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  • 1.
    Bäckman, Karin
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Ekerstad, Niklas
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Lindroth, Katrin
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Förstudie om de mest sjuka äldre i riktlinjer för vård och omsorg2011Other (Other academic)
  • 2.
    Ekerstad, Niklas
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Etiskt tillstånd bör ges för forskning på svårt sjuka äldre2011In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 108, no 42, p. 2072-2073Article in journal (Other (popular science, discussion, etc.))
  • 3.
    Ekerstad, Niklas
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Hjärt-kärlsjuklighet hos sköra äldre2010In: Multisjuklighet och multimedicinering hos äldre: Läkardagarna i Örebro 20-21 april 2010 / [ed] Gunnar Akner, Stockholm: Hjärt-kärlsjuklighet hos sköra äldre , 2010, p. 25-30Chapter in book (Other academic)
  • 4.
    Ekerstad, Niklas
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment. Linköping University, Faculty of Health Sciences.
    Micro Level Priority Setting for Elderly Patients with Acute Cardiovascular Disease and Complex Needs: Practice What We Preach or Preach What We Practice?2011Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Demographic trends and other factors are expected to continue widening the gap between health care demands and available resources, especially in elder services. This growing imbalance signals a need for priority setting in health care. The literature has previously described problems in constructing useable means of priority setting, particularly when evidence is sparse, when patient groups are not satisfactorily defined, when interpretation of the term patient need is unclear, and when uncertainty prevails on how to weigh different ethical values. The chosen study object illustrates these problems. Moreover, the Swedish Government recently stated that care for elderly persons with complex health care needs remains underfunded. The general aim of this thesis is: to study micro-level priority setting for elderly heart patients with complex needs, as illustrated by those with non-ST-elevation myocardial infarction (NSTEMI); to relate the findings to evidence-based priority setting, e.g. guidelines for heart disease; and to analyse how complex needs could be appropriately categorised from a perspective of evidence-based priority setting.

    Paper I presents a register study that uses data from the Patient Register to describe inpatient care utilization, costs, and characteristics of elderly patients with multiple diseases. Paper II presents a confidential survey study from a random sample of 400 Swedish cardiologists. Paper III presents a prospective, clinical, observational multicentre-study of elderly patients with myocardial infarction (NSTEMI). Paper IV presents a questionnaire study from a purposeful, stratified sample of Swedish cardiologists.

    The results from Paper I show that elderly patients with multiple diseases have extensive and complex needs, frequently manifesting chronic and intermittently acute disease and consuming health care at various levels. A large majority have manifested cardiovascular disease. Results from Paper II indicate that although 81% of cardiologists reported extensive use of national guidelines in their clinical decision-making generally, the individual clinician’s personal clinical experience and the patient’s views were used to a greater extent than national guidelines, when making decisions about elderly multiple-diseased patients. Many elderly heart disease patients with complex needs manifest severe, acute or chronic, comorbid conditions that constitute exclusion criteria in evidence-generating studies, thereby limiting the generalisability of evidence and applicability of guidelines for these patients. This was indicated in papers I-IV. Paper III reports that frailty is a strong independent risk factor for adverse, short-term, clinical outcomes, e.g. one-month mortality for elderly NSTEMI patients. Particularly frail patients with a high comorbidity burden manifested a markedly increased risk.

    In the future, prospective clinical studies and registries with few exclusion criteria should be conducted. Consensus-based judgments based on a framework for priority setting as regards elderly patients with complex needs may offer an alternative, estimating the benefitrisk ratio of an intervention and the time-frame of expected benefits in relation to expected life-time. Such a framework, which is tentatively outlined in this thesis, should take into account comorbidity, frailty, and disease-specific risk.

    List of papers
    1. Characteristics of multiple-diseased elderly in Swedish hospital care and clinical guidelines: Do they make evidence-based priority setting a "mission impossible"?
    Open this publication in new window or tab >>Characteristics of multiple-diseased elderly in Swedish hospital care and clinical guidelines: Do they make evidence-based priority setting a "mission impossible"?
    2008 (English)In: International Journal of Ageing and Later Life, ISSN 1652-8670, Vol. 3, no 2, p. 71-95Article in journal (Refereed) Published
    Abstract [en]

    In Sweden, an expected growing gap between available resources and greater potential for medical treatment has brought evidence-based guidelines and priority setting into focus. There are problems, however, in areas where the evidence base is weak and underlying ethical values are controversial. Based on a specified definition of multiple-diseased elderly patients, the aims of this study are: (i) to describe and quantify inpatient care utilisation and patient characteristics, particularly regarding cardiovascular disease and co-morbidity; and (ii) to question the applicability of evidence-based guidelines for these patients with regard to the reported characteristics (i.e. age and co-morbidity), and to suggest some possible strategies in order to tackle the described problem and the probable presence of ageism. We used data from three sources: (a) a literature review, (b) a register study, based on a unique population-based register of inpatient care in Sweden, and (c) a national cost per patient database. The results show that elderly patients with multiple co-morbidities constitute a large and growing population in Swedish inpatient hospital care. They have multiple and complex needs and a large majority have a cardiovascular disease. There is a relationship between reported characteristics, i.e. age and co-morbidity, and limited applicability of evidence-based guidelines, and this can cause an under-use as well as an over-use of medical interventions. As future clinical studies will be rare due to methodological and financial factors, we consider it necessary to condense existing practical-clinical experiences of individual experts into consensus-based guidelines concerning elderly with multi-morbidity. In such priority setting, it will be important to consider co-morbidity and differens degrees of frailty.

