnadseffektivitet. Samtidigt pekar vi på att det finns ett antal motsägelser i avgränsningen av begreppet och i lagen som helhet som strider mot den etiska plattformen och den nationella modellen. Detta rör även de fall när specifika diagnos- eller åtgärdsområden lyfts fram explicit oberoende av hänvisningar till svårighetsgrad, effekt av åtgärd eller kostnadseffektivitet.

Vi drar slutsatsen att även om det är möjligt att peka på några generella kombinationer av svårighetsgrad, effekt av åtgärd och kostnadseffektivitet som kan avgränsa vård som inte kan anstå – så är dessa kombinationer mycket svåra att tillämpa på individnivå. Detta eftersom det är svårt att göra individuella risk och effektbedömningar. När det gäller den folkbokförda befolkningen så är ett normalt förfarande vid bedömning av risk eller effekt att man antingen sätter in behandling för säkerhets skull, eller avvaktar och då har möjlighet som patient att återkomma om tillståndet förvärras eller kan bli föremål för återbesök på vårdgivaren initiativ. Om vårdgivaren bedömer att vården i det fallet kan anstå så finns alltså oftast möjlighet till ny bedömning på patientens eller vårdgivarens initiativ. Eftersom det i fallet med papperslösa personer är mer osäkert om han eller hon kan återkomma för en ny bedömning så kan det förefalla rimligt att oftare sätta in behandling för säkerhets skull i det fallet. Samtidigt måste detta balanseras mot de risker behandlingen kan vara förknippad med och möjligheten att följa upp dessa risker där personen kommer att befinna sig.

Abstract [en]

Method

The assignment from the National Board of Health and Welfare consists of three related parts. Part one presents different interpretations of the concept “care that cannot be deferred” based on an analysis of how the concept is used in the government bill and the wording of the Act. Several criteria are used to specify these interpretations. Part two analyses the interpretations of the concept “care that cannot be deferred” discussed in part one. The analysis is based on the ethics platform for priority setting. Part three aims to analyse how the concept “care that cannot be deferred” relates to the National Model for Transparent Prioritisation in Swedish Health Care and discuss whether it can be used to support prioritisation and rationing. The theoretical analysis is complemented by several examples of practical decision-making situations, as described by clinicians, that involve the care of non-registered individuals.

Analysis

In this report we have formulated several criteria that the concept “care that cannot be deferred” must fulfil according to the law (2012/13:407).

These criteria address: Care need: The individual has a care need – i.e. a discrepancy exists between the desired and actual condition, which can be influenced by a care intervention.

Limitations: The provider may place limitations on “care that cannot be deferred” delivered to non-registered individuals in Sweden and who are 18 years of age or older. Such limitations should be based on considerations involving:

  • Severity of the condition (current ill health, risk for future ill health, or special needs arising from previous assault and trauma).
  • Effect of the intervention if it is provided now compared to deferred intervention.
  • Cost-effectiveness of the intervention if it is provided now compared to deferred intervention.

Limited responsibility: When applying the concept “care that cannot be deferred” the provider should assume that the individual is expected to be in Sweden for a limited time, but it is not necessary to consider the person’s opportunities to receive care once he/she is no longer in Sweden.

Expanded responsibility: When applying the concept “care that cannot be deferred” the provider should assume that the individual is expected to be in Sweden a limited time, but should also consider the person’s opportunities to receive care once he/she is no longer in Sweden.

Conclusions

Based on the care need criterion, we conclude that non-registered individuals who seek care should be adequately evaluated in each case so the provider can determine whether a care need exists.

We conclude that the limited responsibility criterion conflicts with the human dignity principle when it comes to limiting care based on chronological age and national registration. Further we conclude that the rationing of care implied by the limited responsibility criterion does not appear to be based on limited resources, but that the non-registered individual does not have the same right to health services as the nationally registered population does.

We conclude that in choosing between the limited and the expanded responsibility criteria, the latter is preferable in light of the ethical platform since, to a greater extent, the expanded responsibility criterion allows consideration of relevant aspects (e.g. severity level, effect of intervention, and cost effectiveness) similar to the way the registered population is treated. Further, we conclude that the time limitation of the responsibility criteria is difficult to address since in many cases it is highly uncertain how long a person can remain in Sweden without necessary authorisation.

We conclude that the factors presented for determining how to define “care that cannot be deferred” are basically the same as those in the national model for priority setting – i.e. severity of the condition (current and potential), effect of the intervention (and how it changes over time), and cost effectiveness. Concurrently we point to several contradictions in defining the definition, and in the law generally, that conflict with the ethical platform and the national model for priority setting. This includes the cases where specific diagnostic or treatment areas are explicitly noted, regardless of severity level, effect of intervention, or cost effectiveness.

