Loss of health related quality of life following low-trauma fractures in the elderly

BACKGROUND

To estimate the long-term change in health related quality of life (HRQoL) following low-trauma fractures among individuals receiving home care (HC) services or living in long-term care (LTC) facilities using linked healthcare administrative data from Ontario, Canada.

METHODS

HRQoL was estimated using the Health Utility Index (HUI-2) with the InterRai Minimum Data Set (MDS), a mandatory questionnaire for LTC and HC in the province of Ontario (population 14 million). The HUI-2, a validated HRQoL instrument, allows the calculation of health utility where 0 represents death and 1 the best imaginable health state. For reference, the HUI-2 utility value for Canadians aged 80-84 years is 0.61 and the minimal clinically important difference is 0.03. The MDS was linked to Ontario acute care databases for fiscal years 2007-2011 to identify low-trauma fractures using ICD-10-CA codes. Regression models were used to identify predictors of change in HRQoL from pre-fracture levels to 3 years post fracture for several populations. Low-trauma fractures included hip, humerus, vertebral, wrist, multiple and other.

RESULTS

Twenty-three thousand six-hundred fifty-five unique patients with low-trauma fractures were identified with pre- and post-fracture HRQoL assessments, of which 5057 individuals had at least 3 years of follow-up. Compared to patients receiving HC services (N = 3303), individuals residing in LTC (N = 1754) were older, taking more medications, and had more comorbidities. LTC patients had more hip fractures (49 % of total versus 29 %). For all fracture types, HRQoL decreased immediately following fracture. Although levels rebounded after the first month, HRQoL up to 36 months never returned to pre-fracture levels even for non-hip fracture. For both HC and LTC cohorts, clinically important and statistically significant decreases in HUI-2 utility scores were observed 36 months post fracture. Of the 6 HUI-2 domains, mobility had the largest impact on change in HRQoL. Regression analysis indicated that living with a musculoskeletal disorder or a neurological condition and living in LTC were associated with greater decrements in utility following a fracture.

CONCLUSIONS

Based on the analysis of one of the largest studies on HRQoL to date, among individuals living in LTC facilities or receiving HC services, fractures have a significant permanent impact on HRQoL up to 3 years following fracture.

Frailty as a Predictor of Institutionalization Among Adults With Intellectual and Developmental Disabilities

Adults with intellectual and developmental disabilities (IDD) frequently become frail earlier than the general population, resulting in higher care needs. This population is at risk for institutionalization, or re-institutionalization, into long-term care (LTC). Using a retrospective cohort design to follow 3,034 individuals (18-99 years) living in Ontario, Canada, and assessed with the Resident Assessment Instrument-Home Care, individuals were characterized with a frailty index (FI) for persons with IDD. Survival analyses determined differences in rates of admission to LTC and survival in the community. Frail individuals had greater rates of admission than non-frail individuals, adjusted HR = 2.19, 95% CI [1.81, 2.64]. The FI predicts institutionalization.

Trend in Cardiologia Riabilitativa

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[Relations with emergency medical care and primary care doctor, home health care]

Medical care for an ultra-aging society has been shifted from hospital-centered to local community-based. This shift has yielded the so-called Integrated Community Care System. In the system, emergency medical care is considered important, as primary care doctors and home health care providers play a crucial role in coordinating with the department of emergency medicine. Since the patients move depending on their physical condition, a hospital and a community should collaborate in providing a circulating service. The revision of the medical payment system in 2014 clearly states the importance of "functional differentiation and strengthen and coordination of medical institutions, improvement of home health care". As part of the revision, the subacute care unit has been integrated into the community care unit, which is expected to have more than one role in community coordination. The medical fee has been set for the purpose of promoting the home medical care visit, and enhancing the capability of family doctors. In the section of end-of-life care for the elderly, there have been many issues such as reduction of the readmission rate and endorsement of a patient's decision-making, and judgment for active emergency medical care for patient admission. The concept of frailty as an indicator of prognosis has been introduced, which might be applied to the future of emergency medicine. As described above, the importance of a primary doctor and a family doctor should be identified more in the future; thereby it becomes essential for doctors to closely work with the hospital. Advancing the cooperation between a hospital and a community for seamless patient-centered care, the emergency medicine as an integrated community care will further develop by adapting to an ultra-aging society.

Home treatment in preventing hospital admission for moderate and severe mentally ill people

A Home Treatment team was compared with a Psychiatric Emergency Department (PED) on preventing hospitalization among two cohorts of 448 patients matched by diagnosis, sex, and age. The logistic regression showed that HT people were 4.6 times less likely to be admitted than those from PED.

Expectations about future use of long-term services and supports vary by current living arrangement

Most Americans know little about options for long-term services and supports and underestimate their likely future needs for such assistance. Using data from the 2012 National Health Interview Survey, we examined expectations about future use of long-term services and supports among adults ages 40-65 and how these expectations varied by current living arrangement. We found differences by living arrangement in expectations about both future need for long-term services and supports and who would provide such care if needed. Respondents living with minor children were the least likely to expect to need long-term services and supports and to require paid care if the need arose. In contrast, respondents living alone were the most likely to expect that it was "very likely" that they would need long-term services and supports and to rely on paid care. Overall, we found a disconnect between expectations of use and likely future reality: 60 percent of respondents believed that they were unlikely to need long-term services and supports in the future, whereas the evidence suggests that nearly 70 percent of older adults will need them at some point. These findings both underscore the need for programs that encourage people to plan for long-term services and supports and indicate that information about living arrangements can be useful in developing and targeting such programs.