    Place, publisher, year, edition, pages
    Linköping: Linköping University Electronic Press, 2008
    Keywords
    priority setting, evidence-based guidelines, elderly, co-morbidity, cardiovascular disease, ageism
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-56241 (URN)10.3384/ijal.1652-8670.083271 (DOI)
    Available from: 2010-05-04 Created: 2010-05-04 Last updated: 2011-05-11Bibliographically approved
    2. Elderly people with multi-morbidity and acute coronary syndrome: Doctors' views on decision-making
    Open this publication in new window or tab >>Elderly people with multi-morbidity and acute coronary syndrome: Doctors' views on decision-making
    2010 (English)In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 38, no 3, p. 325-331Article 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, problems exist in areas where the evidence base is weak, e.g. elderly patients with heart disease and multiple co-morbidities. Objective: Our aim is to evaluate the views of Swedish cardiologists on decision-making for elderly people with multiple co-morbidities and acute coronary syndrome without ST-elevation (NSTE ACS), and to generate some hypotheses for testing. Methods: A confidential questionnaire study was conducted to assess the views of cardiologists/internists (n = 370). The response rate was 69%. Responses were analyzed with frequencies and descriptive statistics. When appropriate, differences in proportions were assessed by a chi-square test. A content analysis was used to process the answers to the open-ended questions. Results: 81% of the respondents reported extensive use of national quidelines for care of heart disease in their clinical decision-making. However, when making decisions for multiple-diseased elderly patients, the individual physician's own clinical experience and the patient's views of treatment choice were used to an evidently greater extent than national guidelines. Approximately 50% estimated that they treated multiple-diseased elderly patients with NSTE ACS every day. Preferred measures for improving decision-making were: (a) carrying out treatment studies including elderly patients with multiple co-morbidities, and (b) preparing specific national guidelines for multiple-diseased elderly patients. Conclusions: In the future, national guidelines for heart disease should be adapted in order to be applicable for elderly patients with multiple co-morbidities.

    Keywords
    Acute coronary syndrome, co-morbidity, decision-making, elderly, guidelines
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-56309 (URN)10.1177/1403494809354359 (DOI)000277168800014 ()
    Note
    The final, definitive version of this paper has been published in: Scandinavian Journal of Public Health, (38), 3, 325-331, 2010. Niklas Ekerstad, Rurik Löfmark and Per Carlsson, Elderly people with multi-morbidity and acute coronary syndrome: Doctors' views on decision-making http://dx.doi.org/10.1177/1403494809354359 by SAGE Publications Ltd, All rights reserved. http://www.uk.sagepub.com/ Available from: 2010-05-07 Created: 2010-05-07 Last updated: 2017-12-12Bibliographically approved
    3. Frailty as a Predictor of Short-Term Outcomes for Elderly Patients with non-ST-Elevation Myocardial Infarction (NSTEMI)
    Open this publication in new window or tab >>Frailty as a Predictor of Short-Term Outcomes for Elderly Patients with non-ST-Elevation Myocardial Infarction (NSTEMI)
    Show others...
    (English)Manuscript (preprint) (Other academic)
    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 physiologic reserves. We analyzed how the variable frailty predicts short-term outcomes for elderly NSTEMI patients.

    Methods and Results – Patients, aged 75 years or older, with diagnosed NSTEMI were included at three centers, and clinical data including judgement of frailty were collected prospectively. Frailty was defined according to the Canadian Study of Health and Aging (CSHA) Clinical Frailty Scale (CFS). Of 307 patients, 150 (48.5%) were considered frail. Frail patients were slightly older and presented with a greater burden of comorbidity. By multiple logistic regression, frailty was found to be a strong independent risk factor for inhospital mortality, one-month mortality (OR 3.8, 95% CI 1.3 to 10.8) and the primary composite outcome (OR 2.2, 95% CI 1.3 to 3.7). Particularly frail patients with a high comorbidity burden manifested a markedly increased risk for the primary composite outcome. By multiple linear regression, frailty was identified as a strong independent predictor for prolonged hospital care (frail 13.4 bed days, non-frail 7.5 bed days; P<0.0001).

    Conclusions - Frailty is a strong independent predictor of in-hospital mortality, one-month mortality, prolonged hospital care and the primary composite outcome. The combined use of frailty and comorbidity may constitute an ultimate risk prediction concept regarding cardiovascular patients with complex needs.

    Keywords
    Elderly, frailty, NSTEMI, co-morbidity, outcomes
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-67638 (URN)
    Available from: 2011-04-20 Created: 2011-04-20 Last updated: 2013-09-11Bibliographically approved
    4. A Tentative Consensus-Based Model for Priority Setting : An Example from Elderly Patients with Myocardial Infarction and Multi-morbidity
    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
  • 5.
    Ekerstad, Niklas
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Department of Health and Society, Center for Medical Technology Assessment.
    Ny etisk plattform för sjukvården - exit Hippokrates?2007In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 104, no 41Article in journal (Other academic)
  • 6.
    Ekerstad, Niklas
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medicine and Health Sciences, Health Technology Assessment and Health Economics.
    Priority Setting for Elderly with Multimorbidity in Acute Cardiovascular Care: What are the Views of Swedish Cardiologists? (oral presentation)2008In: 7th International Conference on Priorities in Health Care,2008, 2008Conference paper (Other academic)
    Abstract [en]

        

  • 7.
    Ekerstad, Niklas
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Department of Cardiology, NU (NÄL-Uddevalla) Hospital Group, Trollhättan, Sweden.
    Bylin, Kristoffer
    Department of Acute and Internal Medicine, NU (NÄL-Uddevalla) Hospital Group, Trollhättan, Sweden.
    Karlson, Björn W.
    Department of Acute and Internal Medicine, NU (NÄL-Uddevalla) Hospital Group, Trollhättan; Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Early rehospitalizations of frail elderly patients - the role of medications: a clinical, prospective, observational trial2017In: Drug, Healthcare and Patient Safety, ISSN 1179-1365, E-ISSN 1179-1365, Vol. 9, p. 77-88Article in journal (Refereed)
    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.

