Continuity of primary care and emergency department utilization among elderly people

Impact of family physician integrated care program on decreasing utilization of emergency department visit and hospital admission: a population-based retrospective cohort study

BACKGROUND

Hospital admission and emergency department(ED) visits are a massive burden in medical expenditures. In 2003, the Taiwanese government developed Family Physician Integrated Care Program (FPIC) to increase the quality of primary care and decrease medical expenditures. This study's goals were to determine whether FPIC decreased hospital admissions and ED visits and identify the factors influencing the outcomes.

METHODS

This nationwide retrospective cohort study was conducted for the period between 2006 and 2013 by using data obtained from the Taiwan National Health Insurance Research Database. A total of 68,218 individuals were divided into those who joined FPIC and those who did not. We used propensity score matching at a ratio of 1:1 and logistic regression with the generalized estimating equation (GEE) model having a difference-in-difference design to investigate the effects of the FPIC policy on hospital admissions and ED visits in 7 years.

RESULTS

Using logistic regression with the GEE model with the difference-in-difference design, we found no reduction in ED visits and hospital admissions between the two groups. The participants' risk of hospital admissions increased in the first year after joining FPIC (OR: 1.11, 95% CI: 1.03-1.20, P < .05). However, participants who joined FPIC showed an 8% lower risk of hospital admissions in the sixth and seventh years after joining FPIC, compared with those who did not join FPIC (OR: 0.92, 95% CI: 0.85-1.00, P < .05).

CONCLUSIONS

FPIC in Taiwan could not decrease medical utilization initially but might reduce hospital admissions in the long term.

Combined impacts of multimorbidity and mental disorders on frequent emergency department visits: a retrospective cohort study in Quebec, Canada

BACKGROUND

Multimorbidity and mental disorders are independently associated with frequent visits to the emergency department (≥ 3 visits/yr), but their interaction has been little studied. We aimed to measure the interaction between mental disorders and physical multimorbidity with respect to frequent visits to the emergency department.

METHODS

We conducted a population-based cohort study of adults in Quebec from 2012 to 2016, using the Quebec Integrated Chronic Disease Surveillance System. We assessed multimorbidity as the number of physical illnesses and mental disorders as serious (psychotic or bipolar disorders), common or absent, using data from 2012 to 2014. We counted emergency department visits from 2014 to 2015. We used logistic regression to estimate interaction on frequent visits to the emergency department from 2 perspectives: of public health (additive scale as differences in risk) and of individual patients (multiplicative scale as odds ratios).

RESULTS

Each additional physical illness was associated with a greater increase in the absolute risk of frequent visits to the emergency department for people with mental disorders. Between 0 and ≥ 4 physical conditions, the absolute risk increased more for individuals with serious mental disorders (16.2%) than common (15.3%) or no disorders (11.4%). On the relative scale, for people with no mental disorders and ≥ 4 physical conditions, odds of frequent visits to the emergency department were 6.2 (95% confidence interval [CI] 6.08-6.35) times the odds for people with no physical conditions. For individuals with common and serious mental illnesses, corresponding odds ratios were 4.75 (95% CI 4.60-4.90) and 3.7 (95% CI 3.18-3.57), respectively.

INTERPRETATION

Mental disorders interact with physical multimorbidity to increase the odds of frequent visits to the emergency department. More research is needed on interventions that promote high-quality care for mental illness, especially in the context of physical multimorbidity.

Inter- and intra-provincial variation in screen-detected breast cancer across five Canadian provinces: a CanIMPACT study

OBJECTIVE

Breast cancer screening aims to identify cancers in early stages when prognosis is better and treatments less invasive. We describe inter- and intra-provincial variation in the percentage of screen-detected cases under publicly funded healthcare systems and factors related to having screen- vs non-screen-detected breast cancer across five Canadian provinces.

METHODS

Women aged 40+ diagnosed with incident breast cancer from 2007 to 2012 in five Canadian provinces were identified from their respective provincial cancer registries. Standardized provincial datasets were created linking screening, health administrative, and claims data. Province-specific logistic regression models were used to evaluate the association of demographic and healthcare utilization factors in each province with the odds of screen-detected cancer.

RESULTS

There was significant inter- and intra-provincial variation by age. Screen detection ranged from 42% to 52% in ages 50-69 but women aged 50-59 had approximately 4-8% lower screen detection than those aged 60-69 in all provinces. Screening associations with income quintile and rurality varied across provinces. Those least likely to be screen-detected within a province were consistently in the lowest income quintile; OR ranged from 0.62-0.89 relative to highest income quintile/urban patients aged 50-69. Lack of visits to primary care 30 months prior to diagnosis was also consistently associated with lower odds of screen detection (OR range, 0.37-0.76).

CONCLUSION

Breast cancer screen detection rates in the Canadian provinces examined are relatively high. Associations with income-rurality indicate a need for greater attention and/or targeted outreach to specific communities and/or provincial regions to improve access to breast cancer screening services intra-provincially.

Risk of falls and fear of falling in older adults residing in public housing in Ontario, Canada: findings from a multisite observational study

Background

Falls in older adults is a widely researched topic. However, older adults residing in public housing are a vulnerable population that may have unique risk factors for falls. This study aims to describe the prevalence and risk factors for falls, fear of falling, and seeking medical attending for falls in this population.

Methods

Sociodemographic and health-related data was collected as part of a community-based health assessment program with older adults in public housing. Three pre-screening questions identified individuals at potential risk for falls; individuals who screened positive performed the objective Timed Up and Go (TUG) test. Logistic regression was used to evaluate risk factors for four outcome variables: falls in the past year, seeking medical attention for falls, fear of falling, and objectively measured fall risk via TUG test.

Results

A total of 595 participants were evaluated, of which the majority were female (81.3%), white (86.7%), did not have a high school diploma (50.0%), and reported problems in mobility (56.2%). The prevalence of falls in the past year was 34.5%, seeking medical attention for falls was 20.2% and fear of falling was 38.8%. The TUG test was completed by 257 participants. Notably, males had significantly reduced odds of seeking medical attention for a fall (OR = 0.50, 95%CI 0.25–0.98) and having a fear of falling (OR = 0.42, 95%CI 0.24–0.76); daily fruit and vegetable consumption was associated with decreased odds of having a fall in the past year (OR = 0.55, 95%CI 0.37–0.83), and alcohol consumption was associated with increased odds of fear of falling (OR = 1.72, 95%CI 1.03–2.88).

Conclusion

Older adults residing in public housing have unique risk factors associated with social determinants of health, such as low fruit and vegetable consumption, which may increase their risk for falls. The findings of this study can be used to inform falls interventions for this population and identify areas for further research.

Factors associated with inappropriate use of emergency departments: findings from a cross-sectional national study in France

BACKGROUND

Inappropriate visits to emergency departments (EDs) could represent from 20% to 40% of all visits. Inappropriate use is a burden on healthcare costs and increases the risk of ED overcrowding. The aim of this study was to explore socioeconomic and geographical determinants of inappropriate ED use in France.

METHOD

The French Emergency Survey was a nationwide cross-sectional survey conducted on June 11 2013, simultaneously in all EDs in France and covered characteristics of patients, EDs and counties. The survey included 48 711 patient questionnaires and 734 ED questionnaires. We focused on adult patients (≥15 years old). The appropriateness of the ED visit was assessed by three measures: caring physician appreciation of appropriateness (numeric scale), caring physician appreciation of whether or not the patient could have been managed by a general practitioner and ED resource utilisation. Descriptive statistics and multilevel logistic regression were used to examine determinants of inappropriate ED use, estimating adjusted ORs and 95% CIs.

RESULTS

Among the 29 407 patients in our sample, depending on the measuring method, 13.5% to 27.4% ED visits were considered inappropriate. Regardless of the measure method used, likelihood of inappropriate use decreased with older age and distance from home to the ED >10 km. Not having a private supplementary health insurance, having universal supplementary health coverage and symptoms being several days old increased the likelihood of inappropriate use. Likelihood of inappropriate use was not associated with county medical density.

CONCLUSION

Inappropriate ED use appeared associated with socioeconomic vulnerability (such as not having supplementary health coverage or having universal coverage) but not with geographical characteristics. It makes us question the appropriateness of the concept of inappropriate ED use as it does not consider the distress experienced by the patient, and segments of society seem to have few other choices to access healthcare than the ED.

The association between home care visits and same-day emergency department use: a case-crossover study

BACKGROUND

The extent to which home care visits contribute to the delay or avoidance of emergency department use is poorly characterized. We examined the association between home care visits and same-day emergency department use among patients receiving publicly funded home care.