Further, we conclude that it is possible to point to several general combinations of severity level, effect of intervention, and cost effectiveness that can define “care that cannot be deferred” – so these combinations are very difficult to apply at the individual level. The reason is that it is difficult to determine individual risks and effects. As regards the registered population, a normal way to determine risks or effects would be either to provide treatment “for safety’s sake” or to wait, thus providing the opportunity for the patient to return if the  condition deteriorates or for the provider to call the patient for a return visit. If the provider decides that care can be deferred, usually there is an opportunity for a new evaluation at the initiative of the patient or provider. Since it is less certain that patients in the non-registered population can return for a new evaluation, it might seem reasonable to offer treatment more often for safety’s sake. Concurrently, this must be balanced against the risks associated with treatment and the opportunities to follow up on these risks wherever the individual resides.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2014. p. 52
Series
National Center for Priority Setting in Health Care, ISSN 1650-8475 ; 2014:1
Keywords
Prioriteringar inom sjukvården, papperslösa personer, hälso- och sjukvård
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-105393 (URN)
Available from: 2014-03-20 Created: 2014-03-20 Last updated: 2019-06-27Bibliographically approved
Ekerstad, N., Swahn, E., Janzon, M., Alfredsson, J., Löfmark, R., Lindenberger, M. & Carlsson, P. (2012). Frailty is independently associated with short-term outcomes for elderly patients with non-st-segment elevation myocardial infarction. In: : . Paper presented at 17th World Congress on Heart Disease (International Academy of Cardiology ), Annual Scientific Sessions 2012, 27-30 July 2012, Toronto, Canada. Toronto, Canada
Open this publication in new window or tab >>Frailty is independently associated with short-term outcomes for elderly patients with non-st-segment elevation myocardial infarction
Show others...
2012 (English)Conference paper, Published paper (Refereed)
Place, publisher, year, edition, pages
Toronto, Canada: , 2012
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-103423 (URN)
Conference
17th World Congress on Heart Disease (International Academy of Cardiology ), Annual Scientific Sessions 2012, 27-30 July 2012, Toronto, Canada
Available from: 2014-01-20 Created: 2014-01-20 Last updated: 2014-02-03
Sandman, L., Ekerstad, N. & Lindroth, K. (2012). Triage som prioriteringsinstrument på akutmottagning: en etisk analys av RETTS. Linköping: Linköping University Electronic Press
Open this publication in new window or tab >>Triage som prioriteringsinstrument på akutmottagning: en etisk analys av RETTS
2012 (Swedish)Report (Other academic)
Abstract [sv]

På landets akutmottagningar används systemet med triage för att kunna sortera patienterna till olika vårdnivåer. Triage innebär det första steget iomhändertagandet av skadade och sjuka i situationer när inte alla  patienter kan tas omhand omedelbart utan en prioritering måste göras samtidigt patientsäkerheten måste tillgodoses. Det vanligaste triagesystemet på svenska akutmottagningar kallas Rapid Emergency Triage and Treatment System (RETTS1). RETTS består av en kombination av bedömning av sökorsak och bedömning av olika vitalparametrar, d v s livsviktiga fysiologiska funktioner. Den sammantagna bedömningen av sökorsak och vitalparametrar leder fram till fem olika prioriteringsgrader som vart och ett står för olika omhändertaganden. Det ger vägledning var på akuten patienten bör omhändertas, hur snabbt patienten bör träffa en läkare och vilken övervakningsnivå som krävs.

Studiens syfte var att studera hur personal på svenska akutmottagningar beskrev sin upplevelse av triagesystemet ur ett etiskt perspektiv och göra en etisk analys av triagesystemet. De intervjuade beskrev att trots att det inte är garanterat att bedömningar alltid genomförs på ett likvärdigt sätt (vilket kan leda till undereller övertriagering) så innebär införandet av triagesystemet ändå en sorts garanti att riksdagens riktlinjer för prioriteringar efterlevs – att de patienter som har de största behoven får förtur till vård. Att alla patienter blir bedömda efter samma parametrar upplevs som en trygghet hos personalen och gör det lättare att kommunicera mellan olika funktioner på akutmottagningen. Men trots det standardiserade omhändertagandet är systemet inte utan brister, alla patientfall passar inte in i metoden. Multisjuka äldre, personer med psykiska problem eller med missbruksproblem uppfattas på olika sätt som svåra att bedöma och sortera ”rätt” så att de senare ska hamna rätt i vårdkedjan.

