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Lau J, Scott MM, Everett K, Gomes T, Tanuseputro P, Jennings S, Bagnarol R, Zimmermann C, Isenberg SR. Association between opioid use disorder and palliative care: a cohort study using linked health administrative data in Ontario, Canada. CMAJ 2024; 196:E547-E557. [PMID: 38684285 PMCID: PMC11057880 DOI: 10.1503/cmaj.231419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND People with opioid use disorder (OUD) are at risk of premature death and can benefit from palliative care. We sought to compare palliative care provision for decedents with and without OUD. METHODS We conducted a cohort study using health administrative databases in Ontario, Canada, to identify people who died between July 1, 2015, and Dec. 31, 2021. The exposure was OUD, defined as having emergency department visits, hospital admissions, or pharmacologic treatments suggestive of OUD within 3 years of death. Our primary outcome was receipt of 1 or more palliative care services during the last 90 days before death. Secondary outcomes included setting, initiation, and intensity of palliative care. We conducted a secondary analysis excluding sudden deaths (e.g., opioid toxicity, injury). RESULTS Of 679 840 decedents, 11 200 (1.6%) had OUD. Compared with people without OUD, those with OUD died at a younger age and were more likely to live in neighbourhoods with high marginalization indices. We found people with OUD were less likely to receive palliative care at the end of their lives (adjusted relative risk [RR] 0.84, 95% confidence interval [CI] 0.82-0.86), but this difference did not exist after excluding people who died suddenly (adjusted RR 0.99, 95% CI 0.96-1.01). People with OUD were less likely to receive palliative care in clinics and their homes regardless of cause of death. INTERPRETATION Opioid use disorder can be a chronic, life-limiting illness, and people with OUD are less likely to receive palliative care in communities during the 90 days before death. Health care providers should receive training in palliative care and addiction medicine to support people with OUD.
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Affiliation(s)
- Jenny Lau
- Division of Palliative Care (Lau, Bagnarol, Zimmermann), Princess Margaret Cancer Centre, University Health Network; Division of Palliative Care (Lau), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Scott, Tanuseputro), Ottawa, Ont.; ICES Central (Everett, Gomes); Li Ka Shing Knowledge Institute (Gomes), Unity Health; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; Bruyère Research Institute (Tanuseputro, Isenberg), Ottawa, Ont.; Moms Stop The Harm (Jennings); Division of Palliative Medicine (Zimmermann), Department of Medicine, University of Toronto, Toronto, Ont.; Division of Palliative Care (Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont.
| | - Mary M Scott
- Division of Palliative Care (Lau, Bagnarol, Zimmermann), Princess Margaret Cancer Centre, University Health Network; Division of Palliative Care (Lau), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Scott, Tanuseputro), Ottawa, Ont.; ICES Central (Everett, Gomes); Li Ka Shing Knowledge Institute (Gomes), Unity Health; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; Bruyère Research Institute (Tanuseputro, Isenberg), Ottawa, Ont.; Moms Stop The Harm (Jennings); Division of Palliative Medicine (Zimmermann), Department of Medicine, University of Toronto, Toronto, Ont.; Division of Palliative Care (Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - Karl Everett
- Division of Palliative Care (Lau, Bagnarol, Zimmermann), Princess Margaret Cancer Centre, University Health Network; Division of Palliative Care (Lau), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Scott, Tanuseputro), Ottawa, Ont.; ICES Central (Everett, Gomes); Li Ka Shing Knowledge Institute (Gomes), Unity Health; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; Bruyère Research Institute (Tanuseputro, Isenberg), Ottawa, Ont.; Moms Stop The Harm (Jennings); Division of Palliative Medicine (Zimmermann), Department of Medicine, University of Toronto, Toronto, Ont.; Division of Palliative Care (Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - Tara Gomes
- Division of Palliative Care (Lau, Bagnarol, Zimmermann), Princess Margaret Cancer Centre, University Health Network; Division of Palliative Care (Lau), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Scott, Tanuseputro), Ottawa, Ont.; ICES Central (Everett, Gomes); Li Ka Shing Knowledge Institute (Gomes), Unity Health; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; Bruyère Research Institute (Tanuseputro, Isenberg), Ottawa, Ont.; Moms Stop The Harm (Jennings); Division of Palliative Medicine (Zimmermann), Department of Medicine, University of Toronto, Toronto, Ont.; Division of Palliative Care (Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - Peter Tanuseputro
- Division of Palliative Care (Lau, Bagnarol, Zimmermann), Princess Margaret Cancer Centre, University Health Network; Division of Palliative Care (Lau), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Scott, Tanuseputro), Ottawa, Ont.; ICES Central (Everett, Gomes); Li Ka Shing Knowledge Institute (Gomes), Unity Health; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; Bruyère Research Institute (Tanuseputro, Isenberg), Ottawa, Ont.; Moms Stop The Harm (Jennings); Division of Palliative Medicine (Zimmermann), Department of Medicine, University of Toronto, Toronto, Ont.; Division of Palliative Care (Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - Sheila Jennings
- Division of Palliative Care (Lau, Bagnarol, Zimmermann), Princess Margaret Cancer Centre, University Health Network; Division of Palliative Care (Lau), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Scott, Tanuseputro), Ottawa, Ont.; ICES Central (Everett, Gomes); Li Ka Shing Knowledge Institute (Gomes), Unity Health; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; Bruyère Research Institute (Tanuseputro, Isenberg), Ottawa, Ont.; Moms Stop The Harm (Jennings); Division of Palliative Medicine (Zimmermann), Department of Medicine, University of Toronto, Toronto, Ont.; Division of Palliative Care (Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - Rebecca Bagnarol
- Division of Palliative Care (Lau, Bagnarol, Zimmermann), Princess Margaret Cancer Centre, University Health Network; Division of Palliative Care (Lau), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Scott, Tanuseputro), Ottawa, Ont.; ICES Central (Everett, Gomes); Li Ka Shing Knowledge Institute (Gomes), Unity Health; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; Bruyère Research Institute (Tanuseputro, Isenberg), Ottawa, Ont.; Moms Stop The Harm (Jennings); Division of Palliative Medicine (Zimmermann), Department of Medicine, University of Toronto, Toronto, Ont.; Division of Palliative Care (Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - Camilla Zimmermann
- Division of Palliative Care (Lau, Bagnarol, Zimmermann), Princess Margaret Cancer Centre, University Health Network; Division of Palliative Care (Lau), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Scott, Tanuseputro), Ottawa, Ont.; ICES Central (Everett, Gomes); Li Ka Shing Knowledge Institute (Gomes), Unity Health; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; Bruyère Research Institute (Tanuseputro, Isenberg), Ottawa, Ont.; Moms Stop The Harm (Jennings); Division of Palliative Medicine (Zimmermann), Department of Medicine, University of Toronto, Toronto, Ont.; Division of Palliative Care (Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - Sarina R Isenberg
- Division of Palliative Care (Lau, Bagnarol, Zimmermann), Princess Margaret Cancer Centre, University Health Network; Division of Palliative Care (Lau), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Scott, Tanuseputro), Ottawa, Ont.; ICES Central (Everett, Gomes); Li Ka Shing Knowledge Institute (Gomes), Unity Health; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; Bruyère Research Institute (Tanuseputro, Isenberg), Ottawa, Ont.; Moms Stop The Harm (Jennings); Division of Palliative Medicine (Zimmermann), Department of Medicine, University of Toronto, Toronto, Ont.; Division of Palliative Care (Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
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Webber C, Milani C, Pugliese M, Lawlor PG, Bush SH, Watt C, Casey G, Knoefel F, Thavorn K, Momoli F, Tanuseputro P. Long-term cognitive impairment after probable delirium in long-term care residents: A population-based retrospective cohort study. J Am Geriatr Soc 2024; 72:1183-1190. [PMID: 37982327 DOI: 10.1111/jgs.18675] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 10/05/2023] [Accepted: 10/13/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND The impact of delirium on cognition has not been well-studied in long-term care (LTC) residents. This study examined changes in cognition 1 year after a probable delirium episode among LTC residents, compared to LTC residents without probable delirium. We also evaluated whether the relationship between probable delirium and cognitive change differed according to a diagnosis of dementia. METHODS We conducted a population-based retrospective cohort study using linked health administrative data. The study population included adults aged 65+ residing in LTC in Ontario, Canada and assessed via the Resident Assessment Instrument-Minimum Dataset between January 1, 2016 and December 31, 2018. Probable delirium was ascertained via the delirium Clinical Assessment Protocol on the index assessment. Cognition was measured quarterly using the Cognitive Performance Scale (range 0-6, higher values indicate greater impairment). Cognitive decline up to 1 year after index was evaluated using multivariable proportional odds regression models. RESULTS Of 92,005 LTC residents, 2816 (3.1%) had probable delirium at index. Residents with probable delirium had an increased odds of cognitive decline compared to those without probable delirium, with adjusted odds ratios of 1.64 (95% confidence interval [CI] 1.35-1.99), 1.56 (95% CI 1.34-1.85), 1.57 (95% CI 1.32-1.86) and 1.50 (95% CI 1.25-1.80) after 1-3, 4-6, 7-9, and 10-12 months of follow-up. Residents with probable delirium and a comorbid dementia diagnosis had the highest adjusted odds of cognitive decline (adjusted odds ratio 5.57, 95% CI 4.79-6.48) compared to those without probable delirium or dementia. Residents with probable delirium were also more likely to die within 1 year than those without probable delirium (52.5% vs. 23.4%). CONCLUSIONS Probable delirium is associated with increased mortality and worsened cognition in LTC residents that is sustained months after the probable delirium episode. Efforts to prevent delirium in this population may help limit these adverse effects.
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Affiliation(s)
- Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- ICES, Ottawa, Ontario, Canada
| | | | | | - Peter G Lawlor
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Christine Watt
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Genevieve Casey
- Division of Geriatrics, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Frank Knoefel
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- ICES, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Franco Momoli
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- ICES, Ottawa, Ontario, Canada
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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Scott MM, Ramzy A, Isenberg SR, Webber C, Eddeen AB, Murmann M, Mahdavi R, Howard M, Kendall CE, Klinger C, Marshall D, Sinnarajah A, Ponka D, Buchman S, Bennett C, Tanuseputro P, Dahrouge S, May K, Heer C, Cooper D, Manuel D, Thavorn K, Hsu AT. Nurse practitioner and physician end-of-life home visits and end-of-life outcomes. BMJ Support Palliat Care 2023:spcare-2023-004392. [PMID: 37979954 DOI: 10.1136/spcare-2023-004392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 10/13/2023] [Indexed: 11/20/2023]
Abstract
OBJECTIVES Physicians and nurse practitioners (NPs) play critical roles in supporting palliative and end-of-life care in the community. We examined healthcare outcomes among patients who received home visits from physicians and NPs in the 90 days before death. METHODS We conducted a retrospective cohort study using linked data of adult home care users in Ontario, Canada, who died between 1 January 2018 and 31 December 2019. Healthcare outcomes included medications for pain and symptom management, emergency department (ED) visits, hospitalisations and a community-based death. We compared the characteristics of and outcomes in decedents who received a home visit from an NP, physician and both to those who did not receive a home visit. RESULTS Half (56.9%) of adult decedents in Ontario did not receive a home visit from a provider in the last 90 days of life; 34.5% received at least one visit from a physician, 3.8% from an NP and 4.9% from both. Compared with those without any visits, having at least one home visit reduced the odds of hospitalisation and ED visits, and increased the odds of receiving medications for pain and symptom management and achieving a community-based death. Observed effects were larger in patients who received at least one visit from both. CONCLUSIONS Beyond home care, receiving home visits from primary care providers near the end of life may be associated with better outcomes that are aligned with patients' preferences-emphasising the importance of NPs and physicians' role in supporting people near the end of life.
