Reducing overtreatment of older people near the end of life: the role of hospitals in a culture change

Magnolia Cardona, Ebony Lewis, Hatem Alkhouri, Justin Clark, Paulie Stehlik, Nigel Lovell

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Frail elderly people with comorbidities, repeatedly use hospitals in their last year of life. Our research program aims to reduce overtreatment of these patients. We present our results thus far.

We conducted two systematic reviews; developed a prediction checklist (CriSTAL) to estimate risk of death; undertook two prospective validation studies of the checklist; led a national pilot consultation with emergency staff (ED); and completed universal frailty screening in emergency departments.

Systematic review #1 (38 studies with 1.2 million subjects) revealed that a third of older patients in their last 6-months of life are subjected to non-beneficial treatments. Systematic review #2 (16 eligible studies of 491,697 elderly) identified medically inappropriate hospitalisations ranged from 2.0% to 67.0%, and socially-driven admissions prompted by shortage of community services.
CriSTAL validation in ~3,000 subjects (4 countries) yielded high predictive short-term death accuracy (AUROC 79.0%-82.5%). The ED staff consultation supported nurse-led interventions to manage frailty. Frailty prevalence measured by 3 frailty instruments varied (9.7%-43.7%) but frailty consistently and independently predicted poor outcome irrespective of instrument (OR (95%CI): 2·58 (1·72–3·86); 2.20 (1·55–3.12); 2.46 (1.16–5.05)).
Our future research to reduce low-value care includes building electronic decision support for terminal illness; new service models including systematic screening for risk of death and pre-frailty; and determining effective deprescribing strategies near end-of-life.

A hospital culture of less aggressive interventions can enhance the end-of-life experience through identifying frailty and impending death early, initiating end-of-life discussions, and providing coordinating care pathways that meet the demands of the ageing population.
Original languageEnglish
Number of pages1
Publication statusPublished - 2018
EventThe Gold Coast Health Research Week 2018 - Gold Coast, Australia
Duration: 14 Nov 201815 Nov 2018


ConferenceThe Gold Coast Health Research Week 2018
CityGold Coast
OtherThe annual Gold Coast Health Research Week Conference was held on Wednesday 14 and Thursday 15 November at Gold Coast University Hospital, as part of Research and Quality Week.

Attendees included a diverse mix of our staff and university partners, and highlights were lightning talk sessions, a university partnerships evening, and interstate/international guest presentations for our keynote and Medical Grand Rounds.

The event culminated in a closing session celebrating our annual grant scheme recipients and conference award winners.
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