  • 8.
    Ekerstad, Niklas
    et al.
    Linköping University, Department of Medicine and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Carlsson, Per
    Linköping University, Department of Medicine and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Consensus-based priority setting for frail elderly NSTEMI (Non ST Elevation Myocardial Infarction) patients2010Conference paper (Refereed)
    Abstract [en]

    Introduction: Evidence based medicine is difficult to practice when the evidence base is weak. Priority setting for frail elderly patients with heart disease illustrates this problem. We have constructed a tentative model for priority setting for frail elderly patients. Our aim is to evaluate its potential to predict experts’ priority setting. Methods: The tentative model, taking into account cardiovascular risk, frailty and co-morbidity, was based on a literature review, a register study and a questionnaire study. In a pilot study six experienced cardiologists were confronted with 15 validated authentic NSTEMI cases, all of them with different patterns of co-morbidity and frailty. We evaluated the convergence between the rankings of the individual cardiologists and also whether these rankings were in accordance with the suggested model rankings. In the ongoing main study participating cardiologists were recommended by experts. The convergence is measured via an intra-class correlation test. Results: Respondents in the pilot study considered the cases to be clear and relevant. The convergence was evident, both between the cardiologists´ rankings and regarding the model’s suggested rankings compared to the cardiologists’ rankings. The model components were considered relevant and important. The current main study evaluates the same issues on a larger scale. The results will soon be reported. Conclusions: In order to enhance the usability of guidelines in cardiology, they ought to be adapted to frail elderly patients. Our tentative model constitutes a first step in a process towards experts’ consensus-based priority setting when the evidence base is weak.

  • 9.
    Ekerstad, Niklas
    et al.
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics.
    Carlsson, Per
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics.
    Edberg, Annika
    Landstinget i Östergötland.
    Prioritering av multisjuka äldre inom kardiologi: en medicinsk, etisk och hälsoekonomisk utmaning2008Report (Other academic)
    Abstract [sv]

    I Sverige har ett förväntat ökande gap mellan tillgängliga resurser och ökade behandlingsmöjligheter satt fokus på evidensbaserad prioritering. Problem har emellertid konstaterats inom områden med svag evidensgrund och oklar eller kontroversiell värdegrund. Vårt mål har varit att definiera, beskriva och kvantifiera ett typfall, som illustrerar denna problematik, nämligen populationen multisjuka äldre patienter i svensk slutenvård, särskilt de med hjärtkärlsjukdom, samt att diskutera implikationerna för prioriteringsarbete.

    Är det t ex möjligt att utarbeta konsensusbaserade riktlinjer, grundade på befintlig evidens- och värdegrund? Vi vill underbygga denna strategi för multisjuka äldre patienter med kardiovaskulär sjukdom genom att:

    • definiera, beskriva och kvantifiera de multisjuka äldre patienterna i svensk sjukvård, i synnerhet de med hjärtkärlsjukdom

    • uppskatta slutenvårdskostnaden för de multisjuka äldre patienterna

    • på populationsnivå skapa förutsättningar för kategorisering och prioritering av multisjuka äldre med kardiovaskulär sjukdom, företrädesvis på basen av kliniskt relevant komorbiditet

    Detta studeras med hjälp av en litteraturöversikt och en sammanställning av registerdata från Patientregistret för sluten vård och KPP-databasen (Kostnad Per Patient). Dessa källor har använts för att beskriva patientkaraktäristika, särskilt komorbiditet, samt vårdkonsumtion. De multisjuka äldres slutenvårdskonsumtion har uppskattats grovt.

    Resultatet visar att det inte finns någon allmänt vedertagen definition av multisjuka äldre. Socialstyrelsens definition framstår, ur epidemiologisk synvinkel, som den lämpligaste. Den lyder:"Personer 75 år eller äldre som under de senaste 12 månaderna har varit inneliggande tre eller flera gånger inom slutenvården och med tre eller flera diagnoser i tre eller flera skilda diagnosgrupper enligt klassifikationssystemet ICD 10."

    Bland alla människor i Sverige som är 75 år och äldre utgör de multisjuka äldre ungefär 7 procent. Av alla sjukhusvårdade patienter 75 år och äldre utgör de multisjuka äldre 25 procent men de konsumerar 47 procent av sjukhusdagarna i detta åldersintervall. Andelen multisjuka äldre växer på sjukhusen och sannolikt i samhället. Kostnaden för slutenvård av multisjuka äldre uppgår idag till 11.5 miljarder kronor per år.

     

    De multisjuka äldres slutenvårdskonsumtion betingar därmed 19 procent av de totala svenska slutenvårdskostnaderna. De vårdas inom olika specialiteter, men den klart dominerande specialiteten är internmedicin, inom vilken 81 procent av de multisjuka har vårdats. 71 procent av slutenvården av de multisjuka äldre sker på små och medelstora sjukhus.

    De multisjuka äldre, som vårdas på sjukhus, är i genomsnitt 83 år gamla samt har stora, multipla och komplexa vårdbehov. I de äldsta åldersstrata dominerar kvinnor numerärt. Hjärtkärlsjukdomar dominerar och många vårdtillfällen orsakas av akutisering av kronisk hjärtkärlsjukdom. Till de vanligaste, prioriteringsmässigt relevanta, komorbida tillstånden vid slutenvårdskrävande hjärtkärlsjukdom hos multisjuka äldre hör: tumörsjukdomar, tillstånd efter stroke, njursvikt, demens/betydande kognitiv rubbning, kroniskt obstruktiv lungsjukdom och kronisk värk. Några patientfall från kliniken relateras för att ge konkretion åt framställningen.