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Affiliation(s)
- Mary M Scott
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Amy Ramzy
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Sarina Roslyn Isenberg
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Colleen Webber
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Anan Bader Eddeen
- ICES uOttawa, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Maya Murmann
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Roshanak Mahdavi
- ICES uOttawa, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Michelle Howard
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Claire E Kendall
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Christopher Klinger
- Division of Palliative Care, Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Denise Marshall
- Division of Palliative Care, Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Aynharan Sinnarajah
- Division of Palliative Medicine, Department of Medicine, Queen's University, Kingston, Ontario, Canada
- Lakeridge Health, Oshawa, Ontario, Canada
| | - David Ponka
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sandy Buchman
- Division of Palliative Care, Department of Family & Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Carol Bennett
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- ICES uOttawa, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Simone Dahrouge
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Kathryn May
- Emergency Department, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Carrie Heer
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Dana Cooper
- Nurse Practitioners' Association, Toronto, Ontario, Canada
| | - Douglas Manuel
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- ICES uOttawa, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- ICES uOttawa, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Amy T Hsu
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Guan Q, Calzavara A, Cadel L, Hogan ME, McCormack D, Patel T, Lofters AK, Hitzig SL, Guilcher SJT. Indicators of publicly funded prescription opioid use among persons with traumatic spinal cord injury in Ontario, Canada. J Spinal Cord Med 2023; 46:881-888. [PMID: 34698613 PMCID: PMC10653736 DOI: 10.1080/10790268.2021.1969503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE To describe the proportion and identify predictors of community-dwelling individuals with traumatic spinal cord injury (TSCI) who were dispensed ≥1 publicly funded opioid in the year after injury using a retrospective cohort study. SETTING Ontario, Canada. PARTICIPANTS, INTERVENTIONS, OUTCOME MEASURES We used administrative data to identify predictors of receiving publicly funded prescription opioids during the year after injury for individuals who were injured between April 2004 and March 2015. Our outcome was modeled using robust Poisson multivariable regression and we reported adjusted relative risks (aRR) with 95% confidence intervals. RESULTS In our retrospective cohort of 934 individuals with TSCI who were eligible for the provincial drug program, 510 (55%) received ≥1 prescription opioid in the year after their injury. Most individuals were male (71%) and the median age was 63 years (interquartile range: 42-72). Being male (aRR 1.15, 95% confidence interval [CI] 1.01-1.31), having chronic obstructive pulmonary disease (aRR 1.25, 95% CI 1.05-1.50), and using prescription opioids before injury (aRR 1.46, 95% CI 1.29-1.66) were significantly associated with receiving opioids in the year after TSCI. Short durations of hospital stay after injury were also identified as being a significant risk factor of outpatient opioid use (aRR = 1.28, 95% CI = 1.08-1.51) when compared to longer hospital stays. CONCLUSION This study presented evidence showing that most individuals eligible for Ontario's public drug program who experienced a TSCI used opioids in the year following their injury. Due to the paucity of research on this population and their potential for elevated risks of adverse events, it is important for additional studies to be conducted on opioid use in this population to understand short-term and long-term risks and benefits.
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Affiliation(s)
- Qi Guan
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | | | - Lauren Cadel
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Trillium Health Partners, Toronto, Ontario, Canada
| | - Mary-Ellen Hogan
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | | | - Tejal Patel
- University of Waterloo School of Pharmacy, Kitchener, Ontario, Canada
- Schlegel – University of Waterloo Research Institute of Aging, Waterloo, Ontario, Canada
- Waterloo Institute for Complexity and Innovation, Ontario, Canada
| | - Aisha K. Lofters
- ICES, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Women’s College Research Institute, Toronto, Ontario, Canada
| | - Sander L. Hitzig
- Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- St. John’s Rehab Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, North York, Ontario, Canada
- Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sara J. T. Guilcher
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Feng X, Sarma H, Seubsman SA, Sleigh A, Kelly M. The Impact of Multimorbidity on All-Cause Mortality: A Longitudinal Study of 87,151 Thai Adults. Int J Public Health 2023; 68:1606137. [PMID: 37881771 PMCID: PMC10594150 DOI: 10.3389/ijph.2023.1606137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 09/21/2023] [Indexed: 10/27/2023] Open
Abstract
Objectives: To investigate associations between multimorbidity, socio-demographic and health behaviour factors, and their interactions (multimorbidity and these factors) with all-cause mortality among Thai adults. Methods: Associations between multimorbidity (coexistence of two + chronic diseases) and mortality between 2005 and 2019 were investigated among Thai Cohort Study (TCS) participants (n = 87,151). Kaplan-Meier survival curves estimated and compared survival times. Multivariate Cox proportional hazards models examined associations between risk factors, and interactions between multimorbidity, these factors, and survival. Results: 1,958 cohort members died between 2005 and 2019. The risk of death was 43% higher for multimorbid people. In multivariate Cox proportional hazard models, multimorbidity/number of chronic conditions, age, long sleep duration, smoking and drinking were all independent factors that increased mortality risk. Women, urbanizers, university education, over 20,000-baht personal monthly income and soybean products consumption lowered risk. The interactions between multimorbidity and these variables (except for female, urbanizers and soybeans intake) also had significant (p < 0.05) impact on all-cause mortality. Conclusion: The results emphasise the importance of healthy lifestyle and reduced intake of alcohol and tobacco, in reducing premature mortality, especially when suffering from multimorbidity.
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Affiliation(s)
- Xiyu Feng
- National Centre of Epidemiology and Population Health, Australian National University, Canberra, ACT, Australia
| | - Haribondhu Sarma
- National Centre of Epidemiology and Population Health, Australian National University, Canberra, ACT, Australia
| | - Sam-Ang Seubsman
- School of Human Ecology, Sukhothai Thammathirat Open University, Pak Kret, Thailand
| | - Adrian Sleigh
- National Centre of Epidemiology and Population Health, Australian National University, Canberra, ACT, Australia
| | - Matthew Kelly
- National Centre of Epidemiology and Population Health, Australian National University, Canberra, ACT, Australia
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Howard M, Hafid S, Isenberg SR, Webber C, Downar J, Gayowsky A, Jones A, Scott MM, Hsu AT, Conen K, Manuel D, Tanuseputro P. Physician continuity of care in the last year of life in community-dwelling adults: retrospective population-based study. BMJ Support Palliat Care 2023:spcare-2023-004357. [PMID: 37580116 DOI: 10.1136/spcare-2023-004357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 07/25/2023] [Indexed: 08/16/2023]
Abstract
OBJECTIVE To describe the timing of involvement of various physician specialties over the last year of life across different levels of primary care physician continuity for differing causes of death. METHODS We conducted a retrospective cohort study of adults who died in Ontario, Canada, between 1 January 2013 and 31 December 2018, using linked population level health administrative data. Outcomes were median days between death and first and last outpatient palliative care specialist encounter, last outpatient encounter with other specialists and with the usual primary care physician. These were calculated by tertile of score on the Usual Provider Continuity Index, defined as the proportion of outpatient physician encounters with the patient's primary care physician. RESULTS Patients' (n=395 839) mean age at death was 76 years. With increasing category of usual primary care physician continuity, a larger proportion were palliative care generalists, palliative care specialist involvement decreased in duration and was concentrated closer to death, the primary care physician was involved closer to death, and other specialist physicians ceased involvement earlier. For patients with cancer, palliative care specialist involvement was longer than for other patients. CONCLUSIONS Compared with patients with lower continuity, those with higher usual provider continuity were more likely to have a primary care physician involved closer to death providing generalist palliative care.
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Affiliation(s)
- Michelle Howard
- Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Shuaib Hafid
- Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sarina Roslyn Isenberg
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - James Downar
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Anastasia Gayowsky
- McMaster University, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Aaron Jones
- McMaster University, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Mary M Scott
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Amy T Hsu
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Katrin Conen
- Walker Family Cancer Centre and Niagara Health Sciences, McMaster University Department of Medicine, Hamilton, Ontario, Canada
| | - Doug Manuel
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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7
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Scott MM, Webber C, Clarke AE, Hafid A, Isenberg SR, Jones A, Hsu AT, Conen K, Downar J, Manuel DG, Howard M, Tanuseputro P. Physician home visits to rostered patients during their last year of life: a retrospective cohort study. CMAJ Open 2023; 11:E597-E606. [PMID: 37402554 DOI: 10.9778/cmajo.20220123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Physician home visits are associated with better health outcomes, yet most patients near the end of life never receive such a visit. Our objectives were to describe the receipt of physician home visits during the last year of life after a referral to home care - an indication that the patient can no longer live independently - and to measure associations between patient characteristics and receipt of a home visit. METHODS We conducted a retrospective cohort study using linked population-based health administrative databases housed at ICES. We identified adult (aged ≥ 18 yr) decedents in Ontario who died between Mar. 31, 2013, and Mar. 31, 2018, who were receiving primary care and were referred to publicly funded home care services. We described the provision of physician home visits, office visits and telephone management. We used multinomial logistic regression to calculate the odds of receiving home visits from a rostered primary care physician, controlling for referral during the last year of life, age, sex, income quintile, rurality, recent immigrant status, referral by rostered physician, referral during hospital stay, number of chronic conditions and disease trajectory based on the cause of death. RESULTS Of the 58 753 decedents referred in their last year of life, 3125 (5.3%) received a home visit from their family physician. Patient characteristics associated with higher odds of receiving home visits compared to office-based or telephone-based care were being female (adjusted odds ratio [OR] 1.28, 95% confidence interval [CI] 1.21-1.35), being 85 years of age or older (adjusted OR 2.42, 95% CI 1.80-3.26) and living in a rural area (adjusted OR 1.09, 95% CI 1.00-1.18). Increased odds were associated with home care referrals by the patient's primary care physician (adjusted OR 1.49, 95% CI 1.39-1.58) and referrals occurring during a hospital stay (adjusted OR 1.20, 95% CI 1.13-1.28). INTERPRETATION A small proportion of patients near the end of life received home-based physician care, and patient characteristics did not explain the low visit rates. Future work on system- and provider-level factors may be critical to improve access to home-based end-of-life primary care.