METHODS

We conducted a population-based case-crossover study among patients receiving publicly funded home care in the Hamilton-Niagara-Haldimand-Brant region of Ontario between January and December 2015. Within individuals, all days with emergency department visits after 5 pm were selected as cases and matched with control days from the previous week. The cohort was stratified according to whether patients had ongoing home care needs ("long stay") or short-term home care needs ("short stay"). We used conditional logistical regression to estimate the association between receiving a home care visit during the day and visiting the emergency department after 5 pm on the same day.

RESULTS

A total of 4429 long-stay patients contributed 5893 emergency department visits, and 2836 short-stay patients contributed 3476 visits. Receiving a home care nursing visit was associated with an increased likelihood of visiting the emergency department after 5 pm on the same day in both long-stay (odds ratio [OR] 1.32, 95% confidence interval [CI] 1.17-1.48) and short-stay patients (OR 1.22, 95% CI 1.07-1.39). Stronger associations were observed for less acute visits to the emergency department. No associations were observed for other types of home care visits.

INTERPRETATION

Patients receiving home care were more likely to visit the emergency department during the evening on days they received a nursing visit. The mechanism of the association between home care visits and same-day emergency department use and the extent to which same-day emergency department visits could be prevented or diverted require additional investigation.

Continuity of Care, Follow-Up Care, and Outcomes among Breast Cancer Survivors

This retrospective cohort study examined the effects of care continuity on the utilization of follow-up services and outcome of breast cancer patients (stages I-III) in the post-treatment phase of care. Propensity score matching and generalized estimation equations were used in the analysis of data obtained from national longitudinal databases. The continuity of care index (COCI) was calculated separately for primary care physicians (PCP) and oncologists. Our results revealed that breast cancer survivors with a higher oncology COCI were more likely than those with a lower oncology COCI to use mammography or breast ultrasound during the follow-up period (OR = 1.26, 95% CI: 1.19-1.32; OR = 1.12, 95% CI: 1.06-1.18; respectively). In terms of health outcomes, a higher oncology COCI was associated with a lower likelihood of hospitalization (OR = 0.78, 95% CI: 0.71-0.85) and emergency department use (OR = 0.88, 95% CI: 0.82-0.95). A higher PCP COCI was also associated with a lower likelihood of hospitalization (OR = 0.77, 95% CI: 0.70-0.85) and emergency department use (OR = 0.75, 95% CI: 0.68-0.82). Overall, this study determined that ambulatory care continuity is positively associated with the likelihood of using recommended follow-up care services and negatively associated with adverse health events among breast cancer survivors.

Evolution over 11 years of the characteristics of walk-in patients at the emergency department of a university hospital in Brussels

Walk-in patients who do not require urgent treatment at an emergency department (ED) are a known and long-standing problem.

This study aims to investigate the characteristics of walk-in patients visiting the ED over time.

During four days in June 2012, all walk-in patients attending the ED of the University Hospital Brussels between 8 AM and 11 PM were recorded. A similar registration took place in the same ED in June 2001. Patients completed a questionnaire about their characteristics and the reason for the encounter. Data of both study periods were compared.

The mean age of the patients attending the ED was significantly lower in 2001 (40.9 years) than in 2012 (43.9 years) (p=0,02). In 2001, 81% of the participants had Belgian nationality, but in 2012 this proportion increased to 90% (p=0.008). In 2001 as well as in 2012, 21% of the participants had a referral from their family physician (FP) (p=0.9). The proportion of patients that were aware that FP could also handle some emergencies increased from 17% in 2001 to 29% in 2012 (p=0.003). More patients had complaints that begun less than 24h before they attended the ED (48% in 2001 and 58% in 2012) (p=0.03).

The walk-in patients at the ED are getting slightly older and are attending the ED faster after the onset of the complaints. More patients judge their complaints as urgent. However, more patients are getting aware that FP also could handle some emergencies.

The burden of preventable hospitalizations before and after implementation of the health transformation plan in a hospital in west of Iran

Background:

Increased number of preventable hospitalizations (PHs) for ambulatory care sensitive conditions (ACSCs) represents less efficiency and low access to outpatient and primary health care, leading to waste of health system resources.

Aim:

The purpose of this study is to assess the quality of outpatient and primary health care using the rate of PHs for ACSCs and to estimate the economic burden of ASCS before and after the implementation of the health transformation plan (HTP) in Iran.

Methods:

This research was a before–after quasi-experimental study. The study population included all patients hospitalized in the largest general hospital of Kurdistan province with five diseases such as asthma, diabetes, hypertension, congestive heart failure, and chronic obstructive pulmonary disease in 2014 (before the implementation of the HTP) and 2015 (after the implementation of the HTP). Data were analyzed by SPSS v.20 using Chi-square test.

Findings:

Total number of hospitalizations before and after the implementation of the HTP was 1501 and 1405, respectively. Moreover, the proportion of PHs in all types of the hospital admissions before and after the implementation of the HTP was 47% and 49%, respectively. There was no statistically significant difference between the number of PHs before and after the HTP. In total, PHs imposed 885 798 US$ and 9920 bed-days on health system before and after the implementation of the HTP.

Conclusion:

Despite the previous expectations of policy makers for improving quality, efficiency, and access to primary health care through implementation of the HTP, proportion of PHs is considerable and it imposes a lot of costs and bed-days on the health system both before and after the HTP.

Effect of primary health care reforms in the province of Newfoundland and Labrador: Interrupted time-series analysis

OBJECTIVE

To examine the effects of primary health care (PHC) reforms in the Canadian province of Newfoundland and Labrador on ambulatory care-sensitive (ACS) hospitalization rates and mortality.

DESIGN

Interrupted time-series analysis of administrative data.

SETTING

All communities in the province of Newfoundland and Labrador were divided into 3 groups: rural reform (n = 69 143), rural nonreform (n = 228 914), and urban nonreform (n = 197 012). No urban communities introduced PHC reforms.

PARTICIPANTS

All residents of the province who held a valid health card and did not change their address during the 2001-2009 study period were included. Individuals were assigned to 1 of the 3 study groups based on community of residence.

MAIN OUTCOME MEASURES

Hospitalization rates for ACS conditions, hospitalization rates for control conditions, and ACS-related mortality were compared using interrupted time-series models.

RESULTS

Results are reported as rate ratio or odds ratio (OR) (95% CI). In rural reform and rural nonreform communities, there was a decreasing trend in ACS hospitalization rates that preceded reforms (rate ratio of 0.97 [0.94-1.00]) and rate ratio of 0.98 [0.96-1.00], respectively) but no change following reforms. There were no significant changes in the urban group. In all 3 groups, there was a significant increasing trend in ACS-related mortality before reforms (OR of 1.09 [1.02-1.15], OR of 1.10 [1.06-1.13], and OR of 1.09 [1.05-1.14] for rural reform, rural nonreform, and urban communities, respectively), which was reversed after the introduction of reforms (P < .01).

CONCLUSION

Primary health care reforms in Newfoundland and Labrador had no observed effect on ACS hospitalization rates, but a potential effect might have been masked by a decreasing trend that preceded the introduction of reforms. The increase in mortality rates that was reversed after the introduction of reforms cannot be attributed to the reforms because it occurred in all studied populations including those that did not introduce reforms.

Evaluation of bottom-up interventions targeting community-dwelling frail older people in Belgium: methodological challenges and lessons for future comparative effectiveness studies

Background

Optimizing the organization of care for community-dwelling frail older people is an important issue in many Western countries. In Belgium, a series of complex, innovative, bottom-up interventions was recently designed and implemented to help frail older people live at home longer. As the effectiveness of these interventions may vary between different population groups according to their long-term care needs, they must be evaluated by comparison with a control group that has similar needs.

Methods

The goal was to identify target groups for these interventions and to establish control groups with similar needs and to explore, per group, the extent to which the utilization of long-term care is matched to needs. We merged two databases: a clinical prospective database and the routine administrative database for healthcare reimbursements. Through Principal Component Analysis followed by Clustering, the intervention group was first stratified into disability profiles. Per profile, comparable control groups for clinical variables were established, based on propensity scores. Using chi-squared tests and logistic regression analysis, long-term care utilization at baseline was then compared per profile and group studied.

Results

Stratification highlighted five disability profiles: people with low-level limitations; people with limitations in instrumental activities of daily life and low-level of cognitive impairment; people with functional limitations; people with functional and cognitive impairments; and people with functional, cognitive, and behavioral problems. These profiles made it possible to identify long-term care needs. For instance, at baseline, those who needed more assistance with hygiene tasks also received more personal nursing care (P < 0.05). However, there were some important discrepancies between the need for long-term care and its utilization: while 21% of patients who were totally dependent for hygiene tasks received no personal nursing care, personal nursing care was received by 33% of patients who could perform hygiene tasks.