    För att kunna kategorisera de multisjuka äldre och för att kunna rangordna de aktuella prioriteringskategorierna krävs ytterligare kunskap om populationens komorbiditet. Med tanke på patientgruppens komplexa behov krävs emellertid en kompletterande behovsinriktad (snarare än enbart diagnosinriktad) klassifikation. Vidare skulle en prognostisk markör, kopplad till patientens totala sjukdomsbild, vara av värde vid prioritering.

  • 10.
    Ekerstad, Niklas
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. NU NAL Uddevalla Hospital Grp, Sweden.
    Dahlin Ivanoff, Synneve
    University of Gothenburg, Sweden.
    Landahl, Sten
    University of Gothenburg, Sweden.
    Ostberg, Goran
    NU Hospital Grp, Sweden.
    Johansson, Maria
    NU Hospital Grp, Sweden.
    Andersson, David
    University of Gothenburg, Sweden.
    Husberg, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Alwin, Jenny
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Karlson, Bjorn W.
    University of Gothenburg, Sweden.
    Acute care of severely frail elderly patients in a CGA-unit is associated with less functional decline than conventional acute care2017In: Clinical Interventions in Aging, ISSN 1176-9092, E-ISSN 1178-1998, Vol. 12, p. 1239-1248Article in journal (Refereed)
    Abstract [en]

    Background: A high percentage of individuals treated in specialized acute care wards are frail and elderly. Our aim was to study whether the acute care of such patients in a comprehensive geriatric assessment (CGA) unit is superior to care in a conventional acute medical care unit when it comes to activities of daily living (ADLs), frailty, and use of municipal help services. Patients and methods: A clinical, prospective, controlled trial with two parallel groups was conducted in a large county hospital in West Sweden and included 408 frail elderly patients, age 75 or older (mean age 85.7 years; 56% female). Patients were assigned to the intervention group (n=206) or control group (n=202). Primary outcome was decline in functional activity ADLs assessed by the ADL Staircase 3 months after discharge from hospital. Secondary outcomes were degree of frailty and use of municipal help services. Results: After adjustment by regression analyses, treatment in a CGA unit was independently associated with lower risk of decline in ADLs [odds ratio (OR) 0.093; 95% confidence interval (CI) 0.052-0.164; P amp;lt; 0.0001], and with a less prevalent increase in the degree of frailty (OR 0.229; 95% CI 0.131-0.400; P amp;lt; 0.0001). When ADLs were classified into three strata (independence, instrumental ADL-dependence, and personal ADL-dependence), changes to a more dependence-associated stratum were less prevalent in the intervention group (OR 0.194; 95% CI 0.085-0.444; P=0.0001). There was no significant difference between the groups in increased use of municipal help services (OR 0.682; 95% CI 0.395-1.178; P=0.170). Conclusion: Acute care of frail elderly patients in a CGA unit was independently associated with lesser loss of functional ability and lesser increase in frailty after 3 months.

  • 11.
    Ekerstad, Niklas
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Edberg, Annika
    Socialstyrelsen.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Characteristics of multiple-diseased elderly in Swedish hospital care and clinical guidelines: Do they make evidence-based priority setting a "mission impossible"?2008In: International Journal of Ageing and Later Life, ISSN 1652-8670, Vol. 3, no 2, p. 71-95Article in journal (Refereed)
    Abstract [en]

    In Sweden, an expected growing gap between available resources and greater potential for medical treatment has brought evidence-based guidelines and priority setting into focus. There are problems, however, in areas where the evidence base is weak and underlying ethical values are controversial. Based on a specified definition of multiple-diseased elderly patients, the aims of this study are: (i) to describe and quantify inpatient care utilisation and patient characteristics, particularly regarding cardiovascular disease and co-morbidity; and (ii) to question the applicability of evidence-based guidelines for these patients with regard to the reported characteristics (i.e. age and co-morbidity), and to suggest some possible strategies in order to tackle the described problem and the probable presence of ageism. We used data from three sources: (a) a literature review, (b) a register study, based on a unique population-based register of inpatient care in Sweden, and (c) a national cost per patient database. The results show that elderly patients with multiple co-morbidities constitute a large and growing population in Swedish inpatient hospital care. They have multiple and complex needs and a large majority have a cardiovascular disease. There is a relationship between reported characteristics, i.e. age and co-morbidity, and limited applicability of evidence-based guidelines, and this can cause an under-use as well as an over-use of medical interventions. As future clinical studies will be rare due to methodological and financial factors, we consider it necessary to condense existing practical-clinical experiences of individual experts into consensus-based guidelines concerning elderly with multi-morbidity. In such priority setting, it will be important to consider co-morbidity and differens degrees of frailty.

  • 12.
    Ekerstad, Niklas
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. NU NAL Uddevalla Hospital Grp, Sweden.
    Karlson, Björn W.
    University of Gothenburg, Sweden.
    Dahlin Ivanoff, Synneve
    University of Gothenburg, Sweden.
    Landahl, Sten
    University of Gothenburg, Sweden.
    Andersson, David
    Linköping University, Department of Management and Engineering, Economics. Linköping University, Faculty of Arts and Sciences.
    Heintz, Emelie
    Karolinska Institute, Sweden.
    Husberg, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Alwin, Jenny
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Is the acute care of frail elderly patients in a comprehensive geriatric assessment unit superior to conventional acute medical care?2017In: Clinical Interventions in Aging, ISSN 1176-9092, E-ISSN 1178-1998, Vol. 12Article in journal (Refereed)
    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.