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Affiliation(s)
- Mary M Scott
- Bruyère Research Institute (Webber, Isenberg, Hsu, Manuel, Tanuseputro); Ottawa Hospital Research Institute (Scott, Webber, Clarke, Hsu, Manuel, Tanuseputro); School of Epidemiology and Public Health (Scott, Isenberg, Tanuseputro), Department of Medicine, University of Ottawa; ICES uOttawa (Webber, Clarke, Manuel, Tanuseputro), Ottawa, Ont.; Department of Family Medicine (Hafid, Howard), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Isenberg), University of Toronto, Toronto, Ont.; Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Jones); Department of Medicine (Conen), McMaster University, Hamilton, Ont.; Division of Palliative Care (Downar), Department of Medicine, University of Ottawa; Department of Family Medicine (Manuel), University of Ottawa, Ottawa, Ont.
| | - Colleen Webber
- Bruyère Research Institute (Webber, Isenberg, Hsu, Manuel, Tanuseputro); Ottawa Hospital Research Institute (Scott, Webber, Clarke, Hsu, Manuel, Tanuseputro); School of Epidemiology and Public Health (Scott, Isenberg, Tanuseputro), Department of Medicine, University of Ottawa; ICES uOttawa (Webber, Clarke, Manuel, Tanuseputro), Ottawa, Ont.; Department of Family Medicine (Hafid, Howard), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Isenberg), University of Toronto, Toronto, Ont.; Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Jones); Department of Medicine (Conen), McMaster University, Hamilton, Ont.; Division of Palliative Care (Downar), Department of Medicine, University of Ottawa; Department of Family Medicine (Manuel), University of Ottawa, Ottawa, Ont
| | - Anna E Clarke
- Bruyère Research Institute (Webber, Isenberg, Hsu, Manuel, Tanuseputro); Ottawa Hospital Research Institute (Scott, Webber, Clarke, Hsu, Manuel, Tanuseputro); School of Epidemiology and Public Health (Scott, Isenberg, Tanuseputro), Department of Medicine, University of Ottawa; ICES uOttawa (Webber, Clarke, Manuel, Tanuseputro), Ottawa, Ont.; Department of Family Medicine (Hafid, Howard), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Isenberg), University of Toronto, Toronto, Ont.; Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Jones); Department of Medicine (Conen), McMaster University, Hamilton, Ont.; Division of Palliative Care (Downar), Department of Medicine, University of Ottawa; Department of Family Medicine (Manuel), University of Ottawa, Ottawa, Ont
| | - Abe Hafid
- Bruyère Research Institute (Webber, Isenberg, Hsu, Manuel, Tanuseputro); Ottawa Hospital Research Institute (Scott, Webber, Clarke, Hsu, Manuel, Tanuseputro); School of Epidemiology and Public Health (Scott, Isenberg, Tanuseputro), Department of Medicine, University of Ottawa; ICES uOttawa (Webber, Clarke, Manuel, Tanuseputro), Ottawa, Ont.; Department of Family Medicine (Hafid, Howard), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Isenberg), University of Toronto, Toronto, Ont.; Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Jones); Department of Medicine (Conen), McMaster University, Hamilton, Ont.; Division of Palliative Care (Downar), Department of Medicine, University of Ottawa; Department of Family Medicine (Manuel), University of Ottawa, Ottawa, Ont
| | - Sarina R Isenberg
- Bruyère Research Institute (Webber, Isenberg, Hsu, Manuel, Tanuseputro); Ottawa Hospital Research Institute (Scott, Webber, Clarke, Hsu, Manuel, Tanuseputro); School of Epidemiology and Public Health (Scott, Isenberg, Tanuseputro), Department of Medicine, University of Ottawa; ICES uOttawa (Webber, Clarke, Manuel, Tanuseputro), Ottawa, Ont.; Department of Family Medicine (Hafid, Howard), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Isenberg), University of Toronto, Toronto, Ont.; Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Jones); Department of Medicine (Conen), McMaster University, Hamilton, Ont.; Division of Palliative Care (Downar), Department of Medicine, University of Ottawa; Department of Family Medicine (Manuel), University of Ottawa, Ottawa, Ont
| | - Aaron Jones
- Bruyère Research Institute (Webber, Isenberg, Hsu, Manuel, Tanuseputro); Ottawa Hospital Research Institute (Scott, Webber, Clarke, Hsu, Manuel, Tanuseputro); School of Epidemiology and Public Health (Scott, Isenberg, Tanuseputro), Department of Medicine, University of Ottawa; ICES uOttawa (Webber, Clarke, Manuel, Tanuseputro), Ottawa, Ont.; Department of Family Medicine (Hafid, Howard), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Isenberg), University of Toronto, Toronto, Ont.; Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Jones); Department of Medicine (Conen), McMaster University, Hamilton, Ont.; Division of Palliative Care (Downar), Department of Medicine, University of Ottawa; Department of Family Medicine (Manuel), University of Ottawa, Ottawa, Ont
| | - Amy T Hsu
- Bruyère Research Institute (Webber, Isenberg, Hsu, Manuel, Tanuseputro); Ottawa Hospital Research Institute (Scott, Webber, Clarke, Hsu, Manuel, Tanuseputro); School of Epidemiology and Public Health (Scott, Isenberg, Tanuseputro), Department of Medicine, University of Ottawa; ICES uOttawa (Webber, Clarke, Manuel, Tanuseputro), Ottawa, Ont.; Department of Family Medicine (Hafid, Howard), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Isenberg), University of Toronto, Toronto, Ont.; Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Jones); Department of Medicine (Conen), McMaster University, Hamilton, Ont.; Division of Palliative Care (Downar), Department of Medicine, University of Ottawa; Department of Family Medicine (Manuel), University of Ottawa, Ottawa, Ont
| | - Katrin Conen
- Bruyère Research Institute (Webber, Isenberg, Hsu, Manuel, Tanuseputro); Ottawa Hospital Research Institute (Scott, Webber, Clarke, Hsu, Manuel, Tanuseputro); School of Epidemiology and Public Health (Scott, Isenberg, Tanuseputro), Department of Medicine, University of Ottawa; ICES uOttawa (Webber, Clarke, Manuel, Tanuseputro), Ottawa, Ont.; Department of Family Medicine (Hafid, Howard), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Isenberg), University of Toronto, Toronto, Ont.; Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Jones); Department of Medicine (Conen), McMaster University, Hamilton, Ont.; Division of Palliative Care (Downar), Department of Medicine, University of Ottawa; Department of Family Medicine (Manuel), University of Ottawa, Ottawa, Ont
| | - James Downar
- Bruyère Research Institute (Webber, Isenberg, Hsu, Manuel, Tanuseputro); Ottawa Hospital Research Institute (Scott, Webber, Clarke, Hsu, Manuel, Tanuseputro); School of Epidemiology and Public Health (Scott, Isenberg, Tanuseputro), Department of Medicine, University of Ottawa; ICES uOttawa (Webber, Clarke, Manuel, Tanuseputro), Ottawa, Ont.; Department of Family Medicine (Hafid, Howard), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Isenberg), University of Toronto, Toronto, Ont.; Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Jones); Department of Medicine (Conen), McMaster University, Hamilton, Ont.; Division of Palliative Care (Downar), Department of Medicine, University of Ottawa; Department of Family Medicine (Manuel), University of Ottawa, Ottawa, Ont
| | - Douglas G Manuel
- Bruyère Research Institute (Webber, Isenberg, Hsu, Manuel, Tanuseputro); Ottawa Hospital Research Institute (Scott, Webber, Clarke, Hsu, Manuel, Tanuseputro); School of Epidemiology and Public Health (Scott, Isenberg, Tanuseputro), Department of Medicine, University of Ottawa; ICES uOttawa (Webber, Clarke, Manuel, Tanuseputro), Ottawa, Ont.; Department of Family Medicine (Hafid, Howard), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Isenberg), University of Toronto, Toronto, Ont.; Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Jones); Department of Medicine (Conen), McMaster University, Hamilton, Ont.; Division of Palliative Care (Downar), Department of Medicine, University of Ottawa; Department of Family Medicine (Manuel), University of Ottawa, Ottawa, Ont
| | - Michelle Howard
- Bruyère Research Institute (Webber, Isenberg, Hsu, Manuel, Tanuseputro); Ottawa Hospital Research Institute (Scott, Webber, Clarke, Hsu, Manuel, Tanuseputro); School of Epidemiology and Public Health (Scott, Isenberg, Tanuseputro), Department of Medicine, University of Ottawa; ICES uOttawa (Webber, Clarke, Manuel, Tanuseputro), Ottawa, Ont.; Department of Family Medicine (Hafid, Howard), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Isenberg), University of Toronto, Toronto, Ont.; Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Jones); Department of Medicine (Conen), McMaster University, Hamilton, Ont.; Division of Palliative Care (Downar), Department of Medicine, University of Ottawa; Department of Family Medicine (Manuel), University of Ottawa, Ottawa, Ont
| | - Peter Tanuseputro
- Bruyère Research Institute (Webber, Isenberg, Hsu, Manuel, Tanuseputro); Ottawa Hospital Research Institute (Scott, Webber, Clarke, Hsu, Manuel, Tanuseputro); School of Epidemiology and Public Health (Scott, Isenberg, Tanuseputro), Department of Medicine, University of Ottawa; ICES uOttawa (Webber, Clarke, Manuel, Tanuseputro), Ottawa, Ont.; Department of Family Medicine (Hafid, Howard), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Isenberg), University of Toronto, Toronto, Ont.; Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Jones); Department of Medicine (Conen), McMaster University, Hamilton, Ont.; Division of Palliative Care (Downar), Department of Medicine, University of Ottawa; Department of Family Medicine (Manuel), University of Ottawa, Ottawa, Ont
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8
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Mofina A, Miller J, Tranmer J, Li W, Donnelly C. The association between receipt of home care rehabilitation services and acute care hospital utilization in clients with multimorbidity following an acute care unit discharge: a retrospective cohort study. BMC Health Serv Res 2023; 23:269. [PMID: 36934243 PMCID: PMC10024414 DOI: 10.1186/s12913-023-09116-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 01/27/2023] [Indexed: 03/20/2023] Open
Abstract
BACKGROUND Individuals experiencing multimorbidity have more complex healthcare needs, use more healthcare services, and access multiple service providers across the healthcare continuum. They also experience higher rates of functional decline. Rehabilitation therapists are well positioned to address these functional needs; however, little is known about the influence of rehabilitation therapy on patient outcomes, and subsequent unplanned healthcare utilization for people with multimorbidity. The aims of this study were to: 1) describe and compare the characteristics of people with multimorbidity receiving: home care rehabilitation therapy alone, other home care services without rehabilitation therapy, and the combination of home care rehabilitation therapy and other home care services, and 2) determine the association between home care rehabilitation therapy and subsequent healthcare utilization among those recently discharged from an acute care unit. METHODS This retrospective cohort study used linked health administrative data housed within ICES, Ontario, Canada. The cohort included long-stay home care clients experiencing multimorbidity who were discharged from acute care settings between 2007-2015 (N = 43,145). Descriptive statistics, ANOVA's, t-tests, and chi-square analyses were used to describe and compare cohort characteristics. Multivariable logistic regression was used to understand the association between receipt of rehabilitation therapy and healthcare utilization. RESULTS Of those with multimorbidity receiving long-stay home care services, 45.5% had five or more chronic conditions and 46.3% required some assistance with ADLs. Compared to people receiving other home care services, those receiving home care rehabilitation therapy only were less likely to be readmitted to the hospital (OR = 0.78; 95% CI: 0.73-0.83) and use emergency department services (OR = 0.73; 95% CI: 0.69-0.78) within the first 3-months following hospital discharge. CONCLUSIONS Receipt of rehabilitation therapy was associated with less unplanned healthcare service use when transitioning from hospital to home among persons with multimorbidity. These findings suggest rehabilitation therapy may help to reduce the healthcare burden for individuals and health systems. Future research should evaluate the potential cost savings and health outcomes associated with providing rehabilitation therapy services for people with multimorbidity.