Conclusions

The disability profiles provide information on long-term care needs but not on the extent to which those needs are met. To assess the effectiveness of interventions, controls at baseline should have similar disability profiles and comparable long-term care utilization. To allow for large comparative effectiveness studies, these dimensions should ideally be available in routine databases.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4240-9) contains supplementary material, which is available to authorized users.

Capturing Emergency Department Discharge Quality With the Care Transitions Measure: A Pilot Study

BACKGROUND

Recent attention has been given to developing measures to capture the quality of ED transitions of care. We examined the utility of a patient-reported measure of transitional care, the Care Transitions Measure-3 (CTM-3), in the ED setting and its association with outcomes of care after ED discharge.

METHODS

A telephone survey was conducted of a convenience sample of patients 14 days after discharge from two emergency departments (EDs) in an academic health system. Patients responded to three statements using a four-point agreement scale (strongly disagree, disagree, agree, strongly agree): 1) "The hospital staff took my preferences and those of my family or caregiver into account when deciding what my health care needs would be"; 2) " When I left the ER, I had a good understanding of the things I was responsible for in managing my health"; and 3) "When I left the hospital, I clearly understood the purpose for taking each of my medications." Patients were also queried about outcomes after ED discharge that are known to be related to ED care transitions including medication adherence, completion of recommended follow-up, and return visits to the ED. Multivariable logistic regression was used to determine the association between the CTM-3 score (on a 100-point scale) and outcomes of interest.

RESULTS

Among 1,832 patients called, 576 were reached by phone, and 410 consented and completed our survey, representing a 22.4% response rate of patients we attempted to call. A 10-point increase in the CTM-3 score (better care experiences) was associated with a 12% decrease in the odds of having an ED return visit (adjusted odds ratio [AOR] = 0.88, 95% confidence interval [CI] = 0.77-1.00) and a 45% increase in the odds of taking prescribed medications as recommended (AOR = 1.45, 95% CI = 1.12-1.87). There was no association between CTM-3 score and completion of follow-up.

CONCLUSIONS

The CTM-3 is associated with outcomes of care after an ED visit, including ED return visits and medication adherence, and may have utility as a patient-reported measure of ED transitions of care.

Defining High Value Elements for Reducing Cost and Utilization in Patient-Centered Medical Homes for the TOPMED Trial

Introduction:

Like most patient-centered medical home (PCMH) models, Oregon’s program, the Patient-Centered Primary Care Home (PCPCH), aims to improve care while reducing costs; however, previous work shows that PCMH models do not uniformly achieve desired outcomes. Our objective was to describe a process for refining PCMH models to identify high value elements (HVEs) that reduce cost and utilization.

Methods:

We performed a targeted literature review of each PCPCH core attribute. Value-related concepts and their metrics were abstracted, and studies were assessed for relevance and strength of evidence. Focus groups were held with stakeholders and patients, and themes related to each attribute were identified; calculation of HVE attainment versus PCPCH criteria were completed on eight primary care clinics. Analyses consisted of descriptive statistics and criterion validity with stakeholder input.

Results:

2,126 abstracts were reviewed; 22 met inclusion criteria. From these articles and focus groups of stakeholders/experts (n = 49; 4 groups) and patients (n = 7; 1 group), 12 HVEs were identified that may reduce cost and utilization. At baseline, clinics achieved, on average, 31.3 percent HVE levels compared to an average of 87.9 percent of the 35 PCMH measures.

Discussion:

A subset of measures from the PCPCH model were identified as “high value” in reducing cost and utilization. HVE performance was significantly lower than standard measures, and may better calibrate clinic ability to reduce costs.

Conclusion:

Through literature review and stakeholder engagement, we created a novel set of high value elements for advanced primary care likely to be more related to cost and utilization than other models.

Repeat Emergency Department Visits for Individuals With Intellectual and Developmental Disabilities and Psychiatric Disorders

Although individuals with intellectual and developmental disabilities (IDD) and psychiatric concerns are more likely than others to visit hospital emergency departments (EDs), the frequency of their returns to the ED within a short time is unknown. In this population-based study we examined the likelihood of this group returning to the ED within 30 days of discharge and described these visits for individuals with IDD + psychiatric disorders (n = 3,275), and persons with IDD only (n = 1,944) compared to persons with psychiatric disorders only (n = 41,532). Individuals with IDD + psychiatric disorders, and individuals with IDD alone were more likely to make 30-day repeat ED visits. Improving hospital care and postdischarge community linkages may reduce 30-day returns to the ED among adults with IDD.

How to decide adequately? Qualitative study of GPs' view on decision-making in self-referred and physician-referred emergency department consultations in Berlin, Germany

OBJECTIVES

Patients with acute symptoms present not only to general practitioners (GPs), but also frequently to emergency departments (EDs). Patients' decision processes leading up to an ED self-referral are complex and supposed to result from a multitude of determinants. While they are key providers in primary care, little is known about GPs' perception of such patients. This qualitative study explores the GPs' view regarding motives and competences of patients self-referring to EDs, and also GPs' rationale for or against physician-initiated ED referrals.

DESIGN

Qualitative study with semi-structured, face-to-face interviews; qualitative content analysis.

SETTING

GP practices in Berlin, Germany.

PARTICIPANTS

15 GPs (female/male: 9/6; mean age 53.6 years).

RESULTS

The interviewed GPs related a wide spectrum of factors potentially influencing their patients' decision to visit an ED, and also their own decision-making in potential referrals. Considerations go beyond medical urgency. Statements concerning patients' surmised rationale corresponded to GPs' reasoning in a variety of important areas. For one thing, the timely availability of an extended spectrum of diagnostic and therapeutic options may make ED services attractive to both. Access difficulties in the ambulatory setting were mentioned as additional triggers for an ED visit initiated by a patient or a GP. Key patient factors like severity of symptoms and anxiety also play a major role; a desire for reassurance may lead to both self-referred and physician-initiated ED visits. Patients' health competence was prevailingly depicted as limited, with the internet as an important influencing factor. Counselling efforts by GP were described as crucial for improving health literacy.

CONCLUSIONS

Health education could hold promise when aiming to reduce non-urgent ED consultations. Primary care providers are in a key position here. Amelioration of organisational shortages in ambulatory care, for example, limited consultation hours, might also make an important impact, as these trigger both self-referrals and GP-initiated ED referrals.

TRIAL REGISTRATION NUMBER

DRKS00011930.

Difference in frequency and outcome of geriatric emergency department utilization between urban and rural areas

BACKGROUND

Elderly people are susceptible to develop multiple chronic diseases and are thus likely to utilize the emergency department (ED). Access to health care and health outcomes may differ between rural and urban areas. This study aims to compare the frequency and outcome of geriatric ED utilization between urban and rural areas.

METHODS

This population-based study obtained information from the health insurance database. The frequency and outcome of ED utilization in 2013 were compared among people aged ≥65 years living in urban and rural areas. The independent effect of various characteristics on the frequency and outcome of ED utilization was evaluated using multivariate logistic regression analysis.

RESULTS

Of the 6695 people living in urban areas, 1879 (28.07%) utilized the ED and accounted for 3859 ED visits. Meanwhile, 908 (29.75%) of the 3052 people living in rural areas utilized the ED and accounted for 1820 ED visits. No difference in the prevalence of ED utilization was found between the urban and rural areas. Urbanization did not affect the risk of frequent ED utilization among ED users. People living in rural areas had an increased risk of ED visits with a high acuity (adjusted odds ratio: 1.40, 95% CI: 1.12-1.75). Urbanization did not affect the risk of hospitalization or immediate death after ED visits.

CONCLUSION

The frequency of ED utilization showed no urban-rural difference. Elderly people living in rural areas had an increased risk of visiting the ED with a high acuity.

Socio-demographic differences in the frequent use of emergency department care by older persons: a population-based study in Stockholm County

BACKGROUND

In Sweden, the number of older people using emergency department (ED) care is rising. Among older persons an ED visit is a stressful event, which potentially could have been prevented or treated at other levels of care. Frequent ED use (> 4 visits a year) by older persons might reflect issues in the organisation of health care system to address their needs. We aimed to explore socio-demographic differences among older people seeking ED care in terms age and gender, and to investigate the association between income and frequent ED use.