Den etiska analysen visade att själva triagesystemet överensstämde med den etiska plattformens betoning på att det större behovet ska ha förtur till vård, men tar inte hänsyn till effekterna av de åtgärder som patienten kan bli föremål för (eftersom den bedömningen kommer senare i processen). Att tillämpningen av triagemetoden kan drabba vissa grupper negativt är dock problematiskt ur människovärdesprincipens synvinkel. Ur etisk synvinkel är det sammanfattningsvis viktigt att vara medveten om en metods begränsningar och inte lita alltför mycket på att metoden passar lika bra för alla fall. Studien visar på behovet av en fördjupad etisk analys av triage på akutmottagning som även studerar den faktiska tillämpningen och fortsatta processen.

Abstract [en]

Sweden’s emergency departments use a triage system to categorise patients for different levels of care. Triage involves the first step in the care of sick and injured patients in situations where it is not possible to care for everyone immediately, but cases must be prioritized and patient safety assured. The most common triage system used in Swedish emergency departments is called the Rapid Emergency Triage and Treatment System, RETTS (synonymous with METTS). RETTS involves a combination of evaluating the reason for seeking care and various vital parameters, i.e. critical physiological functions. The combined appraisal of the reason for seeking care and the vital parameters leads to five levels of priority, each of which involves different care. This provides guidance on where to treat emergent patients, how quickly the patient must see a physician, and the level of monitoring required.

This study aims to investigate how the staff in Sweden’s emergency  departments described their experience with the triage system from an ethical perspective and also conduct an ethical analysis of the triage system. The interviewees responded that although there is no guarantee that the evaluations are always conducted in a similar way (which could lead to over or under triaging), the introduction of a triage system does provide some guarantee of compliance with the parliament’s guidelines on priority setting – that patients with the greatest need are first in line to receive care. Staff experience some sense of security in using the same parameters to evaluate all patients, which facilitates communication among the different functions in the emergency department. However, despite the standardised process, the system is not without shortcomings, and not all cases are appropriate for the method. Elderly with multiple disorders and people with psychiatric or substance- and alcohol-type problems problems are perceived as being difficult to evaluate and triage “correctly” for later placement in the appropriate continuum of care. The ethical analysis showed that the triage system per se adhered to the ethical platform’s emphasis on caring for those with the greatest needs first, but it does not consider the effects of the interventions that patients might receive (since such evaluation takes place later in the process). Since application of the triage method could have a negative impact on certain groups, this is problematic  from the perspective of the human dignity principle. From an ethical perspective it is important to be aware of a method’s limitations and not always assume that it can manage every case in an equitable manner. The study identifies the need for a deeper ethical analysis of triage in emergency departments that includes investigating actual implementation and its ongoing process.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2012. p. 50 inkl bilagor
Series
National Center for Priority Setting in Health Care, ISSN 1650-8475 ; 2012:2
Keywords
Triage
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-104936 (URN)
Available from: 2014-03-03 Created: 2014-03-03 Last updated: 2019-06-27Bibliographically approved
Ekerstad, N., Löfmark, R., Andersson, D. & Carlsson, P. (2011). A Tentative Consensus-Based Model for Priority Setting : An Example from Elderly Patients with Myocardial Infarction and Multi-morbidity. Scandinavian Journal of Public Health, 39(4), 345-353
Open this publication in new window or tab >>A Tentative Consensus-Based Model for Priority Setting : An Example from Elderly Patients with Myocardial Infarction and Multi-morbidity
2011 (English)In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 39, no 4, p. 345-353Article in journal (Refereed) Published
Abstract [en]

Background: In most Western countries the growing gap between available resources and greater potential for medical treatment has brought evidence-based guidelines into focus. However, such guidelines are difficult to use when the evidence base is weak. Priority setting for frail elderly patients with heart disease illustrates this problem. We have outlined a tentative model for priority setting regarding frail elderly heart patients. The model takes cardiovascular risk, frailty, and comorbidity into account. Objective: Our aim is to validate the model’s components. We want to evaluate the inter-rater reliability of the study experts’ rankings regarding each of the model’s categories. Methods: A confidential questionnaire study consisting of 15 authentic and validated cases was conducted to assess the views of purposefully selected cardiology experts (n = 58). They were asked to rank the cases regarding the need for coronary angiography using their individual clinical experience. The response rate was 71%. Responses were analysed with frequencies and descriptive statistics. The inter-rater reliability regarding the experts’ rankings of the cases was estimated via an intra-class correlation test (ICC). Results: The cardiologists considered the clinical cases to be realistic. The intra-class correlation (two-way random, consistency, average measure) was 0.978 (95% CI 0.958–0.991), which denotes a very good inter-rater reliability on the group level. The model’s components were considered relevant regarding complex cases of non-ST elevation myocardial infarction. Comorbidity was considered to be the most relevant component, frailty the second most relevant, followed by cardiovascular risk.

