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Admission Diagnosis of “FTT” vs. Discharge Diagnosis in Older Adults on a Clinical Teaching Medicine Service in
a Tertiary Care Teaching Hospital
Kristine KimPreceptor: Dr. Martha SpencerPGY 5 Geriatric Medicine Fellow
UBC Geriatric MedicineEmail: [email protected]
Presenter Disclosure• Faculty: Kristine Kim• Relationships with financial sponsors: None
Disclosure of Financial Support• I have no financial disclosures• I have no conflicts of interest
Failure To Thrive
• FTT associated w/ weight loss, PO intake, poor nutrition and inactivity (NIA)
• NOT normal aging
• Associated with • Morbidity• Mortality Rates• Medical Care/Readmission• Institutionalization Kumeliauskas L et al, 2013, Berkman et al, 1989,
Egbert A.M, 1996, Sarkisian 1996
Current Thoughts – A quick feeler
“Better than...Circling...The..Drain”
"The Dwindles“ “Dwindling”
“I prefer Wasting Syndrome. The patient will
need a medical and neurocognitive evaluation in hope to find a reversible
condition. Palliative referral is a common outcome.”
“or ‘piss poor protoplasm’ ”
“It is to avoid the sort of workup someone our age would deserve and would get. I would not give that DX to the average 70 year old. In a 90 year old with chronic problems who took a sudden turn, I would rule out the obvious easy to fix things and then use FTT. Often would suspect occult malignancy, but without some mass somewhere, need a hospice diagnosis.”
Goals of Study
• To determine the disparities between the initial diagnosis of FTT and final discharge diagnosis in a clinical teaching medical service.
• We propose the term FTT is being utilized when an alternative diagnosis for an underlying medical condition is determined as a
diagnosis prior to discharge.
MethodsSubjects Recruited
(n= 94)
Subjects included (n=76)
Subjects Eligible(n=74)
Excluded:‐ Not admitted to CTU/FM
(n= 1) ‐ Admitted prior Jan 1 2016
(n=1)
Excluded:‐ Concurrent Acute
Admission Diagnosis (n= 18)Retrospective cohort study Tertiary university hospital (St. Paul’s Hospital)
Methods
• Electronic Chart Review• Descriptive statistical analysis (means, proportions, ranges)
TABLE 1: Demographics
Age (years)Number of patients % of patients
65‐74 22 29.7%75‐84 27 36.5%85+ 25 33.8%
Range (y) 65‐100Mean ± SD (y) 80 ± 9.2
GenderFemale 33 45%Male 41 55%
TABLE 2: Results
Length of Stays (Days)No.
patients%
patients 0 ‐ 14 37 50.0%15‐30 24 32.4%30‐45 9 12.2%45‐60 3 4.0%>60 1 1.4%
Multimorbidity0 ‐ 5 20 27.0%6 ‐ 10 38 51.4%More than 10 16 21.6%
Geriatric ConsultsYes 15 20.3%No 59 79.7%
P=0.03
P<0.01
KK1
Slide 10
KK1 Kristine Kim, 4/4/2018
Acute vs Chronic:77% (65.8%‐86%, CI 95%) – No less than 2/3 still have an acute medical illness with 95% confidence
TABLE 3: Presentation
PresentationNumber of patients % of patients
Acute only 57 77.0%Chronic only 15 20.3%Mixed 2 2.7%
Diagnosis
Acute Reversible
Medication s/e (10)Infectious disease (12)Cardiac Disease (11)
Respirology (4)GI (3)
Endo (6)Renal (9)
Depression (4)Delirium (5)Anxiety (1)
Acute Non‐reversible
Malignancy –new/metastasis (9)
Fractures (9)
Chronic
Dementia (9)Neurological Disorder (2)
Deconditioning (5)Malignancy ‐Sx (2)
Diagnosis
Acute Reversible
Medication s/e (10)Infectious disease (12)Cardiac Disease (11)
Respirology (4)GI (3)
Endo (6)Renal (9)
Depression (4)Delirium (5)Anxiety (1)
Acute Non‐reversible
Malignancy –new/metastasis (9)
Fractures (9)
Chronic
Dementia (9)Neurological Disorder (2)
Deconditioning (5)Malignancy ‐Sx (2)
Diagnosis
Acute Reversible
Medication s/e (10)Infectious disease (12)Cardiac Disease (11)
Respirology (4)GI (3)
Endo (6)Renal (9)
Depression (4)Delirium (5)Anxiety (1)
Acute Non‐reversible
Malignancy –new/metastasis (9)
Fractures (9)
Chronic
Dementia (9)Neurological Disorder (2)
Deconditioning (5)Malignancy ‐Sx (2)
17.6 % (9.7%‐28.2%, CI 95%)
FEWER than 1/3 contain FTT in discharge diagnosis
17.6%
82.4%
FTT in Discharge Diagnosis
FTT included
Acute Medical Diagnosis
Discussion
‐Misuse of FTT on admission in older adults• High rate of acute medical illnesses• High degree of multimorbidity• ?Delay diagnosis/medical care
‐ Further study needed• Reasons for using FTT (ie focus groups ‐ residents/ED staff)• Outcomes: morbidity/mortality• Intervention: education (residents/ED staff)
Strengths and Limitations
‐ Strengths:• Builds on current literature• Tertiary Hospital in Canada• Practical goal of leading to practice change
‐ Limitations:• Systemic bias – limited algorithmic accessibility• Small sample size• Limited to internal medicine and family medicine
Special Thanks
• CGS (host)• Dr. Martha Spencer (PI)• Elena Szefer (Statistician)• Darby Thompson (Statistician)
Thank youQuestions?