METHODS

A population-based study analysing the utilisation of ED care by (N = 356,375) individuals aged 65+ years. We linked register data on socio-demographic characteristics from 2013 to health care utilisation data in 2014. Multivariable logistic regression was used to estimate the income differences in the frequent use of ED care, adjusting for living situation, country of birth, residential area, age in years, multi-morbidity and the use of other health care services.

RESULTS

Those 65+ years accounted for (27%) of all ED visits in Stockholm County in 2014. In the study population (2.5%) were identified as frequent ED users, who were predominantly in the lower income groups, living alone or in an institution, had more multi-morbidity, and utilised more of other health care services. The lowest income groups had a three-fold greater odds of being a frequent ED user than those in the highest income group. In the adjusted models, the odds were reduced by 12-44% for those in the lowest income groups. However, age and gender differences were observed with men 65-79 years (OR 1.75 CI: 1.51-2.03) and women 80+ years (OR 1.50, CI 1.19-1.87) in the lowest income groups having a higher odds of frequent ED use.

CONCLUSION

This study observed that ED visits by older persons are driven by a need of care, and those that frequently visit hospital-based EDs are a socially disadvantaged group, which suggests that the organisation of care for older people should be reviewed in order to better meet their needs in other levels of care.

General practitioner consultation after a visit to the emergency department: an observational study

BACKGROUND

Some studies have demonstrated an association between poor continuity of care, high likelihood of 'inappropriate' use of emergency departments (EDs) and avoidable hospitalization. However, we lack data concerning primary care use after an ED visit.

OBJECTIVE

Identify the determinants of a visit to the general practitioner (GP) after an ED visit.Methods.

DESIGN

Observational study (single-centre cohort).

SETTING

One emergency department in Paris, France.

SUBJECTS

All adult patients who presented at the ED and were discharged.

MAIN OUTCOME MEASURE

We collected data by the use of a standardized questionnaire, patients' medical records and a telephonic follow-up. Descriptive analyses were performed to compare individuals with and without a GP. Then, for those with a GP, multivariate logistic regression was used to identify the determinants of the GP consultation.

RESULTS

We included 243 patients (mean age 45 years [±19]); 211 (87%) reported having a GP. Among those who reported having a GP, 52% had consulted their GP after the ED visit. Not having a GP was associated with young age, not having complementary health insurance coverage, and being single. GP consultation was associated with increasing age [adjusted odds ratios (aOR) = 1.03], poor self-reported health status (aOR = 2.25), medical complaints versus traumatic injuries (aOR = 2.24) and prescription for sick note (aOR = 5.74).

CONCLUSION

Not having a GP was associated with factors of social vulnerability such as not having complementary health insurance coverage. For patients with a GP, consultation in the month after an ED visit seems appropriate, because it was associated with poor health status and medical complaints.

Continuity of care and multiple chronic conditions impact frequent use of outpatient services

This study investigated the association between care continuity and chronic conditions in relation to highly frequent use of outpatient service in order to find constructive suggestions to bring efficient, high-quality care for patients with multiple chronic conditions. The National Health Insurance database was used and 333,294 patients were identified from 2007 to 2009. The continuity of care index indicates the dispersion of a patient's ambulatory visits among providers. Multivariate logistic regression was used to estimate adjusted odds ratios with 95 percent confidence intervals. Continuity of care index was significantly associated with age, sex, urbanization level, socioeconomic status, emergency department visits, hospitalization, psychological disorders, chronic diseases, and catastrophic illness card; those with low continuity of care index were likely to use outpatient care highly frequently. Improving continuity of care is fundamental, and the best way is to advance the practice of family medicine for primary care.

Disparities in health outcomes among seniors without a family physician in the North West Local Health Integration Network: a retrospective cohort study

BACKGROUND

The relationship between having a family physician and in-hospital and postdischarge health outcomes among older adults is unclear. We ascertained the proportion of seniors who did not have a family physician and were admitted to an Ontario tertiary care centre, and we determined the association between having/not having a family physician and in-hospital mortality, 1-year mortality and readmission after live discharge.

METHODS

This was a retrospective cohort study of community-dwelling seniors who were admitted to a medical service at Thunder Bay Regional Health Sciences Centre. We conducted regression analyses adjusted for demographic factors, prior health care utilization, and factors associated with the index admission to determine the association between family physician status and the study outcomes.

RESULTS

Among the 12 033 seniors admitted to hospital between Apr. 1, 2004, and Mar. 31, 2013, 40.7% lacked a family physician. Among those without a family physician, 8.0% (390/4899) died during the index admission and 15.8% (714/4509) died in the subsequent year. Adjusted regression models showed that not having a family physician was significantly associated with in-hospital mortality (odds ratio 1.56, 95% confidence interval [CI] 1.33-1.83). Regression models of all-cause 1-year mortality and readmission also suggested that lack of a family physician was associated with detrimental health outcomes (hazard ratio 1.14, 95% CI 1.04-1.26; subdistribution hazard ratio 1.17, 95% CI 1.10-1.24, respectively).

INTERPRETATION

Elders without family physicians were disadvantaged during their hospital admission as well as in the subsequent year. Additional interventions aimed at increasing the proportion of seniors admitted to hospital who are connected with a family physician are warranted.

Claims-based measures of continuity of care have non-linear associations with health: data linkage study

Background

Continuity of care (CoC) is considered a central element of good primary care and is often measured using medical claims data. Possible values of CoC depend on the number of claims which is related to health status. This study investigated the relationships between CoC and health status and risk of emergency hospitalisation.

Methods

Health insurance claims for consultations with general practitioners (GPs) in the 24 months following entry to the 45 and Up Study were used to calculate usual provider continuity (UPC) and the Continuity of Care Index (CoC Index). Relationships of CoC with number of claims, self-rated health and emergency hospitalisation were investigated using descriptive statistics and logistic regression models.

Results

Both measures of CoC were strongly related to number of claims and to measures of health status, which were in turn highly associated. Multivariable logistic regression models showed a weak positive relationship between CoC and odds of emergency hospitalisation for those with CoC less than 1, while individuals with perfect CoC had significantly lower odds of hospitalisation compared to all other categories of CoC. However, analyses stratified by, or adjusting for, number of claims showed no clear associations between CoC and risk of hospitalisation.

Conclusions

The pattern of association between CoC categories and emergency hospitalisation was non-linear and was confounded by the effect of number of claims. Future studies should apply caution in using claims-based measures of CoC as a continuous variable or employing an arbitrary cut-point, and should adjust for number of claims.

The global burden of multiple chronic conditions: A narrative review

Globally, approximately one in three of all adults suffer from multiple chronic conditions (MCCs). This review provides a comprehensive overview of the resulting epidemiological, economic and patient burden. There is no agreed taxonomy for MCCs, with several terms used interchangeably and no agreed definition, resulting in up to three-fold variation in prevalence rates: from 16% to 58% in UK studies, 26% in US studies and 9.4% in Urban South Asians. Certain conditions cluster together more frequently than expected, with associations of up to three-fold, e.g. depression associated with stroke and with Alzheimer's disease, and communicable conditions such as TB and HIV/AIDS associated with diabetes and CVD, respectively. Clusters are important as they may be highly amenable to large improvements in health and cost outcomes through relatively simple shifts in healthcare delivery. Healthcare expenditures greatly increase, sometimes exponentially, with each additional chronic condition with greater specialist physician access, emergency department presentations and hospital admissions. The patient burden includes a deterioration of quality of life, out of pocket expenses, medication adherence, inability to work, symptom control and a high toll on carers. This high burden from MCCs is further projected to increase. Recommendations for interventions include reaching consensus on the taxonomy of MCC, greater emphasis on MCCs research, primary prevention to achieve compression of morbidity, a shift of health systems and policies towards a multiple-condition framework, changes in healthcare payment mechanisms to facilitate this change and shifts in health and epidemiological databases to include MCCs.

Associations Between Physical Therapy Continuity of Care and Health Care Utilization and Costs in Patients With Low Back Pain: A Retrospective Cohort Study

BACKGROUND

Patients who consult a physical therapist for low back pain (LBP) may receive initial and subsequent management from different therapists. The impact that physical therapy provider continuity has on health care use in patients with LBP is insufficiently studied.

OBJECTIVE

The objective of this study was to examine the impact of continuity of the physical therapy provider on health care use and costs in patients with LBP referred from primary care.

DESIGN

The study design included a retrospective analysis of claims data.

METHODS

Data from an all-payer claims database were examined. Logistic regression was used to evaluate the association between physical therapy provider continuity and health care use during the 1-year period following a visit with a primary care provider for LBP.