  • 13.
    Ekerstad, Niklas
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Department of Cardiology, NU (NÄL-Uddevalla) Hospital Group, Trollhättan-Uddevalla-Vänersborg, Sweden.
    Karlsson, Björn
    Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Andersson, David
    Linköping University, Department of Management and Engineering, Economics. Linköping University, Faculty of Arts and Sciences.
    Husberg, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Heintz, Emelie
    Department of Learning, Informatics, Management and Ethics (LIME), QRC Research Unit, Karolinska Institutet, Stockholm, Sweden.
    Alwin, Jenny
    Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Short-term Resource Utilization and Cost-Effectiveness of Comprehensive Geriatric Assessment in Acute Hospital Care for Severely Frail Elderly Patients2018In: 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)
    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.

  • 14.
    Ekerstad, Niklas
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. NU NAL Uddevalla Hosp Grp, Sweden.
    Karlsson, Thomas
    Univ Gothenburg, Sweden.
    Soderqvist, Sara
    NU NAL Uddevalla Hosp Grp, Sweden.
    Karlson, Bjorn W.
    NU NAL Uddevalla Hosp Grp, Sweden; Univ Gothenburg, Sweden.
    Hospitalized frail elderly patients - atrial fibrillation, anticoagulation and 12 months outcomes2018In: Clinical Interventions in Aging, ISSN 1176-9092, E-ISSN 1178-1998, Vol. 13, p. 749-756Article in journal (Refereed)
    Abstract [en]

    Background and objective: Multiple chronic conditions and recurring acute illness are frequent among elderly people. One such condition is atrial fibrillation (AF), which increases the risk of stroke up to fivefold. The aim of this study was to investigate the prevalence of AF among hospitalized frail elderly patients, their use of anticoagulation and their 12-month outcomes. Patients and methods: This was a clinical observational study of acutely hospitalized frail patients over the age of 75 years. The CHA2DS2-VASc Score was used to evaluate ischemic stroke risk in patients with AF. Clinically relevant outcomes were the composite of ischemic stroke and/or bleeding within 12 months, which was considered as primary in the analysis, ischemic stroke/transient ischemic attack (TIA), mortality, bleeding and hospital care consumption. Students (test, Fishers exact test, Mann Whitney U test and a Cox proportional hazards model were used for the analyses. Results: The prevalence of AF was 47%, and 63% of them were prescribed an anticoagulant. AF patients without anticoagulation were older, more often females, more often in residential care, and they had worse Mini Nutritional Assessment and activities of daily living scores. Of the patients without anticoagulation, 56% had a documented contraindication. In univariate analysis, there were significantly more events among AF patients without anticoagulation regarding the composite outcome of ischemic stroke and/or bleeding (hazard ratio [1112] 3.65, 95% CI = 1.70-7.86; p amp;lt; 0.001). When adjusting for potential confounders in Cox regression analysis, the difference remained significant (HR 4.54, 95% CI = 1.83-11.25; p = 0.001). Conclusion: The prevalence of AF in a hospitalized frail elderly population was 47%. Of these, 63% were prescribed anticoagulation therapy. Almost half of the patients without stroke pro-phylaxis had no documented contraindication. At 1 year, there were significantly more events in terms of ischemic stroke and/or bleeding among AF patients without anticoagulation therapy than among those with.

  • 15.
    Ekerstad, Niklas
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Löfmark, Rurik
    Stockholm Centre for Healthcare Ethics, LIME, Karolinska Institutet, Stockholm.
    Andersson, David
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    A Tentative Consensus-Based Model for Priority Setting : An Example from Elderly Patients with Myocardial Infarction and Multi-morbidity2011In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 39, no 4, p. 345-353Article in journal (Refereed)
    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.

  • 16.
    Ekerstad, Niklas
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Löfmark, Rurik
    Department of Medical Ethics, Karolinska Institutet.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Elderly people with multi-morbidity and acute coronary syndrome: Doctors' views on decision-making2010In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 38, no 3, p. 325-331Article in journal (Refereed)
    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, problems exist in areas where the evidence base is weak, e.g. elderly patients with heart disease and multiple co-morbidities. Objective: Our aim is to evaluate the views of Swedish cardiologists on decision-making for elderly people with multiple co-morbidities and acute coronary syndrome without ST-elevation (NSTE ACS), and to generate some hypotheses for testing. Methods: A confidential questionnaire study was conducted to assess the views of cardiologists/internists (n = 370). The response rate was 69%. Responses were analyzed with frequencies and descriptive statistics. When appropriate, differences in proportions were assessed by a chi-square test. A content analysis was used to process the answers to the open-ended questions. Results: 81% of the respondents reported extensive use of national quidelines for care of heart disease in their clinical decision-making. However, when making decisions for multiple-diseased elderly patients, the individual physician's own clinical experience and the patient's views of treatment choice were used to an evidently greater extent than national guidelines. Approximately 50% estimated that they treated multiple-diseased elderly patients with NSTE ACS every day. Preferred measures for improving decision-making were: (a) carrying out treatment studies including elderly patients with multiple co-morbidities, and (b) preparing specific national guidelines for multiple-diseased elderly patients. Conclusions: In the future, national guidelines for heart disease should be adapted in order to be applicable for elderly patients with multiple co-morbidities.