Getting some insight into the home care nursing service in Croatia

Croatia, as the other Western societies are facing with the increasing share of the population over 65 years and consequently with more care-dependant people. Community living and care, including home care, is stimulating not just because of efficiency of care but also because of the peopleis preferences that home is a place of emotional and physical associations, memories and comfort. The aim of the study was to see if there is lack or surplus of Home care nursing services within the health care system. Data from the Croatian Health Insurance Fond Data base were analysed. The results of this research indicated that the number of inhabitants per one home nurse and physiotherapist contracted by the Croatian Health Insurance Fond was below the defined Standard. The average number of inhabitants per one home care nurse contracted by the CHIF for 2013 was 3373.9 compared to 3500 defined by the Standard. There was found also the huge regional differences in their distributions. The average number of contracted home physiotherapists for the same year was 9805.2 in comparison to the Standard, which was setup at the level of 15000 inhabitants per one physiotherapist.

[Collaborative and home based treatment for older adults with depression: a review of the literature]

BACKGROUND

Due to the demographic development depressive disorders in old age are becoming a central and urgent healthcare challenge.

OBJECTIVES

The article reviews effective approaches towards treatment of depression in the elderly.

METHODS

A literature review of complex interventions improving depression care was carried out.

RESULTS

Robust evidence exists for the use of collaborative care models which incorporate collaboration between mental health and medical providers in the primary care setting (e.g. general practitioners and specialists), regular monitoring, case management, and evidence-based treatment. Staged treatment approaches seem to be appropriate by which initially use treatment strategies of low intensity. For patients with limited mobility, home-based approaches have proven to be particularly practical and effective.

CONCLUSION

Multidisciplinary and multimodal treatment approaches represent an effective and efficient way of healthcare provision for late life depression. In Germany, only few initiatives inspired by successful international models have so far been identified.

Home based exercise to improve turning and mobility performance among community dwelling older adults: protocol for a randomized controlled trial

BACKGROUND

Turning is a common activity for older people, and is one of the activities commonly associated with falls during walking. Falls that occur while walking and turning have also been associated with an increased risk of hip fracture in older people. Despite the importance of stability during turning, there has been little focus on identifying this impairment in at risk older people, or in evaluating interventions aiming to improve this outcome. This study will evaluate the effectiveness of a 16 week tailored home based exercise program in older adults aged (50 years and above) who were identified as having unsteadiness during turning.

METHODS/DESIGN

A single blind randomized controlled trial will be conducted, with assessors blind to group allocation. Study participants will be aged 50 years and above, living in the community and have been identified as having impaired turning ability [outside of age and gender normal limits on the Step Quick Turn (180 degree turn) task on the Neurocom® Balance Master with long plate]. After a comprehensive baseline assessment, those classified as having balance impairment while turning will be randomized to intervention or control group. The intervention group will receive a 16 week individualized balance and strength home exercise program, based on the Otago Exercise Program with additional exercises focused on improving turning ability. Intervention group will attend four visit to the assessment centre over 16 weeks period, for provision, monitoring, modification of the exercise and encourage ongoing participation. Participants in the control group will continue with their usual activities. All participants will be re-assessed on completion of the 16 week program. Primary outcome measures will be the Step Quick Turn Test and Timed-Up and Go test. Secondary outcomes will include other clinical measures of balance, psychological aspects of falls, incidence of falls and falls risk factors.

DISCUSSION

Results of this study will provide useful information for clinicians on the types of exercises to improve turning ability in older people with increased falls risk and the effectiveness of these exercises in improving outcomes.

TRIAL REGISTRATION

ACTRN12613000855729.

Transitions between care settings in dementia: are they relevant in economic terms?

OBJECTIVES

This study was performed to assess the economic effect of interventions affecting transitions between dementia care settings in Germany.

METHODS

A Markov-model that models the course of dementia with respect to typical care setting transitions was derived. Model data and parameters were retrieved by literature reviews. A deterministic and probabilistic sensitivity analysis was conducted to account for parameter uncertainty.

RESULTS

In the base case, the expected present value of remaining lifetime costs is €25,326 for each cohort member. As a function of effectiveness, pharmaceutical interventions may reduce the costs by 2% to 13% and psychosocial interventions come with savings of 1% to 10%. A structural intervention-promoting group living as a substitute for nursing home care increases costs by 2% to 8%. Sensitivity analyses indicate high variance and variability of results, as well as valuation of informal care being a crucial parameter.

CONCLUSIONS

There are economic benefits of delayed transitions to institutional settings, especially from the viewpoint of statutory care insurances, but these do unlikely exceed intervention costs. Thus, further intervention effects should be considered. Ultimately, concentrating research on preventive and protective factors of dementia could lead to an efficient intervention from every perspective.