RESULTS

Patients who experienced greater physical therapy provider continuity had a decreased likelihood of receiving lumbar surgery. They also paid less (mean = ${\$}$1737 [95% confidence interval, ${\$}$1602-${\$}$1871]) than those who experienced less physical therapy provider continuity (mean = ${\$}$2577 [95% confidence interval, ${\$}$2008-${\$}$3145]).

LIMITATIONS

The degree of causality between any predictor and outcome variables cannot be determined due to the observational nature of the study.

CONCLUSIONS

Greater continuity of the physical therapy provider appears to be associated with a decreased likelihood of surgical treatment for LBP and lower health care costs related to LBP.

Comparative morbidities and the share of emergencies in hospital admissions in deprived areas: a method and evidence from English administrative data

OBJECTIVE

Various studies find that the share of emergencies in hospital admissions is higher in deprived areas, but both the explanation and policy implications are unclear. We estimate the extent to which this finding is due to a different disease mix in deprived areas, rather than other explanations such as patient behaviour and general practitioner effectiveness.

DESIGN

Secondary analysis using English Hospital Episode Statistics data, with disease for elective and emergency admissions in 2008/2009 coded at 186 blocks or 1230 categories and aggregated to lower layer super output area of residence. It is then linked to an appropriate measure of deprivation.

OUTCOME MEASURES

The difference in the share of emergencies in hospital admissions between communities in the highest and lowest deciles of deprivation; and the percentage of this difference that is explained if areas in the least deprived decile have the same disease mix as those in the most deprived decile.

RESULTS

Using the finest disease classification scheme (1230 categories), 71% of the higher share of admissions that were emergencies in decile 1 areas relative to decile 10, is explained by the "adverse" case mix (CM) in deprived areas. The remainder reflects the higher relative use of emergency care in deprived areas for the same conditions. Higher incidence of respiratory and circulatory diseases in deprived areas explains about 30% of the CM contribution. Diseases of the digestive system and abdomen have a high relative use of emergency care in deprived areas.

CONCLUSIONS

The higher use of emergency care in deprived areas is primarily a symptom of the higher prevalence of diseases which have high national rates of emergency to elective care-especially respiratory diseases-rather than an indication of less effective primary care. Nevertheless, there is a higher share of emergency care in admissions in deprived areas for several diseases, most notably of the digestive system.

A Multilevel Analysis of the determinants of emergency care visits by the elderly in France

BACKGROUND

Rising numbers of visits to emergency departments (EDs), especially amongst the elderly, is a source of pressure on hospitals and on the healthcare system. This study aims to establish the determinants of ED visits in France at a territorial level with a focus on the impact of ambulatory care organisation on ED visits by older adults aged 65 years and over.

METHODS

We use multilevel regressions to analyse how the organisation of healthcare provision at municipal and wider 'department' levels impacts ED utilisation by the elderly while controlling for the local demographic, socioeconomic and health context of the area in which patients live.

RESULTS

ED visits vary significantly by health context and economic level of municipalities. Controlling for demand-side factors, ED rates by the elderly are lower in areas where accessibility to primary care is high, measured as availability of primary care professionals, out-of-hours care and home visits in an area. Proximity (distance) and size of ED are drivers of ED use.

CONCLUSION

High rates of ED visits are partly linked to inadequate accessibility of health services provided in ambulatory settings. Redesigning ambulatory care at local level, in particular by improving accessibility and continuity of primary and social care services for older adults could reduce ED visits and, therefore, improve the efficient use of available healthcare resources.

The impact of rural health insurance and the family physician program on hospitalizations, a beforeafter study at the county level conducted in Tehran province, Iran

Background: The health insurance and family physician reform in Iran were implemented in 2005. This study was conducted to assess the effect of these reforms on avoidable hospitalizations among the rural population of Eslam-shahr County, Iran. Methods: We conducted a before-after study in Eslam-shahr County's single existing hospital. This county is a part of the Tehran Province of Iran. The demographic characteristics and diagnostic codes of the rural population that were hospitalized during the 2 years leading to, and after the reforms were extracted from the hospital's electronic information system. A list of 61 three-character and 131 four-character AHs codes were developed based on the literature review. We estimated a logistic regression model which included gender and age as independent variables to assess changes in the probability of avoidable hospitalizations following reform implementation. Analyses were carried out using STATA version 13. Results: We recorded 817 rural hospitalizations before and 967 hospitalizations after reform implementation, suggesting that hospitalization growth after the reforms was almost 18.4%. The logistic regression results show that the probability of avoidable hospitalizations after the interventions had decreased compared to before the interventions were put into place (OR: 0.46; 95% CI: 0.24-0.88). Also, the probability of AHs among the 60< year-old age group was considerably higher compared to other age groups. No statistical relationship was found between avoidable hospitalizations and gender. Conclusion: The reforms may have had a mixed effect on hospitalization. They may result in increased hospitalizations due to responding to the unmet needs of the population, and simultaneously they may lead to a decrease in avoidable hospitalizations and eliminate the costs imposed by them upon the health system.

A before-after study of hospital use in two frail populations receiving different home-based services over the same time in Vancouver, Canada

Background

As individuals age, they are more likely to experience increasing frailty and more frequent use of hospital services. First, we explored whether initiating home-based primary care in a frail homebound cohort, influenced hospital use. Second, we explored whether initiating regular home care support for personal care with usual primary care, in a second somewhat less frail cohort, influenced hospital use.

Methods

This was a before-after retrospective cohort study of two frail populations in Vancouver, Canada using administrative data to assess the influence of two different services started in two different cohorts over the same time period. The participants were 246 recipients of integrated home-based primary care and 492 recipients of home care followed between July 1st, 2008 and June 30th, 2013 before and after starting their respective services. Individuals in each group were linked to their hospital emergency department visit and discharge abstract records. The main outcome measures were mean emergency department visit and hospital admission rates per 1000 patient days for 21 months before versus the period after receipt of services, and the adjusted incidence rate ratios (IRRs) on these outcomes post receipt of service.

Results

Before versus after starting integrated home-based primary care, emergency department visit rates per 1000 patient days (95% confidence intervals) were 4.1 (3.8, 4.4) versus 3.7 (3.3, 4.1), and hospital admissions rates were 2.3 (2.1, 2.5) versus 2.2 (1.9, 2.5). Before versus after starting home care, emergency department visit rates per 1000 patient days (95% confidence intervals) were 3.0 (2.8, 3.2) versus 4.0 (3.7, 4.3) visits and hospital admissions rates were 1.3 (1.2, 1.4) versus 1.9 (1.7, 2.1). Home-based primary care IRRs were 0.91 (0.72, 1.15) and 0.99 (0.76, 1.27) and home care IRRs were 1.34 (1.15, 1.56) and 1.46 (1.22, 1.74) for emergency department visits and hospital admissions respectively.

Conclusions

After enrollment in integrated home-based primary care, emergency department visit and hospital admission rates stabilized. After starting home care with usual primary care, emergency department visit and hospital admission rates continued to rise.

The effects of continuity of care on hospital utilization in patients with knee osteoarthritis: analysis of Nationwide insurance data

BACKGROUND

Korea's rapidly aging population has led to a rise in the prevalence of knee osteoarthritis (which reached upwards of 21.3% in 2017) in elderly people aged 65 years and over. Most patients with knee osteoarthritis require ongoing management in the community or through primary care. Continuity of care is a desirable attribute of primary care. However, previous studies on the association between continuity of care and health outcomes have focused on specific disease populations, particularly diabetes mellitus and hypertension. The objectives of this study were to determine whether there is an association between continuity of care for outpatients with knee osteoarthritis and health outcomes.

METHODS

We conducted a cohort study using claims data from 2014. The study population included 131,566 patients. We measured hospital admission and medical costs during the final 3 months and the continuity of care by Most Frequent Provider Continuity (MFPC), Modified Modified Continuity Index (MMCI), and Continuity of Care (COC) index in the 9 preceding months, using multiple logistic regression analyses to determine which index best explains continuity. We evaluated the relationship between COC and hospital admissions, using negative binomial regression analysis due to over-dispersion. Finally, multiple regressions were used to examine the relationship between the COC and medical costs.

RESULTS

We selected the COC index to determine the association between hospital admission and cost; the area under the receiver operating characteristic curve (AUC) of the COC was the largest (0.904), while those for the MFPC (0.894) and MMCI (0.893) were similar. The negative binomial regression analysis showed that continuity of care was significantly related to hospitalization, with the relative risk (RR) of hospital admission being low for patients with high continuity of care [RR = 27.17 for those with the reference group COC (0.76-1.00); 95% CI, 3.09-3.51]. Continuity of care was significantly related to medical costs after considering other covariates. A higher COC index was associated with a lower cost.