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Affiliation(s)
- Amanda Mofina
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada.
| | - Jordan Miller
- School of Rehabilitation Therapy, Queen's University, Kingston, ON, Canada
| | - Joan Tranmer
- School of Nursing, Queen's University, Kingston, ON, Canada
- ICES, Queen's, Kingston, ON, Canada
| | | | - Catherine Donnelly
- School of Rehabilitation Therapy, Queen's University, Kingston, ON, Canada
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9
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Alarilla A, Mondor L, Knight H, Hughes J, Koné AP, Wodchis WP, Stafford M. Socioeconomic gradient in mortality of working age and older adults with multiple long-term conditions in England and Ontario, Canada. BMC Public Health 2023; 23:472. [PMID: 36906531 PMCID: PMC10008074 DOI: 10.1186/s12889-023-15370-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 03/02/2023] [Indexed: 03/13/2023] Open
Abstract
BACKGROUND There is currently mixed evidence on the influence of long-term conditions and deprivation on mortality. We aimed to explore whether number of long-term conditions contribute to socioeconomic inequalities in mortality, whether the influence of number of conditions on mortality is consistent across socioeconomic groups and whether these associations vary by working age (18-64 years) and older adults (65 + years). We provide a cross-jurisdiction comparison between England and Ontario, by replicating the analysis using comparable representative datasets. METHODS Participants were randomly selected from Clinical Practice Research Datalink in England and health administrative data in Ontario. They were followed from 1 January 2015 to 31 December 2019 or death or deregistration. Number of conditions was counted at baseline. Deprivation was measured according to the participant's area of residence. Cox regression models were used to estimate hazards of mortality by number of conditions, deprivation and their interaction, with adjustment for age and sex and stratified between working age and older adults in England (N = 599,487) and Ontario (N = 594,546). FINDINGS There is a deprivation gradient in mortality between those living in the most deprived areas compared to the least deprived areas in England and Ontario. Number of conditions at baseline was associated with increasing mortality. The association was stronger in working age compared with older adults respectively in England (HR = 1.60, 95% CI 1.56,1.64 and HR = 1.26, 95% CI 1.25,1.27) and Ontario (HR = 1.69, 95% CI 1.66,1.72 and HR = 1.39, 95% CI 1.38,1.40). Number of conditions moderated the socioeconomic gradient in mortality: a shallower gradient was seen for persons with more long-term conditions. CONCLUSIONS Number of conditions contributes to higher mortality rate and socioeconomic inequalities in mortality in England and Ontario. Current health care systems are fragmented and do not compensate for socioeconomic disadvantages, contributing to poor outcomes particularly for those managing multiple long-term conditions. Further work should identify how health systems can better support patients and clinicians who are working to prevent the development and improve the management of multiple long-term conditions, especially for individuals living in socioeconomically deprived areas.
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Affiliation(s)
- Anne Alarilla
- The Health Foundation, 8 Salisbury Square, London, UK.
| | - Luke Mondor
- ICES, Toronto, ON, M4N 3M5, Canada
- Health System Performance Network, Toronto, ON, Canada
| | - Hannah Knight
- The Health Foundation, 8 Salisbury Square, London, UK
| | - Jay Hughes
- The Health Foundation, 8 Salisbury Square, London, UK
| | - Anna Pefoyo Koné
- Health System Performance Network, Toronto, ON, Canada
- Department of Health Sciences, Lakehead University, Thunder Bay, ON, Canada
| | - Walter P Wodchis
- ICES, Toronto, ON, M4N 3M5, Canada
- Health System Performance Network, Toronto, ON, Canada
- Institute of Health Policy Management & Evaluation, University of Toronto, Toronto, ON, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | - Mai Stafford
- The Health Foundation, 8 Salisbury Square, London, UK
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10
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Leigh J, Qureshi D, Sucha E, Mahdavi R, Kushnir I, Lavallée LT, Bosse D, Webber C, Tanuseputro P, Ong M. A population-based study of factors associated with systemic treatment in advanced prostate cancer decedents. Cancer Med 2023; 12:5569-5579. [PMID: 36397730 PMCID: PMC10028120 DOI: 10.1002/cam4.5401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/13/2022] [Accepted: 10/23/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Life-prolonging therapies (LPTs) are rapidly evolving for the treatment of advanced prostate cancer, although factors associated with real-world uptake are not well characterized. METHODS In this cohort of prostate-cancer decedents, we analyzed factors associated with LPT access. Population-level databases from Ontario, Canada identified patients 65 years or older with prostate cancer receiving androgen deprivation therapy and who died of prostate cancer between 2013 and 2017. Univariate and multivariable analyses assessed the association between baseline characteristics and receipt of LPT in the 2 years prior to death. RESULTS Of 3575 patients who died of prostate cancer, 40.4% (n = 1443) received LPT, which comprised abiraterone (66.3%), docetaxel (50.3%), enzalutamide (17.2%), radium-223 (10.0%), and/or cabazitaxel (3.5%). Use of LPT increased by year of death (2013: 22.7%, 2014: 31.8%, 2015: 41.8%, 2016: 49.1%, and 2017: 57.9%, p < 0.0001), driven by uptake of all agents except docetaxel. Adjusted odds of use were higher for patients seen at Regional Cancer Centers (OR: 1.8, 95% CI: 1.5-2.1) and who received prior prostate-directed therapy (OR: 1.3, 95% CI: 1.0-1.5), but lower with advanced age (≥85: OR: 0.54, 95% CI:0.39-0.75), increased chronic conditions (≥6: OR: 0.62, 95% CI: 0.43-0.92), and long-term care residency (OR: 0.38, 95% CI: 0.17-0.89). Income, stage at presentation, and distance to the cancer center were not associated with LPT uptake. CONCLUSION In this cohort of prostate cancer-decedents, real-world uptake of novel prostate cancer therapies occurred at substantially higher rates for patients receiving care at Regional Cancer Centers, reinforcing the potential benefits for treatment access for patients referred to specialist centers.
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Affiliation(s)
- Jennifer Leigh
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Danial Qureshi
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Nuffield Department of Population Health, University of Oxford, England, UK
| | - Ewa Sucha
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- ICES University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Roshanak Mahdavi
- ICES University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Igal Kushnir
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Luke T Lavallée
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Division of Urology, Department of Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Dominick Bosse
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- ICES University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Michael Ong
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
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11
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Hafid A, Howard M, Webber C, Gayowsky A, Scott M, Jones A, Hsu AT, Tanuseputro P, Downar J, Conen K, Manuel D, Isenberg SR. Describing settings of care in the last 100 days of life for cancer decedents: a population-based descriptive study. Cancer Med 2023; 12:4809-4820. [PMID: 36281530 PMCID: PMC9972173 DOI: 10.1002/cam4.5291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 08/24/2022] [Accepted: 09/13/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Few studies have described the settings cancer decedents spend their end-of-life stage, with none considering homecare specifically. We describe the different settings of care experienced in the last 100 days of life by individuals with cancer and how settings of care change as they approached death. METHODS A retrospective cohort study from January 2013 to December 2017, of decedents whose primary cause of death was cancer, using linked population-level health administrative datasets in Ontario, Canada. RESULTS Decedents 125,755 were included in our cohort. The average age at death was 73, 46% were female, and 14% resided in rural regions. And 24% died of lung cancer, 7% breast, 7% colorectal, 7% pancreatic, 5% prostate, and 50% other cancers. In the last 100 days of life, decedents spent 25.9 days in institutions, 25.8 days receiving care in the community, and 48.3 days at home without any care. Individuals who died of lung and pancreatic cancers spent the most days at home without any care (52.1 and 52.6 days), while individuals who died of prostate and breast cancer spent the least days at home without any care (41.6 and 45.1 days). Regardless of cancer type, decedents spent fewer days at home and more days in institutions as they approached death, despite established patient preferences for an end-of-life experience at home. CONCLUSIONS In the last 100 days of life, cancer decedents spent most of their time in either institutions or at home without any care. Improving homecare services during the end-of-life may provide people dying of cancer with a preferred dying experience.
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Affiliation(s)
- Abe Hafid
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Michelle Howard
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Canada.,Bruyère Research Institute, Ottawa, Canada.,ICES uOttawa, Ottawa, Canada
| | | | - Mary Scott
- Ottawa Hospital Research Institute, Ottawa, Canada.,Bruyère Research Institute, Ottawa, Canada
| | - Aaron Jones
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Amy T Hsu
- Ottawa Hospital Research Institute, Ottawa, Canada.,Bruyère Research Institute, Ottawa, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, Canada.,Bruyère Research Institute, Ottawa, Canada.,ICES uOttawa, Ottawa, Canada.,Department of Medicine, University of Ottawa, Ottawa, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - James Downar
- Ottawa Hospital Research Institute, Ottawa, Canada.,Bruyère Research Institute, Ottawa, Canada.,Department of Medicine, University of Ottawa, Ottawa, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Katrin Conen
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Doug Manuel
- Ottawa Hospital Research Institute, Ottawa, Canada.,ICES uOttawa, Ottawa, Canada.,Department of Family Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Sarina R Isenberg
- Ottawa Hospital Research Institute, Ottawa, Canada.,Bruyère Research Institute, Ottawa, Canada.,Department of Medicine, University of Ottawa, Ottawa, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Canada
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12
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Ryan BL, Mondor L, Wodchis WP, Glazier RH, Meredith L, Fortin M, Stewart M. Effect of a multimorbidity intervention on health care utilization and costs in Ontario: randomized controlled trial and propensity-matched analyses. CMAJ Open 2023; 11:E45-E53. [PMID: 36649982 PMCID: PMC9851625 DOI: 10.9778/cmajo.20220006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Patients with multimorbidity require coordinated and patient-centred care. Telemedicine IMPACT Plus provides such care for complex patients in Toronto, Ontario. We conducted a randomized controlled trial (RCT) comparing health care utilization and costs at 1-year postintervention for an intervention group and 2 control groups (RCT and propensity matched). METHODS Data for 82 RCT intervention and 74 RCT control participants were linked with health administrative data. We created a second control group using health administrative data-derived propensity scores to match (1:5) intervention participants with comparators. We evaluated 5 outcomes: acute hospital admissions, emergency department visits, costs of all insured health care, 30-day hospital readmissions and 7-day family physician follow-up after hospital discharge using generalized linear models for RCT controls and generalized estimating equations for propensity-matched controls. RESULTS There were no significant differences between intervention participants and either control group. For hospital admissions, emergency department visits, costs and readmissions, the relative differences ranged from 1.00 (95% confidence interval [CI] 0.39-2.60) to 1.67 (95% CI 0.82-3.38) with intervention costs at about Can$20 000, RCT controls costs at around Can$15 000 and propensity controls costs at around Can$17 000. There was a higher rate of follow-up with a family physician for the intervention participants compared with the RCT controls (53.13 v. 21.43 per 100 hospital discharges; relative difference 2.48 [95% CI 0.98-6.29]) and propensity-matched controls (49.94 v. 28.21 per 100 hospital discharges; relative difference 1.81 [95% CI 0.99-3.30]). INTERPRETATION Despite a complex patient-centred intervention, there was no significant improvement in health care utilization or cost. Future research requires larger sample sizes and should include outcomes important to patients and the health care system, and longer follow-up periods. ONTARIO ClinicalTrials.gov : 104191.