  • 17.
    Ekerstad, Niklas
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. NU NAL Uddevalla Hosp Grp, Sweden.
    Pettersson, Staffan
    Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Alexander, Karen
    Duke Clin Res Inst, NC USA.
    Andersson, David
    Linköping University, Department of Management and Engineering, Economics. Linköping University, Faculty of Arts and Sciences.
    Eriksson, Sofia
    Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Janzon, Magnus
    Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping. Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine.
    Lindenberger, Marcus
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Swahn, Eva
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Alfredsson, Joakim
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Frailty as an instrument for evaluation of elderly patients with non-ST-segment elevation myocardial infarction: A follow-up after more than 5 years2018In: European Journal of Preventive Cardiology, ISSN 2047-4873, E-ISSN 2047-4881, Vol. 25, no 17, p. 1813-1821Article in journal (Refereed)
    Abstract [en]

    Background There is a growing body of evidence on the relevance of using frailty measures also in a cardiovascular context. The estimated time to death is crucial in clinical decision-making in cardiology. However, data on the importance of frailty in long-term mortality are very scarce. The aim of the study was to assess the prognostic value of frailty on mortality at long-term follow-up of more than 5 years in patients 75 years or older hospitalised for non-ST-segment elevation myocardial infarction. We hypothesised that frailty is independently associated with long-term mortality. Design This was a prospective, observational study conducted at three centres. Methods and results Frailty was assessed according to the Canadian Study of Health and Aging clinical frailty scale (CFS). Of 307 patients, 149 (48.5%) were considered frail according to the study instrument (degree 5-7 on the scale). The long-term all-cause mortality of more than 5 years (median 6.7 years) was significantly higher among frail patients (128, 85.9%) than non-frail patients (85, 53.8%), (P amp;lt; 0.001). In Cox regression analysis, frailty was independently associated with mortality from the index hospital admission to the end of follow-up (hazard ratio 2.06, 95% confidence interval 1.51-2.81; P amp;lt; 0.001) together with age (P amp;lt; 0.001), ejection fraction (P = 0.012) and Charlson comorbidity index (P = 0.018). Conclusions In elderly non-ST-segment elevation myocardial infarction patients, frailty was independently associated with all-cause mortality at long-term follow-up of more than 6 years. The combined use of frailty and comorbidity may be the ultimate risk prediction concept in the context of cardiovascular patients with complex needs.

  • 18.
    Ekerstad, Niklas
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Swahn, Eva
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Cardiology in Linköping.
    Janzon, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Cardiology in Linköping.
    Alfredsson, Joakim
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Cardiology in Linköping.
    Löfmark, Rurik
    Stockholm Centre for Healthcare Ethics, LIME, Karolinska Institutet, Sweden .
    Lindenberger, Marcus
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Cardiology in Linköping. Ryhov County Hospital, Jönköping, Sweden .
    Andersson, David
    Linköping University, Department of Management and Engineering, Economics. Linköping University, Faculty of Arts and Sciences.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Frailty is independently associated with 1-year mortality for elderly patients with non-ST-segment elevation myocardial infarction2014In: European Journal of Preventive Cardiology, ISSN 2047-4873, E-ISSN 2047-4881, Vol. 21, no 10, p. 1216-1224Article in journal (Refereed)
    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.

  • 19.
    Ekerstad, Niklas
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Swahn, Eva
    Linköping University, Department of Medical and Health Sciences, Cardiology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Centre, Department of Cardiology UHL.
    Janzon, Magnus
    Linköping University, Department of Medical and Health Sciences, Cardiology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Centre, Department of Cardiology UHL.
    Alfredsson, Joakim
    Linköping University, Department of Medical and Health Sciences, Cardiology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Centre, Department of Cardiology UHL.
    Löfmark, Rurik
    Stockholm Centre for Healthcare Ethics, LIME, Karolinska Institutet, Stockholm.
    Lindenberger, Marcus
    Linköping University, Department of Medical and Health Sciences, Physiology. Linköping University, Faculty of Health Sciences.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Frailty as a Predictor of Short-Term Outcomes for Elderly Patients with non-ST-Elevation Myocardial Infarction (NSTEMI)Manuscript (preprint) (Other academic)
    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 physiologic reserves. We analyzed how the variable frailty predicts short-term outcomes for elderly NSTEMI patients.

    Methods and Results – Patients, aged 75 years or older, with diagnosed NSTEMI were included at three centers, and clinical data including judgement of frailty were collected prospectively. Frailty was defined according to the Canadian Study of Health and Aging (CSHA) Clinical Frailty Scale (CFS). Of 307 patients, 150 (48.5%) were considered frail. Frail patients were slightly older and presented with a greater burden of comorbidity. By multiple logistic regression, frailty was found to be a strong independent risk factor for inhospital mortality, one-month mortality (OR 3.8, 95% CI 1.3 to 10.8) and the primary composite outcome (OR 2.2, 95% CI 1.3 to 3.7). Particularly frail patients with a high comorbidity burden manifested a markedly increased risk for the primary composite outcome. By multiple linear regression, frailty was identified as a strong independent predictor for prolonged hospital care (frail 13.4 bed days, non-frail 7.5 bed days; P<0.0001).

    Conclusions - Frailty is a strong independent predictor of in-hospital mortality, one-month mortality, prolonged hospital care and the primary composite outcome. The combined use of frailty and comorbidity may constitute an ultimate risk prediction concept regarding cardiovascular patients with complex needs.