CONCLUSIONS

Higher continuity of care for knee osteoarthritis patients might decrease hospital admission and medical costs.

Association of socioeconomic status with outcomes in older adult community-dwelling patients after visiting the emergency department: a retrospective cohort study

OBJECTIVES

Older adults frequently visit the emergency department (ED). Socioeconomic status (SES) has an important impact on health and ED utilisation; however, the association between SES and ED utilisation in elderly remains unclear. The aim of this study was to investigate the association between SES in older adult patients visiting the ED on outcomes.

DESIGN

A retrospective study.

PARTICIPANTS

Older adults (≥65 years) visiting the ED, in the Netherlands. SES was stratified into tertiles based on average household income at zip code level: low (<€1800/month), intermediate (€1800-€2300/month) and high (>€2300/month).

PRIMARY OUTCOMES

Hospitalisation, inhospital mortality and 30-day ED return visits. Effect of SES on outcomes for all groups were assessed by logistic regression and adjusted for confounders.

RESULTS

In total, 4828 older adults visited the ED during the study period. Low SES was associated with a higher risk of hospitalisation among community-dwelling patients compared with high SES (adjusted OR 1.3, 95% CI 1.1 to 1.7). This association was not present for intermediate SES (adjusted OR 1.1, 95% CI 0.95 to 1.4). Inhospital mortality was comparable between the low and high SES group, even after adjustment for age, comorbidity and triage level (low OR 1.4, 95% CI 0.8 to 2.6, intermediate OR 1.3, 95% CI 0.8 to 2.2). Thirty-day ED revisits among community-dwelling patients were also equal between the SES groups (low: adjusted OR 1.0, 95% CI 0.7 to 1.4, and intermediate: adjusted OR 0.8, 95% CI 0.6 to 1.1).

CONCLUSION

In older adult ED patients, low SES was associated with a higher risk of hospitalisation than high SES. However, SES had no impact on inhospital mortality and 30-day ED revisits after adjustment for confounders.

Emergency Department Visits Can Be Reduced by Having a Regular Doctor for Adults with Diabetes Mellitus: Secondary Analysis of 2013 Korea Health Panel Data

Chronic diseases pose a major challenge to population health worldwide. Diabetes is a major chronic disease that is managed overwhelmingly in primary care. There is an increasing recognition of the role that primary care physicians play to achieve high-quality care for patients with diabetes. By analyzing 2013 Korean Health Panel data, the authors aimed to determine the current status of having a regular doctor (RD) for adults (aged 18 years or older) with diabetes. In addition, the association of having a RD with the experience of emergency department (ED) visits was determined in this study. Among adults with diabetes, those with RD accounted for 41.0%. The older the age group and the higher the Charlson comorbidity index score, the higher the percentage of adults with diabetes had RD. Even for those with RD, coordination of care was very poor (positive answer: 27.1%). After adjustment for confounding variables, those having (vs. not having) a RD (odds ratio [OR], 0.57; 95% confidence interval [CI], 0.35-0.94), especially those whose RDs delivered good comprehensiveness of care (OR, 0.47; 95% CI, 0.26-0.84) or worked at a primary care clinic (OR, 0.43; 95% CI, 0.22-0.81), and those whose longitudinal relationship with a RD was 5 years or less (OR, 0.45; 95% CI, 0.22-0.91) were less likely to have ED visits within the last year. In conclusion, health care policies that promote having a RD who delivers high-quality primary care could decrease unnecessary ED visits by diabetic adults. This can partly reduce ED overcrowding in Korea.

Relation between family physician retention and avoidable hospital admission in Newfoundland and Labrador: a population-based cross-sectional study

BACKGROUND

Physician turnover, involving physicians' leaving clinical practice in a specific area, may disrupt continuity of care, leading to poorer health outcomes and greater use of health care services. The purpose of this study was to investigate the relation between family physician retention and avoidable hospital admission for ambulatory-care-sensitive conditions.

METHODS

We conducted a population-based cross-sectional study using provincial health administrative data for residents of Newfoundland and Labrador who held a provincial health card between 2001 and 2009. Five-year family physician retention was calculated by regional economic zone, and residents within economic zones were grouped into tertiles based on physician retention level. We compared hospital admission for ambulatory-care-sensitive conditions among tertiles while adjusting for covariates.

RESULTS

For 475 691 residents of the province, there was a negative relation between physician retention and hospital admission for ambulatory-care-sensitive conditions: residents of areas with moderate or low physician retention had admission rates that were 16.5% (95% confidence interval [CI) 12.6%-20.4%) and 19.9% (95% CI 15.2%-24.7%) higher, respectively, compared to areas with high retention. No relation was found when analysis was limited to those aged 65 years or more.

INTERPRETATION

The findings suggest that high physician retention is associated with lower rates of hospital admission for ambulatory-care-sensitive conditions even after control for other factors. This is consistent with our hypothesis that physician turnover acts to disrupt continuity of care, resulting in higher admission rates.

The impact of team-based primary care on health care services utilization and costs: Quebec's family medicine groups

We investigate the effects on health care costs and utilization of team-based primary care delivery: Quebec's Family Medicine Groups (FMGs). FMGs include extended hours, patient enrolment and multidisciplinary teams, but they maintain the same remuneration scheme (fee-for-service) as outside FMGs. In contrast to previous studies, we examine the impacts of organizational changes in primary care settings in the absence of changes to provider payment and outside integrated care systems. We built a panel of administrative data of the population of elderly and chronically ill patients, characterizing all individuals as FMG enrollees or not. Participation in FMGs is voluntary and we address potential selection bias by matching on GP propensity scores, using inverse probability of treatment weights at the patient level, and then estimating difference-in-differences models. We also use appropriate modelling strategies to account for the distributions of health care cost and utilization data. We find that FMGs significantly decrease patients' health care services utilization and costs in outpatient settings relative to patients not in FMGs. The number of primary care visits decreased by 11% per patient per year among FMG enrolees and specialist visits declined by 6%. The declines in costs were of roughly equal magnitude. We found no evidence of an effect on hospitalizations, their associated costs, or the costs of ED visits. These results provide support for the idea that primary care organizational reforms can have impacts on the health care system in the absence of changes to physician payment mechanisms. The extent to which the decline in GP visits represents substitution with other primary care providers warrants further investigation.

Implementing Community Based Primary Healthcare for Older Adults with Complex Needs in Quebec, Ontario and New-Zealand: Describing Nine Cases

The aim of this paper is to set the foundation for subsequent empirical studies of the "Implementing models of primary care for older adults with complex needs" project, by introducing and presenting a brief descriptive comparison of the nine case studies in Quebec, Ontario and New Zealand. Each case is described based on key dimensions of Rainbow model of Valentijn and al (2013) with a focus on "meso level" integration. Meso level integration is represented by organizational and professional elements of the Rainbow Model, which are of particular interest in our nine case studies. Each of the three cases in Ontario and three in New Zealand are different and described separately. In Quebec, a local health services network model is presented across the three cases studied with variations in the way it is implemented. The three cases selected in the three jurisdictions under study were not chosen to be representative of wider practice within each country, but rather represent interesting and unique models of community-based primary healthcare integration. Similarities and variations in the integrated care models, context and dimension of integration offer insights regarding core component of integration of services, offering a foundational understanding of the cases on which future analysis will be based.

Association between continuity of care in Swedish primary care and emergency services utilisation: a population-based cross-sectional study

OBJECTIVE

The primary objective of this study was to determine the association between longitudinal continuity of care (CoC) in Swedish primary care (PC) and emergency services (ES) utilisation.

STUDY DESIGN

A cross-sectional analysis of longitudinal population data.

SETTING

PC centres, out-of-hours PC facilities and emergency departments (EDs) in Blekinge County in southern Sweden.

SUBJECTS

People of all ages who lived in Blekinge County and who had made two or more visits per year to a general practitioner (GP) during office hours from 1 January 2012 to 31 December 2014.

MAIN OUTCOME MEASURE

ES utilisation.

RESULTS

Eight-thousand one-hundred and eighty-five people were included in the study. CoC was quantified using three different indices-Usual Provider of Care index (UPC), Continuity of Care index (CoCI), and Sequential Continuity index (SECON). The CoC that the PC centres could offer their enrolled patients varied significantly between the different centres, ranging from 0.23-0.57 for UPC, 0.12-0.43 for CoCI, and 0.25-0.52 for SECON. Association between the three CoC indices and ES utilisation was computed as an incidence rate ratio which ranged between 0.50 and 0.59.