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Affiliation(s)
- Bridget L Ryan
- Centre for Studies in Family Medicine and the Department of Epidemiology and Biostatistics (Ryan), Schulich School of Medicine & Dentistry, Western University, London, Ont.; Health System Performance Network (Mondor); ICES (Mondor, Wodchis); Institute for Better Health, Trillium Health Partners (Wodchis), Mississauga, Ont.; Health System Performance Network and Institute of Health Policy, Management and Evaluation (Wodchis), University of Toronto; Department of Family and Community Medicine (Glazier), University of Toronto, Toronto Ont.; Centre for Studies in Family Medicine, Department of Family Medicine (Meredith), Schulich School of Medicine & Dentistry, Western University, London, Ont.; Department of Family Medicine and Emergency Medicine (Fortin), Université de Sherbrooke, Sherbrooke, Que.; Centre for Studies in Family Medicine (Stewart), Schulich School of Medicine & Dentistry, Western University, London, Ont.
| | - Luke Mondor
- Centre for Studies in Family Medicine and the Department of Epidemiology and Biostatistics (Ryan), Schulich School of Medicine & Dentistry, Western University, London, Ont.; Health System Performance Network (Mondor); ICES (Mondor, Wodchis); Institute for Better Health, Trillium Health Partners (Wodchis), Mississauga, Ont.; Health System Performance Network and Institute of Health Policy, Management and Evaluation (Wodchis), University of Toronto; Department of Family and Community Medicine (Glazier), University of Toronto, Toronto Ont.; Centre for Studies in Family Medicine, Department of Family Medicine (Meredith), Schulich School of Medicine & Dentistry, Western University, London, Ont.; Department of Family Medicine and Emergency Medicine (Fortin), Université de Sherbrooke, Sherbrooke, Que.; Centre for Studies in Family Medicine (Stewart), Schulich School of Medicine & Dentistry, Western University, London, Ont
| | - Walter P Wodchis
- Centre for Studies in Family Medicine and the Department of Epidemiology and Biostatistics (Ryan), Schulich School of Medicine & Dentistry, Western University, London, Ont.; Health System Performance Network (Mondor); ICES (Mondor, Wodchis); Institute for Better Health, Trillium Health Partners (Wodchis), Mississauga, Ont.; Health System Performance Network and Institute of Health Policy, Management and Evaluation (Wodchis), University of Toronto; Department of Family and Community Medicine (Glazier), University of Toronto, Toronto Ont.; Centre for Studies in Family Medicine, Department of Family Medicine (Meredith), Schulich School of Medicine & Dentistry, Western University, London, Ont.; Department of Family Medicine and Emergency Medicine (Fortin), Université de Sherbrooke, Sherbrooke, Que.; Centre for Studies in Family Medicine (Stewart), Schulich School of Medicine & Dentistry, Western University, London, Ont
| | - Richard H Glazier
- Centre for Studies in Family Medicine and the Department of Epidemiology and Biostatistics (Ryan), Schulich School of Medicine & Dentistry, Western University, London, Ont.; Health System Performance Network (Mondor); ICES (Mondor, Wodchis); Institute for Better Health, Trillium Health Partners (Wodchis), Mississauga, Ont.; Health System Performance Network and Institute of Health Policy, Management and Evaluation (Wodchis), University of Toronto; Department of Family and Community Medicine (Glazier), University of Toronto, Toronto Ont.; Centre for Studies in Family Medicine, Department of Family Medicine (Meredith), Schulich School of Medicine & Dentistry, Western University, London, Ont.; Department of Family Medicine and Emergency Medicine (Fortin), Université de Sherbrooke, Sherbrooke, Que.; Centre for Studies in Family Medicine (Stewart), Schulich School of Medicine & Dentistry, Western University, London, Ont
| | - Leslie Meredith
- Centre for Studies in Family Medicine and the Department of Epidemiology and Biostatistics (Ryan), Schulich School of Medicine & Dentistry, Western University, London, Ont.; Health System Performance Network (Mondor); ICES (Mondor, Wodchis); Institute for Better Health, Trillium Health Partners (Wodchis), Mississauga, Ont.; Health System Performance Network and Institute of Health Policy, Management and Evaluation (Wodchis), University of Toronto; Department of Family and Community Medicine (Glazier), University of Toronto, Toronto Ont.; Centre for Studies in Family Medicine, Department of Family Medicine (Meredith), Schulich School of Medicine & Dentistry, Western University, London, Ont.; Department of Family Medicine and Emergency Medicine (Fortin), Université de Sherbrooke, Sherbrooke, Que.; Centre for Studies in Family Medicine (Stewart), Schulich School of Medicine & Dentistry, Western University, London, Ont
| | - Martin Fortin
- Centre for Studies in Family Medicine and the Department of Epidemiology and Biostatistics (Ryan), Schulich School of Medicine & Dentistry, Western University, London, Ont.; Health System Performance Network (Mondor); ICES (Mondor, Wodchis); Institute for Better Health, Trillium Health Partners (Wodchis), Mississauga, Ont.; Health System Performance Network and Institute of Health Policy, Management and Evaluation (Wodchis), University of Toronto; Department of Family and Community Medicine (Glazier), University of Toronto, Toronto Ont.; Centre for Studies in Family Medicine, Department of Family Medicine (Meredith), Schulich School of Medicine & Dentistry, Western University, London, Ont.; Department of Family Medicine and Emergency Medicine (Fortin), Université de Sherbrooke, Sherbrooke, Que.; Centre for Studies in Family Medicine (Stewart), Schulich School of Medicine & Dentistry, Western University, London, Ont
| | - Moira Stewart
- Centre for Studies in Family Medicine and the Department of Epidemiology and Biostatistics (Ryan), Schulich School of Medicine & Dentistry, Western University, London, Ont.; Health System Performance Network (Mondor); ICES (Mondor, Wodchis); Institute for Better Health, Trillium Health Partners (Wodchis), Mississauga, Ont.; Health System Performance Network and Institute of Health Policy, Management and Evaluation (Wodchis), University of Toronto; Department of Family and Community Medicine (Glazier), University of Toronto, Toronto Ont.; Centre for Studies in Family Medicine, Department of Family Medicine (Meredith), Schulich School of Medicine & Dentistry, Western University, London, Ont.; Department of Family Medicine and Emergency Medicine (Fortin), Université de Sherbrooke, Sherbrooke, Que.; Centre for Studies in Family Medicine (Stewart), Schulich School of Medicine & Dentistry, Western University, London, Ont
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13
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Howard M, Hafid A, Webber C, Isenberg SR, Gayowsky A, Jones A, Scott M, Hsu AT, Conen K, Downar J, Manuel D, Tanuseputro P. Continuity of physician care over the last year of life for different cause-of-death categories: a retrospective population-based study. CMAJ Open 2022; 10:E971-E980. [PMID: 36347560 PMCID: PMC9648626 DOI: 10.9778/cmajo.20210294] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The mix of care provided by family physicians, specialists and palliative care physicians can vary by the illnesses leading to death, which may result in disruptions of continuity of care at the end of life. We measured continuity of outpatient physician care in the last year of life across differing causes of death and assessed factors associated with higher continuity. METHODS We conducted a retrospective descriptive study of adults who died in Ontario between 2013 and 2018, using linked provincial health administrative data. We calculated 3 measures of continuity (usual provider, Bice-Boxerman and sequential continuity), which range from 0 to 1, from outpatient physician visits over the last year of life for terminal illness, organ failure, frailty, sudden death and other causes of death. We used multivariable logistic regression models to evaluate associations between characteristics and a continuity score of 0.5 or greater. RESULTS Among the 417 628 decedents, we found that mean usual provider, Bice-Boxerman and sequential continuity indices were 0.37, 0.30 and 0.37, respectively, with continuity being the lowest for those with terminal illness (0.27, 0.23 and 0.33, respectively). Higher number of comorbidities, higher neighbourhood income quintile and all non-sudden death categories were associated with lower continuity. INTERPRETATION We found that continuity of physician care in the last year of life was low, especially in those with cancer. Further research is needed to validate measures of continuity against end-of-life health care outcomes.
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Affiliation(s)
- Michelle Howard
- Departments of Family Medicine (Howard, Hafid), Medicine (Conen), and Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Gayowsky); Hamilton, Ont.; Ottawa Hospital Research Institute (Webber, Scott, Hsu, Manuel, Tanuseputro); Bruyère Research Institute (Webber, Isenberg, Scott, Hsu, Manuel, Tanuseputro); Division of Palliative Care (Downar), and Departments of Medicine (Isenberg) and Family Medicine (Manuel), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro), Ottawa, Ont.