  • 20.
    Ekerstad, Niklas
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Swahn, Eva
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Cardiology in Linköping.
    Janzon, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Cardiology in Linköping.
    Alfredsson, Joakim
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Cardiology in Linköping.
    Löfmark, Rurik
    LIME, Karolinska Institutet, Stockholm, Sweden.
    Lindenberger, Marcus
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Cardiology in Linköping.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Frailty is independently associated with short-term outcomes for elderly patients with non-st-segment elevation myocardial infarction2012Conference paper (Refereed)
  • 21.
    Ekerstad, Niklas
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Swahn, Eva
    Linköping University, Department of Medical and Health Sciences, Cardiology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Centre, Department of Cardiology UHL.
    Janzon, Magnus
    Linköping University, Department of Medical and Health Sciences, Cardiology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Centre, Department of Cardiology UHL.
    Alfredsson, Joakim
    Linköping University, Department of Medical and Health Sciences, Cardiology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Centre, Department of Cardiology UHL.
    Löfmark, Rurik
    Department of Medical Ethics, LIME, Karolinska Institutet.
    Lindenberger, Marcus
    Department of Medicine, Ryhov County Hospital Jönköping.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Frailty Is Independently Associated With Short-Term Outcomes for Elderly Patients With Non-ST-Segment Elevation Myocardial Infarction2011In: Circulation, ISSN 0009-7322, E-ISSN 1524-4539, Vol. 124, no 22, p. 2397-2404Article in journal (Refereed)
    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.

  • 22.
    Ekerstad, Niklas
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. NU NAL Uddevalla Hosp Grp, Sweden.
    Östberg, Göran
    NU Hosp Grp, Sweden.
    Johansson, Maria
    NU Hosp Grp, Sweden.
    Karlson, Björn W.
    NU Hosp Grp, Sweden; Univ Gothenburg, Sweden.
    Are frail elderly patients treated in a CGA unit more satisfied with their hospital care than those treated in conventional acute medical care?2018In: Patient Preference and Adherence, ISSN 1177-889X, E-ISSN 1177-889X, Vol. 12, p. 233-240Article in journal (Refereed)
    Abstract [en]

    Objectives: Our aim was to study whether the acute care of frail elderly patients directly admitted to a comprehensive geriatric assessment (CGA) unit is superior to the care in a conventional acute medical care unit in terms of patient satisfaction. Design: TREEE (Is the TReatment of frail Elderly patients Effective in an Elderly care unit?) is a clinical, prospective, controlled, one-center intervention trial comparing acute treatment in CGA units and in conventional wards. Setting: This study was conducted in the NAL-Uddevalla county hospital in western Sweden. Participants: In this follow-up to the TREEE study, 229 frail patients, aged amp;gt;= 75 years, in need of acute in-hospital treatment, were eligible. Of these patients, 139 patients were included in the analysis, 72 allocated to the CGA unit group and 67 to the conventional care group. Mean age was 85 years and 65% were female. Intervention: Direct admittance to an acute elderly care unit with structured, systematic interdisciplinary CGA-based care, compared to conventional acute medical care via the emergency room. Measurements: The primary outcome was the satisfaction reported by the patients shortly after discharge from hospital. A four-item confidential questionnaire was used. Responses were given on a 4-graded scale. Results: The response rate was 61%. In unadjusted analyses, significantly more patients in the intervention group responded positively to the following three questions about the hospitalization: "Did you get the nursing from the ward staff that you needed?" (p=0.003), "Are you satisfied with the information you received on your diseases and medication?" (p=0.016), and "Are you satisfied with the planning before discharge from the hospital?" (p=0.032). After adjusted analyses by multiple regression, a significant difference in favor of the intervention remained for the first question (p=0.027). Conclusion: Acute care in a CGA unit with direct admission was associated with higher levels of patient satisfaction compared with conventional acute care via the emergency room.

  • 23.
    Sandman, Lars
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Broqvist, Mari
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Gustavsson, Erik
    Linköping University, Department of Medical and Health Sciences, Division of Health and Society. Linköping University, Faculty of Arts and Sciences.
    Arvidsson, Eva
    Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Health Sciences.
    Ekerstad, Niklas
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Vård som inte kan anstå: Tolkning i relation till den etiska plattformen och nationella modellen för öppna prioriteringar2014Report (Other academic)
    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.

  • 24.
    Sandman, Lars
    et al.
    Högskolan i Borås.
    Ekerstad, Niklas
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Lindroth, Kartrin
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
    Triage som prioriteringsinstrument på akutmottagning: en etisk analys av RETTS2012Report (Other academic)
    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.

  • 25.
    Åhlund, Kristina
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. NU Hospital Grp, Sweden.
    Bäck, Maria
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Sahlgrens University Hospital, Sweden.
    Öberg, Birgitta
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences.
    Ekerstad, Niklas
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. NU Hospital Grp, Sweden.
    Effects of comprehensive geriatric assessment on physical fitness in an acute medical setting for frail elderly patients2017In: Clinical Interventions in Aging, ISSN 1176-9092, E-ISSN 1178-1998, Vol. 12, p. 1929-1939Article in journal (Refereed)
    Abstract [en]