CONCLUSION

Longitudinal CoC was shown to have a negative association with ES utilisation. The association was significant and of a magnitude that implies clinical relevance. Computed incidence rate ratios suggest that patients with the lowest CoC had twice as many ES visits compared to patients with the highest CoC.

ED Utilization and Self-Reported Symptoms in Community-Dwelling Older Adults

The rise in ED utilization among older adults is a nursing concern, because emergency nurses are uniquely positioned to have a positive impact on the care of older adults. Symptoms have been associated with ED utilization; however, it remains unclear whether symptoms are the primary reason for ED utilization. The purpose of this study was to describe the self-reported symptoms of community-dwelling older adults prior to accessing the emergency department and to examine the differences in self-reported symptoms among those who did and did not utilize the emergency department.

METHODS

A prospective longitudinal design was used. The sample included 403 community-dwelling older adults aged 75 years and older. Baseline in-home interviews were conducted followed by monthly telephone interviews over 15 months.

RESULTS

Commonly reported symptoms at baseline included pain, feeling tired, and having shortness of breath. In univariate analysis, pain, shortness of breath, fair/poor well-being, and feeling tired were significantly correlated with ED utilization. In multivariable models, problems with balance and fair/poor well-being were significantly associated with ED utilization.

DISCUSSION

Several symptoms were common among this cohort of older adults. However, no significant differences were found in the types of symptoms reported by older adults who utilized the emergency department compared with those who did not utilize the emergency department. Based on these findings, it appears that symptoms among community-dwelling older adults may not be the primary reason for ED utilization.

A comparative analysis of centralized waiting lists for patients without a primary care provider implemented in six Canadian provinces: study protocol

BACKGROUND

Having a regular primary care provider (i.e., family physician or nurse practitioner) is widely considered to be a prerequisite for obtaining healthcare that is timely, accessible, continuous, comprehensive, and well-coordinated with other parts of the healthcare system. Yet, 4.6 million Canadians, approximately 15% of Canada's population, are unattached; that is, they do not have a regular primary care provider. To address the critical need for attachment, especially for more vulnerable patients, six Canadian provinces have implemented centralized waiting lists for unattached patients. These waiting lists centralize unattached patients' requests for a primary care provider in a given territory and match patients with providers. From the little information we have on each province's centralized waiting list, we know the way they work varies significantly from province to province. The main objective of this study is to compare the different models of centralized waiting lists for unattached patients implemented in six provinces of Canada to each other and to available scientific knowledge to make recommendations on ways to improve their design in an effort to increase attachment of patients to a primary care provider.

METHODS

A logic analysis approach developed in three steps will be used. Step 1: build logic models that describe each province's centralized waiting list through interviews with key stakeholders in each province; step 2: develop a conceptual framework, separate from the provincially informed logic models, that identifies key characteristics of centralized waiting lists for unattached patients and factors influencing their implementation through a literature review and interviews with experts; step 3: compare the logic models to the conceptual framework to make recommendations to improve centralized waiting lists in different provinces during a pan Canadian face-to-face exchange with decision-makers, clinicians and researchers.

DISCUSSION

This study is based on an inter-provincial learning exchange approach where we propose to compare centralized waiting lists and analyze variations in strategies used to increase attachment to a regular primary care provider. Fostering inter-provincial healthcare systems connectivity to improve centralized waiting lists' practices across Canada can lever attachment to a regular provider for timely access to continuous, comprehensive and coordinated healthcare for all Canadians and particular for those who are vulnerable.

Mental Illness Is Not Associated with Adherence to Colorectal Cancer Screening: Results from the California Health Interview Survey

BACKGROUND

Colorectal cancer is the second leading cause of cancer-specific death in the USA. Evidence suggests people with mental illness are less likely to receive preventive health services, including cancer screening. We hypothesized that mental illness is a risk factor for non-adherence to colorectal cancer-screening guidelines.

METHODS

We analyzed results of the 2007 California Health Interview Survey to test whether mental illness is a risk factor for non-adherence to colorectal cancer-screening recommendations among individuals age 50 or older (N = 15,535). This cross-sectional dataset is representative of California. Screening was defined as either fecal occult blood testing during the preceding year, sigmoidoscopy, or colonoscopy during the preceding 5 years. Mental illness was identified using the Kessler K6 screening tool. Associations were evaluated using weighted multivariate logistic regressions.

RESULTS

Mental illness was not associated with colorectal cancer-screening adherence (OR 0.89; 95% CI 0.63-1.25). Risk factors for non-adherence included being female (OR 1.25; 95% CI 1.09-1.44), delaying accessing health care during the previous year (OR 1.89; 95% CI 1.56-2.29).

CONCLUSION

Unlike previous studies, this study did not find a relationship between mental illness and colorectal cancer-screening adherence. This could be due to differences in study populations. State-specific healthcare policies involving care coordination for individuals with mental illness could also influence colorectal cancer-screening adherence in California.

What Contributes to the Regularity of Patients with Hypertension or Diabetes Seeking Health Services? A Pilot Follow-Up, Observational Study in Two Sites in Hubei Province, China

Regular maintenance of non-communicable chronic diseases can constrain disease progression in diabetic and hypertensive patients. To identify the individual and social factors that are associated with positive health-seeking behaviors and regular maintenance of chronic diseases, we have conducted a follow up study in 2015 on diabetic and hypertensive patients in Hubei Province. We used binary logistic regression models to determine specific factors associated with diabetic and hypertensive patients that sought healthcare services for their conditions in accordance with current Chinese Centers for Disease Prevention and Control (CDC) guidelines. Our findings show that 42.16% of 510 people living with chronic conditions (PLCDs) sought health services in line with existing guidelines. Findings also show a higher probability (8.418 times) for PLCDs seeking healthcare services at higher-tiered hospitals (secondary and tertiary hospitals) than for PLCDs seeking care at primary hospitals (odds ratio (OR) = 8.418, 95% confidence interval (CI) = 4.82, 14.27, p < 0.001). These analyses underscore the importance of having patient advocates who can provide support, where necessary, and encourage positive health-seeking behavior. The study also shows a negative impact on regular maintenance for PLCDs in households with high financial constraints. In contrast, the study shows positive impacts for increased household income, age, and residency in rural locations. In sum, this study underscores the importance of primary hospitals as key points of care and critical players in care coordination for PLCDs. The study provides more evidence for Chinese policymakers seeking to contain costs and improve population health. The findings also underscore the need for community-based interventions, specifically interventions that link local primary hospitals, friends/family members, and PLCDs.

Spatial Accessibility to Health Care Services: Identifying under-Serviced Neighbourhoods in Canadian Urban Areas

BACKGROUND

Urban environments can influence many aspects of health and well-being and access to health care is one of them. Access to primary health care (PHC) in urban settings is a pressing research and policy issue in Canada. Most research on access to healthcare is focused on national and provincial levels in Canada; there is a need to advance current understanding to local scales such as neighbourhoods.

METHODS

This study examines spatial accessibility to family physicians using the Three-Step Floating Catchment Area (3SFCA) method to identify neighbourhoods with poor geographical access to PHC services and their spatial patterning across 14 Canadian urban settings. An index of spatial access to PHC services, representing an accessibility score (physicians-per-1000 population), was calculated for neighborhoods using a 3km road network distance. Information about primary health care providers (this definition does not include mobile services such as health buses or nurse practitioners or less distributed services such as emergency rooms) used in this research was gathered from publicly available and routinely updated sources (i.e. provincial colleges of physicians and surgeons). An integrated geocoding approach was used to establish PHC locations.

RESULTS

The results found that the three methods, Simple Ratio, Neighbourhood Simple Ratio, and 3SFCA that produce City level access scores are positively correlated with each other. Comparative analyses were performed both within and across urban settings to examine disparities in distributions of PHC services. It is found that neighbourhoods with poor accessibility scores in the main urban settings across Canada have further disadvantages in relation to population high health care needs.

CONCLUSIONS

The results of this study show substantial variations in geographical accessibility to PHC services both within and among urban areas. This research enhances our understanding of spatial accessibility to health care services at the neighbourhood level. In particular, the results show that the low access neighbourhoods tend to be clustered in the neighbourhoods at the urban periphery and immediately surrounding the downtown area.

Primary Care Performance Measurement and Reporting at a Regional Level: Could a Matrix Approach Provide Actionable Information for Policy Makers and Clinicians?

OBJECTIVE

Primary care services form the foundation of modern healthcare systems, yet the breadth and complexity of services and diversity of patient populations may present challenges for creating comprehensive primary care information systems. Our objective is to develop regional-level information on the performance of primary care in Canada.