Conclusions: A framework taking comorbidity, frailty, and cardiovascular risk into account could constitute a foundation for consensus-based guidelines for frail elderly heart patients. From a priority setting perspective, it is reasonable to believe that the framework is applicable to other groups of elderly patients with acute disease and complex needs.

Place, publisher, year, edition, pages
Sage, 2011
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-67637 (URN)10.1177/1403494811405092 (DOI)000290757500002 ()
Available from: 2011-04-20 Created: 2011-04-20 Last updated: 2017-12-11Bibliographically approved
Ekerstad, N. (2011). Etiskt tillstånd bör ges för forskning på svårt sjuka äldre. Läkartidningen, 108(42), 2072-2073
Open this publication in new window or tab >>Etiskt tillstånd bör ges för forskning på svårt sjuka äldre
2011 (Swedish)In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 108, no 42, p. 2072-2073Article in journal (Other (popular science, discussion, etc.)) Published
Place, publisher, year, edition, pages
Stockholm: Läkartidningen Förlag AB, 2011
National Category
Medical Ethics
Identifiers
urn:nbn:se:liu:diva-73764 (URN)
Available from: 2012-01-12 Created: 2012-01-12 Last updated: 2017-12-08
Ekerstad, N., Swahn, E., Janzon, M., Alfredsson, J., Löfmark, R., Lindenberger, M. & Carlsson, P. (2011). Frailty Is Independently Associated With Short-Term Outcomes for Elderly Patients With Non-ST-Segment Elevation Myocardial Infarction. Circulation, 124(22), 2397-2404
Open this publication in new window or tab >>Frailty Is Independently Associated With Short-Term Outcomes for Elderly Patients With Non-ST-Segment Elevation Myocardial Infarction
Show others...
2011 (English)In: Circulation, ISSN 0009-7322, E-ISSN 1524-4539, Vol. 124, no 22, p. 2397-2404Article in journal (Refereed) Published
Abstract [en]

Background: For the large and growing population of elderly patients with cardiovascular disease, it is important to identify clinically relevant measures of biological age and their contribution to risk. Frailty is an emerging concept in medicine denoting increased vulnerability and decreased physiological reserves. We analyzed the manner in which the variable frailty predicts short-term outcomes for elderly non-ST-segment elevation myocardial infarction patients.

Methods and results: Patients aged ≥ 75 years, with diagnosed non-ST-segment elevation myocardial infarction were included at 3 centers, and clinical data including judgment of frailty were collected prospectively. Frailty was defined according to the Canadian Study of Health and Aging Clinical Frailty Scale. The impact of the comorbid conditions on risk was quantified by the coronary artery disease-specific index. Of 307 patients, 149 (48.5%) were considered frail. By multiple logistic regression, frailty was found to be strongly and independently associated with risk for the primary composite outcome (death from any cause, myocardial reinfarction, revascularization due to ischemia, hospitalization for any cause, major bleeding, stroke/transient ischemic attack, and need for dialysis up to 1 month after inclusion) (odds ratio, 2.2; 95% confidence interval, 1.3-3.7) in-hospital mortality (odds ratio, 4.6; 95% confidence interval, 1.3-16.8), and 1-month mortality (odds ratio, 4.7; 95% confidence interval, 1.7-13.0).

Conclusions: Frailty is strongly and independently associated with in-hospital mortality, 1-month mortality, prolonged hospital care, and the primary composite outcome. The combined use of frailty and comorbidity may constitute an ultimate risk prediciton concept in regard to cardiovascular patients with complex needs.

Place, publisher, year, edition, pages
Dallas, USA: American Heart Association, 2011
Keywords
elderly frailty non-ST-segment elevation acute coronary syndromes outcomes research
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:liu:diva-73752 (URN)10.1161/CIRCULATIONAHA.111.025452 (DOI)000298130700011 ()
Note
funding agencies|Medical Research Council of Southeast Sweden||Available from: 2012-01-12 Created: 2012-01-12 Last updated: 2017-12-08
Organisations

Search in DiVA

Show all publications