Point-of-care technology to avoid acute hospital admissions among older adults

Research output: ThesisPh.D. thesis

Abstract

Background
Diagnosing acute disease in older adults is often challenging due to atypical disease presentation, leading to delayed recognition and severe outcomes like loss of independence, increased hospital admissions, and higher mortality. Timely diagnosis and treatment are important to mitigate these adverse health outcomes and reduce healthcare system strain. Point-of-care technologies (POCT) provide rapid bedside results and can extend diagnostic capabilities to patients’ homes. In Denmark, all municipalities have been obliged since 2018 to implement Acute Community Health Care Services aimed at reducing avoidable hospital admissions by offering in-home assessments for older adults. Acute community nurses (ACNs) conduct these assessments using basic POCT, but a more comprehensive set of tools could enhance diagnostics. Integrating extended POCT into ACNs’ in-home assessments and communicating results to primary care physicians is hypothesised to improve diagnostics and clinical decision-making, potentially reducing hospital admissions and adverse health outcomes.

Aim and Objectives
This PhD thesis examines the impact of extended POCT during in-home assessments of older adults on various health outcomes, organised into three studies:

1. Study I aimed to develop and assess the feasibility and potential clinical impact of an intervention, resulting in a pilot and feasibility study (Paper 1) and a protocol paper (Paper 2).
2. Study II determined ACNs’ diagnostic accuracy for using focused lung ultrasound (FLUS) compared to a blinded FLUS expert, documented in a diagnostic accuracy study (Paper 3).
3. Study III assessed extended POCTs effect on hospital admissions and other adverse health outcomes, detailed in a paper on an open-labelled randomised controlled trial (RCT) (Paper 4). 

Results
Study I, the pilot and feasibility study, conducted in 2021, developed and tested an intervention consisting of extended POCT (FLUS, blood analysis for electrolytes, creatinine, white blood cell differential count, nasopharyngeal swab for PCR for upper respiratory pathogens, and urine samples for flow-cytometry) (Paper 1). The study found that the overall study design for the planned randomised controlled trial was feasible, and in-home blood analyses and FLUS have potential clinical impact by identifying acute conditions earlier in the diagnostic process. Results from the pilot and feasibility study guided the development of a protocol for an individualised randomised controlled trial (Paper 2).  

Study II (Paper 3) was embedded within the randomised trial, and analysed FLUS scans from 291 participants in the intervention group. This showed a high diagnostic accuracy for pleural effusions (sensitivity 93.9% (91.2-96.6 95% CI) and specificity 94.2% (91.5-96.9 95% CI)), and interstitial syndrome (sensitivity 83.3% (79.0-87.6 95% CI) and specificity 98% (96.6-99.7 95% CI)). The sensitivity for pneumonia had a lower diagnostic accuracy (sensitivity 41.6% (36.0- 47.3 95% CI) and specificity 79.6% (75.0-84.2 95% CI)).

The open-labelled individual randomised controlled trial, Study III (Paper 4), was conducted from October 2022 to November 2023. The study included 623 participants, with a mean age of 82.5 (SD ±7.8); 313 in the control group and 310 in the intervention group. While extended POCT did not reduce hospital admission (RR 0.99, 95% CI 0.81-1.21), it significantly reduced mortality in the intervention group (11 deaths out of 310) compared to control group (25 deaths out of 313) during 30 days follow-up (RR 0.44, 95% CI 0.22-0.88). There were no differences between groups in amount of home care (RR 1.04, 95% CI 0.89- 1.21), use of skilled nursing home facilities (RR 0.89, 95% CI 0.41 to 1.94), rereferrals to the acute community health care service (RR 0.97, 95% CI 0.75- 1.25), or number of contacts to the primary care physician (IRR 0.96, 95% CI 0.84-1.09) at 30 days follow-up.

Conclusion
Implementing extended POCT during in-home assessments of older adults is feasible and promising for early diagnosis and prompt clinical decision-making. FLUS, in the hands of ACNs, yields high diagnostic accuracy in detecting pleural effusion and interstitial syndrome, thereby potentially enhancing clinical decision-making for respiratory conditions. While extended POCT did not reduce hospital admissions among older adults, it reduced mortality rates without increasing primary health care usage, underscoring its value in primary care settings. Further research is required to replicate these findings, assess cost-effectiveness of extended POCT during in-home assessment, and users’ perception of extended POCT. 
Translated title of the contributionUdvidet hjemmeundersøgelser til forebyggelse af indlæggelse blandt ældre
Original languageEnglish
Awarding Institution
  • University of Southern Denmark
Supervisors/Advisors
  • Andersen-Ranberg, Karen, Principal supervisor
  • Laursen, Christian Borbjerg, Co-supervisor
  • Jarbøl, Dorte Ejg, Co-supervisor
  • Rosenvinge, Flemming, Co-supervisor
Date of defence27. Sept 2024
Publisher
DOIs
Publication statusPublished - 13. Aug 2024

Note re. dissertation

Print copy of the thesis is restricted to reference use in the library. 

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