METHODS

A scoping review was conducted to identify existing initiatives in primary care performance measurement and reporting across 11 countries. The results of this review were used by our international team of primary care researchers and clinicians to propose an approach for regional-level primary care reporting.

RESULTS

We found a gap between conceptual primary care performance measurement frameworks in the peer-reviewed literature and real-world primary care performance measurement and reporting activities. We did not find a conceptual framework or analytic approach that could readily form the foundation of a regional-level primary care information system. Therefore, we propose an approach to reporting comprehensive and actionable performance information according to widely accepted core domains of primary care as well as different patient population groups.

CONCLUSIONS

An approach that bridges the gap between conceptual frameworks and real-world performance measurement and reporting initiatives could address some of the potential pitfalls of existing ways of presenting performance information (i.e., by single diseases or by age). This approach could produce meaningful and actionable information on the quality of primary care services.

Ontario primary care models: a descriptive study

BACKGROUND

Between 2001 and 2006, the Ontario government introduced a menu of new primary care models, with elements such as patient enrolment and minimum group sizes, and various combinations of fee-for-service, capitation, pay-for-performance and salary. From the statistical perspective of physicians, as opposed to patients, we looked at the distribution of physician characteristics, group size and patient visit patterns across models to describe primary care practice in Ontario.

METHODS

Using administrative data for fiscal year 2010/11 containing information on physician characteristics, patient rostering status, patient visits and other practice information, we described similarities and differences across primary care models.

RESULTS

Our sample included 11 626 family physicians. Compared with physicians in the new primary care models, physicians in fee-for-service models are much more likely to work part-time and many, particularly younger and female physicians, do not work in full-year full-scope practices. Among the new primary care models, physicians in capitated models are slightly younger, are less likely to be an international medical graduate, work in smaller physician teams and do not practice in urban areas. On average, physicians saw and rostered 1888 patients. Although there is still substantial variation within each model, fee-for-service physicians saw the fewest patients; physicians in capitated models saw somewhat more, and those in the noncapitated models saw the most patients.

INTERPRETATION

Practice and physician characteristics vary systematically across models. A high percentage of rostered patients see physicians outside the group with which they are rostered. Group-based primary care models may not have a large impact on group integration and continuity in the provision of primary care services.

Using a complex adaptive system lens to understand family caregiving experiences navigating the stroke rehabilitation system

BACKGROUND

Family caregivers provide the stroke survivor with social support and continuity during the transition home from a rehabilitation facility. In this exploratory study we examined family caregivers' perceptions and experiences navigating the stroke rehabilitation system. The theories of continuity of care and complex adaptive systems were integrated to examine the transition from a stroke rehabilitation facility to the patient's home. This study provides an understanding of the interacting complexities at the macro and micro levels.

METHODS

A convenient sample of family caregivers (n = 14) who provide care for a stroke survivor were recruited 4-12 weeks following the patient's discharge from a stroke rehabilitation facility in Ontario, Canada. Interviews were conducted with family caregivers to examine their perceptions and experiences navigating the stroke rehabilitation system. Directed and inductive content analysis and the theory of Complex Adaptive Systems were used to interpret the perceptions of family caregivers.

RESULTS

Health system policies and procedures at the macro-level determined the types and timing of information being provided to caregivers, and impacted continuity of care and access to supports and services at the micro-level. Supports and services in the community, such as outpatient physiotherapy services, were limited or did not meet the specific needs of the stroke survivors or family caregivers.

CONCLUSION

Relationships with health providers, informational support, and continuity in case management all influence the family caregiving experience and ultimately the quality of care for the stroke survivor, during the transition home from a rehabilitation facility.

Primary care physician use across the breast cancer care continuum: CanIMPACT study using Canadian administrative data

OBJECTIVE

To describe primary care physician (PCP) use and continuity of PCP care across the breast cancer care continuum.

DESIGN

Population-based, retrospective cohort study using provincial cancer registries linked to health administrative databases.

SETTING

British Columbia, Manitoba, and Ontario.

PARTICIPANTS

All women with incident invasive breast cancer from 2007 to 2012 in Manitoba and Ontario and from 2007 to 2011 in British Columbia.

MAIN OUTCOME MEASURES

The number and proportions of visits to PCPs were determined. Continuity of care was measured using the Usual Provider of Care index calculated as the proportion of visits to the most-often-visited PCP in the 6 to 30 months before a breast cancer diagnosis (baseline) and from 1 to 3 years following a breast cancer diagnosis (survivorship).

RESULTS

More than three-quarters of patients visited their PCPs 2 or more times during the breast cancer diagnostic period, and more than 80% of patients had at least 1 PCP visit during breast cancer adjuvant treatment. Contact with the PCP decreased over time during breast cancer survivorship. Of the 3 phases, women appeared to be most likely to not have PCP contact during adjuvant treatment, with 10.7% (Ontario) to 18.7% (British Columbia) of women having no PCP visits during this phase. However, a sizable minority of women had at least monthly visits during the treatment phase, particularly in Manitoba and Ontario, where approximately a quarter of women saw a PCP at least monthly. We observed higher continuity of care with PCPs in survivorship (compared with baseline) in all provinces.

CONCLUSION

Primary care physicians were generally involved throughout the breast cancer care continuum, but the level of involvement varied across care phases and by province. Future interventions will aim to further integrate primary and oncology care.

Effect of Primary Care Involvement on End-of-Life Care Outcomes: A Systematic Review

OBJECTIVES

To investigate the relationship between primary care involvement in end-of-life (EOL) care and health and utilization outcomes.

DESIGN

Systematic review using MEDLINE and Web of Science.

SETTING

All English literature published between 1994 and August 31, 2014, that included terms related to primary care providers (PCPs), continuity of care, EOL care, and palliative care.

PARTICIPANTS

Individuals receiving care from a PCP at the end of life.

MEASUREMENTS

Study design, subject characteristics, study outcomes and results.

RESULTS

Of 2,812 studies screened, 13 were included in this study. The studies were mostly conducted in the United States (n = 5) and Canada (n = 4) and analyzed data collected from 1989 to 2010. Almost all studies used different definitions of PCP involvement in care, but in general, individuals who received more care from PCPs were more likely to be discharged or die with supportive care (home or hospice) than those receiving less PCP care. A few studies indicated that individuals seeing a PCP were less likely to have hospital or emergency department admissions, although the evidence for this was mixed. Studies linking PCP involvement to resource use, symptom management, and survival had mixed results or showed no association.

CONCLUSION

When PCPs are involved in EOL care, people are more likely to die out of the hospital. Thus, the relationship with the PCP may be particularly important in EOL care, because PCPs may help individual establish goals of care and determine treatment preferences.

Relationship Between Continuity of Ambulatory Care and Risk of Emergency Department Episodes Among Older Adults

STUDY OBJECTIVE

We determine whether visit patterns indicative of higher continuity are related to a lower risk of presenting at the emergency department (ED) among older adults.

METHODS

This study was a survival analysis between 2011 and 2013 of a 20% random sample of fee-for-service Medicare beneficiaries aged 66 years or older. Ambulatory visit patterns were measured starting in 2011 for up to 24 months using 2 continuity metrics measured on a 0 to 1 scale-Continuity of Care (COC) score and the Usual Provider Continuity (UPC) score. The composite outcome of an ED episode was defined as occurrence of an ED visit with discharge home, an observation stay, or hospital admission. Time-dependent Cox proportional hazards regression models controlled for patient demographic characteristics, comorbidities, previous use, and regional factors, with censoring for death or occurrence of the composite outcome. In a secondary analysis, continuity was measured in the 12 months preceding an ED episode to test whether it was associated with type of ED episode.

RESULTS

The relative rate of ED episodes decreased approximately 1% for every 0.1-point increase in the COC score (adjusted hazard ratio 0.99; 95% confidence interval 0.99 to 0.99; P<.001) and 2% for every 0.1-point increase in the UPC score (adjusted hazard ratio 0.98; 95% CI 0.98 to 0.99; P<.001), or up to a 10% lower rate between the lowest and highest COC score and a 20% lower rate for the UPC score. Among beneficiaries with an ED episode, higher continuity was associated with a 1% lower risk of observation stay but a 3% to 4% higher risk of hospital admission relative to an ED visit with discharge home.

CONCLUSION

Ambulatory visit patterns exhibiting more continuity were associated with a lower rate of ED utilization for older adults with fee-for-service Medicare coverage. The association of higher continuity with lower risk of ED use but differences in outcome when an ED visit does occur may reflect more appropriate referral to the ED when outpatient management is no longer adequate.