| | - Abe Hafid
- Departments of Family Medicine (Howard, Hafid), Medicine (Conen), and Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Gayowsky); Hamilton, Ont.; Ottawa Hospital Research Institute (Webber, Scott, Hsu, Manuel, Tanuseputro); Bruyère Research Institute (Webber, Isenberg, Scott, Hsu, Manuel, Tanuseputro); Division of Palliative Care (Downar), and Departments of Medicine (Isenberg) and Family Medicine (Manuel), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro), Ottawa, Ont
| | - Colleen Webber
- Departments of Family Medicine (Howard, Hafid), Medicine (Conen), and Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Gayowsky); Hamilton, Ont.; Ottawa Hospital Research Institute (Webber, Scott, Hsu, Manuel, Tanuseputro); Bruyère Research Institute (Webber, Isenberg, Scott, Hsu, Manuel, Tanuseputro); Division of Palliative Care (Downar), and Departments of Medicine (Isenberg) and Family Medicine (Manuel), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro), Ottawa, Ont
| | - Sarina R Isenberg
- Departments of Family Medicine (Howard, Hafid), Medicine (Conen), and Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Gayowsky); Hamilton, Ont.; Ottawa Hospital Research Institute (Webber, Scott, Hsu, Manuel, Tanuseputro); Bruyère Research Institute (Webber, Isenberg, Scott, Hsu, Manuel, Tanuseputro); Division of Palliative Care (Downar), and Departments of Medicine (Isenberg) and Family Medicine (Manuel), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro), Ottawa, Ont
| | - Ana Gayowsky
- Departments of Family Medicine (Howard, Hafid), Medicine (Conen), and Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Gayowsky); Hamilton, Ont.; Ottawa Hospital Research Institute (Webber, Scott, Hsu, Manuel, Tanuseputro); Bruyère Research Institute (Webber, Isenberg, Scott, Hsu, Manuel, Tanuseputro); Division of Palliative Care (Downar), and Departments of Medicine (Isenberg) and Family Medicine (Manuel), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro), Ottawa, Ont
| | - Aaron Jones
- Departments of Family Medicine (Howard, Hafid), Medicine (Conen), and Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Gayowsky); Hamilton, Ont.; Ottawa Hospital Research Institute (Webber, Scott, Hsu, Manuel, Tanuseputro); Bruyère Research Institute (Webber, Isenberg, Scott, Hsu, Manuel, Tanuseputro); Division of Palliative Care (Downar), and Departments of Medicine (Isenberg) and Family Medicine (Manuel), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro), Ottawa, Ont
| | - Mary Scott
- Departments of Family Medicine (Howard, Hafid), Medicine (Conen), and Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Gayowsky); Hamilton, Ont.; Ottawa Hospital Research Institute (Webber, Scott, Hsu, Manuel, Tanuseputro); Bruyère Research Institute (Webber, Isenberg, Scott, Hsu, Manuel, Tanuseputro); Division of Palliative Care (Downar), and Departments of Medicine (Isenberg) and Family Medicine (Manuel), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro), Ottawa, Ont
| | - Amy T Hsu
- Departments of Family Medicine (Howard, Hafid), Medicine (Conen), and Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Gayowsky); Hamilton, Ont.; Ottawa Hospital Research Institute (Webber, Scott, Hsu, Manuel, Tanuseputro); Bruyère Research Institute (Webber, Isenberg, Scott, Hsu, Manuel, Tanuseputro); Division of Palliative Care (Downar), and Departments of Medicine (Isenberg) and Family Medicine (Manuel), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro), Ottawa, Ont
| | - Katrin Conen
- Departments of Family Medicine (Howard, Hafid), Medicine (Conen), and Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Gayowsky); Hamilton, Ont.; Ottawa Hospital Research Institute (Webber, Scott, Hsu, Manuel, Tanuseputro); Bruyère Research Institute (Webber, Isenberg, Scott, Hsu, Manuel, Tanuseputro); Division of Palliative Care (Downar), and Departments of Medicine (Isenberg) and Family Medicine (Manuel), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro), Ottawa, Ont
| | - James Downar
- Departments of Family Medicine (Howard, Hafid), Medicine (Conen), and Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Gayowsky); Hamilton, Ont.; Ottawa Hospital Research Institute (Webber, Scott, Hsu, Manuel, Tanuseputro); Bruyère Research Institute (Webber, Isenberg, Scott, Hsu, Manuel, Tanuseputro); Division of Palliative Care (Downar), and Departments of Medicine (Isenberg) and Family Medicine (Manuel), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro), Ottawa, Ont
| | - Doug Manuel
- Departments of Family Medicine (Howard, Hafid), Medicine (Conen), and Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Gayowsky); Hamilton, Ont.; Ottawa Hospital Research Institute (Webber, Scott, Hsu, Manuel, Tanuseputro); Bruyère Research Institute (Webber, Isenberg, Scott, Hsu, Manuel, Tanuseputro); Division of Palliative Care (Downar), and Departments of Medicine (Isenberg) and Family Medicine (Manuel), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro), Ottawa, Ont
| | - Peter Tanuseputro
- Departments of Family Medicine (Howard, Hafid), Medicine (Conen), and Health Research Methods, Evidence and Impact (Jones), McMaster University; ICES McMaster (Gayowsky); Hamilton, Ont.; Ottawa Hospital Research Institute (Webber, Scott, Hsu, Manuel, Tanuseputro); Bruyère Research Institute (Webber, Isenberg, Scott, Hsu, Manuel, Tanuseputro); Division of Palliative Care (Downar), and Departments of Medicine (Isenberg) and Family Medicine (Manuel), University of Ottawa; ICES uOttawa (Manuel, Tanuseputro), Ottawa, Ont
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14
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Webber C, Isenberg SR, Scott M, Hafid A, Hsu AT, Conen K, Jones A, Clarke A, Downar J, Kadu M, Tanuseputro P, Howard M. Inpatient Palliative Care Is Associated with the Receipt of Palliative Care in the Community after Hospital Discharge: A Retrospective Cohort Study. J Palliat Med 2022; 25:897-906. [PMID: 35007439 DOI: 10.1089/jpm.2021.0496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: For hospitalized patients with palliative care needs, there is little evidence on whether postdischarge outcomes differ if inpatient palliative care was delivered by a palliative care specialist or nonspecialist/generalist. Objective: To evaluate relationships between inpatient palliative care involvement and physician-delivered palliative care in the community after hospital discharge among individuals with limited life expectancy. Design: Population-based retrospective cohort study using administrative health data. Settings/Subjects: Adults with a predicted median survival of six months or less admitted to acute care hospitals in Ontario, Canada, between April 1, 2013, and March 31, 2017, and discharged to the community. Measurements: Inpatient palliative care involvement was classified as high (e.g., palliative care unit), medium (e.g., palliative care specialist consult), low (e.g., generalist-delivered palliative care), or none. Community palliative care included outpatient and home and clinic visits three weeks postdischarge. Results: Among 3660 hospitalized adults, 82 (2.2%) received inpatient palliative care with high level of involvement, 462 (12.6%) with medium level of involvement, 525 (14.3%) with low level of involvement, and 2591 (70.8%) had no inpatient palliative care. Patients who received inpatient palliative care were more likely to receive community palliative care after discharge than those who received no inpatient palliative care. These associations were stronger among patients who received high/medium palliative care involvement than patients who received low palliative care involvement. Conclusions: Inpatient palliative care, including that delivered by generalists, is associated with an increased likelihood of community palliative care after discharge. Increased inpatient generalist palliative care may help support patients' palliative care needs.
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Affiliation(s)
- Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,ICES, Ottawa, Ontario, Canada
| | - Sarina R Isenberg
- Bruyère Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Mary Scott
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Abe Hafid
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Amy T Hsu
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Katrin Conen
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Aaron Jones
- ICES, Ottawa, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Anna Clarke
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,ICES, Ottawa, Ontario, Canada
| | - James Downar
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Mudathira Kadu
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,ICES, Ottawa, Ontario, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Michelle Howard
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
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15
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Li A, Rosella LC, Kurdyak P, Wodchis WP. Depression as a Risk Factor for Physical Illness and Multimorbidity in a Cohort with No Prior Comorbidity. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2021; 66:726-736. [PMID: 33242993 PMCID: PMC8329899 DOI: 10.1177/0706743720974832] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This study examines whether depression is associated with the development of physical illness and multimorbidity, after controlling for socioeconomic, behavioral, and other potential confounders. METHODS This is a retrospective cohort study in which adult respondents to three nationally representative population health surveys were linked to health administrative databases in Ontario, Canada, and followed for 10 years from survey index. Respondents with any of the study outcome conditions at baseline were excluded to create a final cohort of 29,838 participants. The main exposure of interest was depression, measured using the Composite International Diagnostic Interview-Short Form for Major Depression. We controlled for age, body mass index, marital status, immigrant status, annual household income, smoking, alcohol consumption, physical activity, health status, and having a regular doctor. The outcome measure was the development of physical illness over 10 years of follow-up, defined as 1 of 15 common chronic conditions using administrative data. RESULTS Among the 29,838 participants (15,259 [51%] female), 8% of females and 4% of males had depression at baseline. In this cohort with no comorbidities at baseline, even in the fully adjusted model, depression increased the risk of developing a first physical illness for females (hazard ratio [HR] 1.16; 95% CI, 1.07 to 1.26) and males (HR 1.20; 95% CI, 1.07 to 1.36) and increased the risk of developing a second physical illness for females (HR 1.16; 95% CI, 1.02 to 1.33) over 10 years of follow-up. CONCLUSIONS For individuals with no prior comorbidities, depression is associated with a greater risk of developing subsequent physical illness and multimorbidity over time. Thus, depression identifies a population of people who may benefit from early identification, additional screening, and intervention. Further study needs to be done to determine whether interventions to manage and support people with depression can prevent or delay the increased risk of multimorbidity.
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Affiliation(s)
- Allanah Li
- Department of Family and Community Medicine, University of Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
| | - Laura C Rosella
- Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Paul Kurdyak
- Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Walter P Wodchis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
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16
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Probable Delirium and Associated Patient Characteristics in Long-Term Care and Complex Continuing Care: A Population-Based Observational Study. J Am Med Dir Assoc 2021; 23:66-72.e2. [PMID: 34174195 DOI: 10.1016/j.jamda.2021.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/13/2021] [Accepted: 05/22/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To estimate the prevalence of probable delirium in long-term care (LTC) and complex continuing care (CCC) settings and to describe the resident characteristics associated with probable delirium. DESIGN Population-based cross-sectional study using routinely collected administrative health data. SETTING AND PARTICIPANTS All LTC and CCC residents in Ontario, Canada, assessed with the Resident Assessment Instrument-Minimum Dataset (RAI-MDS) assessment between July 1, 2016, and December 31, 2016 (LTC n=86,454, CCC n=10,217). METHODS Probable delirium was identified via the delirium Clinical Assessment Protocol on the RAI-MDS assessment, which is triggered when individuals display at least 1 of 6 delirium symptoms that are of recent onset and different from their usual functioning. RAI-MDS assessments were linked to demographic and health services utilization databases to ascertain resident demographics and health status. Multivariable logistic regression was used to identify characteristics associated with probable delirium, with adjusted odds ratios (ORs) and 95% confidence intervals (CIs) reported. RESULTS Delirium was probable in 3.6% of LTC residents and 16.5% of CCC patients. LTC patients displayed fewer delirium symptoms than CCC patients. The most common delirium symptom in LTC was periods of lethargy (44.6% of delirium cases); in CCC, it was mental function varying over the course of the day (63.5% of delirium cases). The odds of probable delirium varied across individual demographics and health characteristics, with increased health instability having the strongest association with the outcome in both care settings (LTC: OR 30.4, 95% CI 26.2-35.3; CCC: OR 21.0, 95% CI 16.7-26.5 for high vs low instability). CONCLUSIONS AND IMPLICATIONS There were differences in the presentation and burden of delirium symptoms between LTC and CCC, potentially reflecting differences in delirium severity or symptom identification. Several risk factors for probable delirium in LTC and CCC were identified that may be amenable to interventions to prevent this highly distressing condition.
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17
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Brown CRL, Webber C, Seow HY, Howard M, Hsu AT, Isenberg SR, Jiang M, Smith GA, Spruin S, Tanuseputro P. Impact of physician-based palliative care delivery models on health care utilization outcomes: A population-based retrospective cohort study. Palliat Med 2021; 35:1170-1180. [PMID: 33884934 DOI: 10.1177/02692163211009440] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Increasing involvement of palliative care generalists may improve access to palliative care. It is unknown, however, if their involvement with and without palliative care specialists are associated with different outcomes. AIM To describe physician-based models of palliative care and their association with healthcare utilization outcomes including: emergency department visits, acute hospitalizations and intensive care unit (ICU) admissions in last 30 days of life; and, place of death. DESIGN Population-based retrospective cohort study using linked health administrative data. We used descriptive statistics to compare outcomes across three models (generalist-only palliative care; consultation palliative care, comprising of both generalist and specialist care; and specialist-only palliative care) and conducted a logistic regression for community death. SETTING/PARTICIPANTS All adults aged 18-105 who died in Ontario, Canada between April 1, 2012 and March 31, 2017. RESULTS Of the 231,047 decedents who received palliative services, 40.3% received generalist, 32.3% consultation and 27.4% specialist palliative care. Across models, we noted minimal to modest variation for decedents with at least one emergency department visit (50%-59%), acute hospitalization (64%-69%) or ICU admission (7%-17%), as well as community death (36%-40%). In our adjusted analysis, receipt of a physician home visit was a stronger predictor for increased likelihood of community death (odds ratio 9.6, 95% confidence interval 9.4-9.8) than palliative care model (generalist vs consultation palliative care 2.0, 1.9-2.0). CONCLUSION The generalist palliative care model achieved similar healthcare utilization outcomes as consultation and specialist models. Including a physician home visit component in each model may promote community death.