    Introduction: Frail elderly people often use emergency care. During hospitalization, physical decline is common, implying an increased risk of adverse health outcomes. Comprehensive Geriatric Assessment (CGA) has been shown to be beneficial for these patients in hospital care. However, there is very limited evidence about the effects on physical fitness. The aim was to compare effects on physical fitness in the acute care of frail elderly patients at a CGA unit versus conventional care, 3 months after discharge. Patients and methods: A clinical, prospective, controlled trial with two parallel groups was conducted. Patients aged $ 75 years, assessed as frail and in need of inpatient care, were assigned to a CGA unit or conventional care. Measurements of physical fitness, including handgrip strength (HS), timed up-and-go (TUG), and the 6-minute walk test (6-MWT) were made twice, at the hospital index care period and at the 3-month follow-up. Data were analyzed as the mean change from index to the 3-month follow-up, and dichotomized as decline versus stability/improvement in physical fitness. Results: In all, 408 participants, aged 85.7 +/- 5.4 years, were included. The intervention group improved significantly in all components of physical fitness. The controls improved in TUG and declined in HS and 6-MWT. When the changes were dichotomized the intervention group declined to a lesser extent; HS pamp;lt;0.001, 6-MWT pamp;lt;0.001, TUG pamp;lt;0.003. The regression analysis showed the following odds ratios (ORs) for how these outcomes were influenced by the intervention; HS OR 4.4 (confidence interval [CI] 95% 2.2-9.1), 6-MWT OR 13.9 (CI 95% 4.2-46.2), and TUG OR 2.5 (CI 95% 1.1-5.4). Conclusion: This study indicates that the acute care of frail elderly patients at a CGA unit is superior to conventional care in terms of preserving physical fitness at 3 months follow-up. CGA management may positively influence outcomes of great importance for these patients, such as mobility, strength, and endurance.

  • 26.
    Åhlund, Kristina
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Department of Physiotherapy, NU Hospital Group, Trollhättan, Sweden.
    Ekerstad, Niklas
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. Department of Research and Development, NU Hospital Group, Trollhättan, Sweden.
    Bäck, Maria
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Gothenburg, Sweden.
    Karlson, Bjorn W.
    Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Internal and Acute Medicine, NU Hospital Group, Trollhättan-Uddevalla, Sweden.
    Öberg, Birgitta
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences.
    Preserved physical fitness is associated with lower 1-year mortality in frail elderly patients with a severe comorbidity burden2019In: Clinical Interventions in Aging, ISSN 1176-9092, E-ISSN 1178-1998, Vol. 14, p. 577-586Article in journal (Refereed)
    Abstract [en]

    Introduction: Physical deterioration in connection with a care episode is common. The aim of this study was, in frail elderly patients with a severe comorbidity burden, to analyze 1) the association between physical fitness measurements and 1-year mortality and 2) the association between preserved physical fitness during the first three months after discharge from emergency hospital care and 1-year prognosis.

    Methods: Frail elderly patients (≥75 years) in need of inpatient emergency medical care were included. Aerobic capacity (six-minute walk test, 6MWT) and muscle strength (handgrip strength test, HS) were assessed during the hospital stay and at a three-month follow-up. The results were analyzed using multivariate Cox regression; 1) 0–12-month analysis and 2) 0–3-month change in physical fitness in relation to 1-year mortality. The analyses were adjusted for age, gender, comorbidity and frailty.

    Results: This study comprised 408 frail elderly hospitalized patients of whom 390 were evaluable (mean age 85.7 years, Charlson’s index mean 6.8). The three-month mortality was 11.5% and the 1-year mortality was 37.9%. After adjustments, the Cox-regression analysis showed that both 6MWT and HS were associated with 1-year mortality, HR6MWT 3.31 (95% CI 1.89–5.78, p<0.001) and HRHS2.39 (95% CI 1.33–4.27, p=0.003). The 0–3-month change in the 6MWT and the HS were associated with 1-year mortality, where patients who deteriorated had a poorer prognosis than those with improved fitness, HR6MWT 3.80 (95% CI 1.42–10.06, p=0.007) and HRHS 2.21 (95% CI 1.07–4.58, p=0.032).

    Conclusion: In frail elderly patients with a severe comorbidity burden, physical fitness in connection with emergency hospital care was independently associated with 1-year mortality. Moreover, a change in physical fitness during the first months after hospital care was important for the long-term prognosis. These results emphasize the importance of providing hospital care designed to prevent physical deterioration in frail elderly patients.

  • 27.
    Åhlund, Kristina
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. NU Hosp Grp, Sweden.
    Ekerstad, Niklas
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences. NU Hosp Grp, Sweden.
    Öberg, Birgitta
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences.
    Bäck, Maria
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Sahlgrens Univ Hosp, Sweden.
    Physical Performance Impairments and Limitations Among Hospitalized Frail Older Adults2018In: Journal of Geriatric Physical Therapy, ISSN 1539-8412, E-ISSN 2152-0895, Vol. 41, no 4, p. 230-235Article in journal (Refereed)
    Abstract [en]

    Background and purpose: Early rehabilitation is important for frail older adults due to reduced reserve capacity and physical fitness. To facilitate individualized rehabilitation programs, we need tools to make it possible to assess physical fitness in relation to frailty, instead of chronological age. The purpose of this study was, in a Swedish context, to describe measures of physical fitness in hospitalized frail older adults in relation to their degree of frailty. Methods: This was a cross-sectional study. A total of 408 frail older adults, mean age 86.6 years (75-99 years), in need of emergency medical inpatient care, were included in the NAL-Uddevalla (NU) hospital group in Sweden. During the hospital stay, physical fitness was assessed using 4 different tests: hand-grip strength, the Timed Up and Go Test, 5-time sit-to-stand test, and 6-minute walk test. In the analyses, the physical fitness outcomes were related to the degree of frailty using the FRail Elderly Support ResearcH group screening instrument and previously used cutoffs or age-related reference values for older adults. Results and Discussion: This study showed that most hospitalized frail older adults perform far lower than previously described age-related reference values relating to physical fitness. An increased degree of frailty contributes to reduced physical fitness in tests assessing strength and endurance. Conclusions: A frail-related screening instrument may be useful in the evaluation of physical fitness in hospitalized frail older adults and may facilitate the development of realistic, individualized rehabilitation programs beneficial to an early start on the emergency medical ward.

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