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Affiliation(s)
- Catherine R L Brown
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Colleen Webber
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada.,ICES, Ottawa, ON, Canada
| | - Hsien-Yeang Seow
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Michelle Howard
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Amy T Hsu
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada.,ICES, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sarina R Isenberg
- Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Mengzhu Jiang
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Glenys A Smith
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada.,ICES, Ottawa, ON, Canada
| | - Sarah Spruin
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada.,ICES, Ottawa, ON, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada.,ICES, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada
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18
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Webber C, Watt CL, Bush SH, Lawlor PG, Talarico R, Tanuseputro P. Hospitalization Outcomes of Delirium in Patients Admitted to Acute Care Hospitals in Their Last Year of Life: A Population-Based Retrospective Cohort Study. J Pain Symptom Manage 2021; 61:1118-1126.e5. [PMID: 33157179 DOI: 10.1016/j.jpainsymman.2020.10.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/26/2020] [Accepted: 10/27/2020] [Indexed: 12/20/2022]
Abstract
CONTEXT Delirium is a highly distressing neurocognitive disorder for patients at the end of life. OBJECTIVES To compare hospitalization outcomes between patients with and without delirium admitted to acute care hospitals in the last year of life. METHODS Using linked administrative data from ICES (previously known as the Institute for Clinical Evaluative Sciences), this population-based retrospective cohort study included adults who died in Ontario between January 1, 2014 and December 31, 2016 and were admitted to an acute care hospital in their last year of life. Delirium was identified via diagnosis codes on the hospitalization discharge record. Outcomes included lengths of stay, discharge location, and in-hospital mortality. We used multivariable generalized estimating equations to compare outcomes between patients with and without delirium. RESULTS Of 208,715 decedents, 9.3% experienced delirium in at least one hospitalization in the last year of life. The mean hospitalization lengths of stay was 13.8 days in patients with delirium (SD = 21.1) or 1.80 times longer (95% CI = 1.75-1.84) compared with those without delirium. Among patients discharged alive, patients with delirium were 1.32 times (95% CI = 1.27-1.38) more likely to be discharged to another institution rather than discharged home. There was no difference in in-hospital mortality between patients with and without delirium (relative risk = 1.01; 95% CI = 0.98-1.05). CONCLUSION In the last year of life, hospitalized patients with recorded delirium experience poorer outcomes, including longer lengths of stay and increased risk of postdischarge institution use, compared with those without delirium. These outcomes illustrate added burden for patients, their families, and the health care system, thus highlighting the need for delirium prevention and early detection in addition to informed transitional care decisions.
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Affiliation(s)
- Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; ICES, Ottawa, Ontario, Canada.
| | - Christine L Watt
- Bruyère Research Institute, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter G Lawlor
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; ICES, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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19
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Funnell S, Walker J, Letendre A, Bearskin RLB, Manuel D, Scott M, Spruin S, Tanuseputro P. Places of death and places of care for Indigenous Peoples in Ontario: a retrospective cohort study. Canadian Journal of Public Health 2021; 112:685-696. [PMID: 34008135 DOI: 10.17269/s41997-021-00482-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 01/25/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Most people, including Indigenous people in Ontario, wish to die in their communities. How often Indigenous people in Ontario die in their preferred settings is unknown. This study aims to describe the places of care and death for Indigenous people in Ontario who received provincially funded home care services. METHODS We conducted a retrospective cohort study using linked health administrative databases housed at ICES. We used a population-based cohort of Indigenous and non-Indigenous people in Ontario who died between April 1, 2010 and March 31, 2015 to describe characteristics of people, places of death, and places of care. RESULTS Indigenous decedents were on average 8.8 years younger, had more chronic diseases, and lived in lower income neighbourhoods compared with their non-Indigenous counterparts. Indigenous decedents spent nearly 8 more days in acute care in the last year of life and more died in acute care (56.1% versus 46.1%). When controlling for covariates, Indigenous decedents received 1.9 fewer home care nursing hours and 5 fewer personal support worker hours and showed decreased odds (OR 0.72) of receiving a palliative physician visit in the last 90 days of life. Among Indigenous decedents, a palliative physician visit lowered odds of dying in acute care by 50% and total days in acute care by 18%. CONCLUSION Our study identified a gap in end-of-life care for Indigenous Peoples in Ontario receiving provincially funded home care. Without continued efforts to address challenges that perpetuate health inequalities, we expect many Indigenous people will continue to die in acute care away from their people, families, and culturally relevant supports.
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Affiliation(s)
- Sarah Funnell
- Department of Family Medicine, Queen's University, 220 Bagot Street, Kingston, ON, K7L 3G2, Canada.
| | | | - Angeline Letendre
- Canadian Indigenous Nurses Association (CINA), Ottawa, Ontario, Canada
| | | | - Douglas Manuel
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,The Ottawa Hospital, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Statistics Canada, Ottawa, Ontario, Canada.,C.T. Lamont Primary Health Care Research Centre, Ottawa, Ontario, Canada
| | | | | | - Peter Tanuseputro
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,The Ottawa Hospital, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,ICES, Toronto, Ontario, Canada
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Kone AP, Mondor L, Maxwell C, Kabir US, Rosella LC, Wodchis WP. Rising burden of multimorbidity and related socio-demographic factors: a repeated cross-sectional study of Ontarians. Canadian Journal of Public Health 2021; 112:737-747. [PMID: 33847995 PMCID: PMC8043089 DOI: 10.17269/s41997-021-00474-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 01/06/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE This study aimed to provide population-level data regarding trends in multimorbidity over 13 years. METHODS We linked provincial health administrative data in Ontario, Canada, to create 3 cross-sectional panels of residents of any age in 2003, 2009, and 2016 to describe: (i) 13-year trends in multimorbidity prevalence and constellations among residents and across age, sex, and income; and (ii) chronic condition clusters. Multimorbidity was defined as having at least any 2 of 18 selected conditions, and further grouped into levels of 2, 3, 4, or 5 or more conditions. Age-sex standardized multimorbidity prevalence was estimated using the 2009 population as the standard. Clustering was defined using the observed combinations of conditions within levels of multimorbidity. RESULTS Standardized prevalence of multimorbidity increased over time (26.5%, 28.8%, and 30.0% across sequential panels), across sex, age, and area-based income. Females, older adults and those living in lower income areas exhibited higher rates in all years. However, multimorbidity increased relatively more among males, younger adults, and those with 4 or 5 or more conditions. We observed numerous and increasing diversity in disease clusters, namely at higher levels of multimorbidity. CONCLUSION Our study provides relevant and needed population-based information on the growing burden of multimorbidity, and related socio-demographic risk factors. Multimorbidity is markedly increasing among younger age cohorts. Also, there is an increasing complexity and lack of common clustering patterns at higher multimorbidity levels.
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Affiliation(s)
- Anna Pefoyo Kone
- Department of Health Sciences, Lakehead University, Thunder Bay, ON, Canada. .,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada. .,Health System Performance Network (HSPN), Toronto, ON, Canada.
| | - Luke Mondor
- Health System Performance Network (HSPN), Toronto, ON, Canada.,ICES, Toronto, ON, Canada
| | - Colleen Maxwell
- Health System Performance Network (HSPN), Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,School of Pharmacy, University of Waterloo, Waterloo, ON, Canada.,School of Public Health & Health Systems, University of Waterloo, Waterloo, ON, Canada
| | - Umme Saika Kabir
- Department of Health Sciences, Lakehead University, Thunder Bay, ON, Canada
| | - Laura C Rosella
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Health System Performance Network (HSPN), Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | - Walter P Wodchis
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Health System Performance Network (HSPN), Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
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21
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Howard M, Hafid A, Isenberg SR, Hsu AT, Scott M, Conen K, Webber C, Bronskill SE, Downar J, Tanuseputro P. Intensity of outpatient physician care in the last year of life: a population-based retrospective descriptive study. CMAJ Open 2021; 9:E613-E622. [PMID: 34088732 PMCID: PMC8191591 DOI: 10.9778/cmajo.20210039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND For many patients, health care needs increase toward the end of life, but little is known about the extent of outpatient physician care during that time. The objective of this study was to describe the volume and mix of outpatient physician care over the last 12 months of life among patients dying with different end-of-life trajectories. METHODS We conducted a retrospective descriptive study involving adults (aged ≥ 18 yr) who died in Ontario between 2013 and 2017, using linked provincial health administrative databases. Decedents were grouped into 5 mutually exclusive end-of-life trajectories (terminal illness, organ failure, frailty, sudden death and other). Over the last 12 months and 3 months of life, we examined the number of physician encounters, the number of unique physician specialties involved per patient and specialty of physician, the number of unique physicians involved per patient, the 5 most frequent types of specialties involved and the number of encounters that took place in the home; these patterns were examined by trajectory. RESULTS Decedents (n = 359 559) had a median age of 78 (interquartile range 66-86) years. The mean number of outpatient physician encounters over the last year of life was 16.8 (standard deviation [SD] 13.7), of which 9.0 (SD 9.2) encounters were with family physicians. The mean number of encounters ranged from 11.6 (SD 10.4) in the frailty trajectory to 24.2 (SD 15.0) in the terminal illness trajectory across 3.1 (SD 2.0) to 4.9 (SD 2.1) unique specialties, respectively. In the last 3 months of life, the mean number of physician encounters was 6.8 (SD 6.4); a mean of 4.1 (SD 5.4) of these were with family physicians. INTERPRETATION Multiple physicians are involved in outpatient care in the last 12 months of life for all end-of-life trajectories, with family physicians as the predominant specialty. Those who plan health care models of the end of life should consider support for family physicians as coordinators of patient care.
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Affiliation(s)
- Michelle Howard
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont.
| | - Abe Hafid
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Sarina R Isenberg
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Amy T Hsu
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Mary Scott
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Katrin Conen
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Colleen Webber
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Susan E Bronskill
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - James Downar
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Peter Tanuseputro
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
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22
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Chau E, Rosella LC, Mondor L, Wodchis WP. Association between continuity of care and subsequent diagnosis of multimorbidity in Ontario, Canada from 2001-2015: A retrospective cohort study. PLoS One 2021; 16:e0245193. [PMID: 33705429 PMCID: PMC7951913 DOI: 10.1371/journal.pone.0245193] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 12/23/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Continuity of care is a well-recognized principle of the primary care discipline owing to its medical, interpersonal, and cost-saving benefits. Relationship continuity or the ongoing therapeutic relationship between a patient and their physician is a particularly desirable goal, but its role in preventing the accumulation of chronic conditions diagnoses in individuals is unknown. The objective of this study was to investigate the effect of continuity of care with physicians on the rate of incident multimorbidity diagnoses in patients with existing conditions. METHODS This was a population-based, retrospective cohort study from 2001 to 2015 that focused on patients aged 18 to 105 years with at least one chronic condition (n = 166,665). Our primary exposure was relationship continuity of care with general practitioners and specialists measured using the Bice-Boxerman Continuity of Care Index (COCI). COCI was specified as a time-dependent exposure prior to the observation period. Our outcomes of interest were the time to diagnosis of a second, third, and fourth chronic condition estimated using cause-specific hazard regressions accounting for death as a competing risk. FINDINGS We observed that patients with a single chronic condition and high continuity of care (>0.50) were diagnosed with a second chronic condition or multimorbidity at an 8% lower rate compared to individuals with low continuity (cause-specific hazard ratio (HR) 0.92 (95% Confidence Interval 0.90-0.93; p<0.0001) after adjusting for age, sex, income, place of residence, primary care enrolment, and the annual number of physician visits. Continuity remained protective as the degree of multimorbidity increased. Among patients with two conditions, the risk of diagnosis of a third chronic condition was also 8% lower for individuals with high continuity (HR 0.92; CI 0.90-0.94; p<0.0001). Patients with three conditions and high continuity had a 9% lower risk of diagnosis with a fourth condition (HR 0.91; CI 0.89-0.93; p<0.0001). CONCLUSIONS Continuity of care is a potentially modifiable health system factor that reduces the rate at which diagnoses of chronic conditions are made over time in patients with multimorbidity. Additional research is needed to explain the underlying mechanisms through which continuity is related to a protective effect and the clinical sequalae.
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Affiliation(s)
- Edward Chau
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Laura C. Rosella
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Canada
- ICES, Toronto, Canada
| | | | - Walter P. Wodchis
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Canada
- ICES, Toronto, Canada
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23
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Kadu M, Mondor L, Hsu A, Webber C, Howard M, Tanuseputro P. Does Inpatient Palliative Care Facilitate Home-Based Palliative Care Postdischarge? A Retrospective Cohort Study. Palliat Med Rep 2021; 2:25-33. [PMID: 34223500 PMCID: PMC8241378 DOI: 10.1089/pmr.2020.0095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Evidence of the impact of inpatient palliative care on receiving home-based palliative care remains limited. Objectives: The objective of this study was to examine, at a population level, the association between receiving inpatient palliative care and home-based palliative care postdischarge. Design: We conducted a retrospective cohort study to examine the association between receiving inpatient palliative care and home-based palliative care within 21 days of hospital discharge among decedents in the last six months of life. Setting/Subjects: We captured all decedents who were discharged alive from an acute care hospital in their last 180 days of life between April 1, 2014, and March 31, 2017, in Ontario, Canada. The index event was the first hospital discharge furthest away from death (i.e., closest to 180 days before death). Results: Decedents who had inpatient palliative care were significantly more likely to receive home-based palliative care after discharge (80.0% vs. 20.1%; p < 0.001). After adjusting for sociodemographic and clinical covariates, the odds of receiving home-based palliative care were 11.3 times higher for those with inpatient palliative care (95% confidence interval [CI]: 9.4–13.5; p < 0.001). The strength of the association incrementally decreased as death approached. The odds of receiving home-based palliative care after a hospital discharge 60 days before death were 7.7 times greater for those who received inpatient palliative care (95% CI: 6.0–9.8). Conclusion: Inpatient palliative care offers a distinct opportunity to improve transitional care between hospital and home, through enhancing access to home-based palliative care.
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Affiliation(s)
- Mudathira Kadu
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Luke Mondor
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Amy Hsu
- Bruyère Research Institute, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Colleen Webber
- Bruyère Research Institute, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Michelle Howard
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Peter Tanuseputro
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada.,Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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24
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Webber C, Chan R, Scott M, Brown C, Spruin S, Hsu AT, Bush SH, Isenberg SR, Quinn K, Scott J, Tanuseputro P. Delivery of Palliative Care in Acute Care Hospitals: A Population-Based Retrospective Cohort Study Describing the Level of Involvement and Timing of Inpatient Palliative Care in the Last Year of Life. J Palliat Med 2020; 24:1000-1010. [PMID: 33337265 DOI: 10.1089/jpm.2020.0056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Background: Much end-of-life care is provided in hospital, yet little is known about the delivery of palliative care during end-of-life hospitalizations. Objectives: To characterize the level of palliative care involvement across hospitalizations in the last year of life. Methods: A population-based retrospective cohort study of adults in Ontario, Canada, who died between April 1, 2012, and March 31, 2017, and had at least one acute care hospitalization in their last year of life. Using linked administrative health data, we developed a hierarchy of inpatient palliative care involvement reflecting the degree to which care was delivered with palliative intent. This hierarchy was based on palliative care diagnosis and service provider codes on hospitalization records and physician claims. We examined variations in the level of palliative care involvement across key patient characteristics. Results: In the last year of life, 65.1% of hospitalizations had no indication of palliative care involvement, 16.7% had a low level of involvement, 13.5% had a medium level of involvement, and 4.7% had a high level of involvement. Most hospitalizations with palliative care involvement (85.6%) occurred in the two months before death. Compared to patients who received no inpatient palliative care, patients who received a high level of palliative care involvement tended to be younger, died of cancer, resided in urban or lower income neighborhoods, and had fewer chronic conditions. Discussion: While many hospitalizations occurred in the last year of life, the majority did not involve palliative care, and very few had a high level of palliative care involvement.
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Affiliation(s)
- Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Raphael Chan
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Mary Scott
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Catherine Brown
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Sarah Spruin
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,ICES, Ottawa, Ontario, Canada
| | - Amy T Hsu
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Sarina R Isenberg
- Temmy Latner Centre for Palliative Care and Lunenfeld Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada.,Department of Family and Community Medicine and University of Toronto, Toronto, Ontario, Canada
| | - Kieran Quinn
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John Scott
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
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25
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Steele Gray C, Tang T, Armas A, Backo-Shannon M, Harvey S, Kuluski K, Loganathan M, Nie JX, Petrie J, Ramsay T, Reid R, Thavorn K, Upshur R, Wodchis WP, Nelson M. Building a Digital Bridge to Support Patient-Centered Care Transitions From Hospital to Home for Older Adults With Complex Care Needs: Protocol for a Co-Design, Implementation, and Evaluation Study. JMIR Res Protoc 2020; 9:e20220. [PMID: 33237037 PMCID: PMC7725647 DOI: 10.2196/20220] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/10/2020] [Accepted: 09/13/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Older adults with multimorbidity and complex care needs (CCN) are among those most likely to experience frequent care transitions between settings, particularly from hospital to home. Transition periods mark vulnerable moments in care for individuals with CCN. Poor communication and incomplete information transfer between clinicians and organizations involved in the transition from hospital to home can impede access to needed support and resources. Establishing digitally supported communication that enables person-centered care and supported self-management may offer significant advantages as we support older adults with CCN transitioning from hospital to home. OBJECTIVE This protocol outlines the plan for the development, implementation, and evaluation of a Digital Bridge co-designed to support person-centered health care transitions for older adults with CCN. The Digital Bridge builds on the foundation of two validated technologies: Care Connector, designed to improve interprofessional communication in hospital, and the electronic Patient-Reported Outcomes (ePRO) tool, designed to support goal-oriented care planning and self-management in primary care settings. This project poses three overarching research questions that focus on adapting the technology to local contexts, evaluating the impact of the Digital Bridge in relation to the quadruple aim, and exploring the potential to scale and spread the technology. METHODS The study includes two phases: workflow co-design (phase 1), followed by implementation and evaluation (phase 2). Phase 1 will include iterative co-design working groups with patients, caregivers, hospital providers, and primary care providers to develop a transition workflow that will leverage the use of Care Connector and ePRO to support communication through the transition process. Phase 2 will include implementation and evaluation of the Digital Bridge within two hospital systems in Ontario in acute and rehab settings (600 patients: 300 baseline and 300 implementation). The primary outcome measure for this study is the Care Transitions Measure-3 to assess transition quality. An embedded ethnography will be included to capture context and process data to inform the implementation assessment and development of a scale and spread strategy. An Integrated Knowledge Translation approach is taken to inform the study. An advisory group will be established to provide insight and feedback regarding the project design and implementation, leading the development of the project knowledge translation strategy and associated outputs. RESULTS This project is underway and expected to be complete by Spring 2024. CONCLUSIONS Given the real-world implementation of Digital Bridge, practice changes in the research sites and variable adherence to the implementation protocols are likely. Capturing and understanding these considerations through a mixed-methods approach will help identify the range of factors that may influence study results. Should a favorable evaluation suggest wide adoption of the proposed intervention, this project could lead to positive impact at patient, clinician, organizational, and health system levels. TRIAL REGISTRATION ClinicalTrials.gov NCT04287192; https://clinicaltrials.gov/ct2/show/NCT04287192. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/20220.
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Affiliation(s)
- Carolyn Steele Gray
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Terence Tang
- Institute for Better Health, Trillium Health Partners, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Alana Armas
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
| | - Mira Backo-Shannon
- Clinical, Health System Strategy, Integration and Planning, Ontario Health (Central Region), Mississauga Halton Local Health Integration Network, Toronto, ON, Canada
| | | | - Kerry Kuluski
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Institute for Better Health, Trillium Health Partners, Toronto, ON, Canada
| | - Mayura Loganathan
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Mount Sinai Academic Family Health Team, Toronto, ON, Canada
| | - Jason X Nie
- Institute for Better Health, Trillium Health Partners, Toronto, ON, Canada
| | - John Petrie
- Institute for Better Health, Trillium Health Partners, Toronto, ON, Canada
| | - Tim Ramsay
- Ottawa Methods Centre, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
- School of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Robert Reid
- Institute for Better Health, Trillium Health Partners, Toronto, ON, Canada
| | - Kednapa Thavorn
- Ottawa Methods Centre, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
- School of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Ross Upshur
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Walter P Wodchis
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Institute for Better Health, Trillium Health Partners, Toronto, ON, Canada
| | - Michelle Nelson
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- March of Dimes Canada, Toronto, ON, Canada
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26
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Riad K, Webber C, Batista R, Reaume M, Rhodes E, Knight B, Prud'homme D, Tanuseputro P. The impact of dementia and language on hospitalizations: a retrospective cohort of long-term care residents. BMC Geriatr 2020; 20:397. [PMID: 33032528 PMCID: PMC7545542 DOI: 10.1186/s12877-020-01806-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 09/30/2020] [Indexed: 12/22/2022] Open
Abstract
Background Hospitalizations carry considerable risks for frail, elderly patients; this is especially true for patients with dementia, who are more likely to experience delirium, falls, functional decline, iatrogenic complications, and infections when compared to their peers without dementia. Since up to two thirds of patients in long-term care (LTC) facilities have dementia, there is interest in identifying factors associated with transitions from LTC facilities to hospitals. The purpose of this study was to investigate the association between dementia status and incidence of hospitalization among residents in LTC facilities in Ontario, Canada, and to determine whether this association is modified by linguistic factors. Methods We used linked administrative databases to establish a prevalent cohort of 81,188 residents in 628 LTC facilities from April 1st 2014 to March 31, 2017. Diagnoses of dementia were identified with a previously validated algorithm; all other patient characteristics were obtained from in-person assessments. Residents’ primary language was coded as English or French; facility language (English or French) was determined using language designation status according to the French Language Services Act. We identified all hospitalizations within 3 months of the first assessment performed after April 1st 2014. We performed multivariate logistic regression analyses to determine the impact of dementia and resident language on the incidence of hospitalization; we also considered interactions between dementia and both resident language and resident-facility language discordance. Results The odds of hospitalization were 39% lower for residents with dementia compared to residents without dementia (OR 0.61, 95% CI 0.57–0.65). Francophones had lower odds of hospitalization than Anglophones, but this difference was not statistically significant (OR 0.91, 95% CI 0.81–1.03). However, Francophones without dementia were significantly less likely to be hospitalized compared to Anglophones without dementia (OR 0.71, 95% CI 0.53–0.94). Resident-facility language discordance did not significantly affect hospitalizations. Conclusions Residents in LTC facilities were generally less likely to be hospitalized if they had dementia, or if their primary language was French and they did not have dementia. These findings could be explained by differences in end-of-life care goals; however, they could also be the result of poor patient-provider communication.
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Affiliation(s)
- Karine Riad
- Faculty of Medicine, University of Ottawa, Ottawa, Canada.,Institut du Savoir Montfort, Ottawa, Canada
| | | | - Ricardo Batista
- Institut du Savoir Montfort, Ottawa, Canada.,Department of Medicine, Clinical Epidemiology Program, Ottawa Hospital Research Institute, 1053 Carling Ave, Ottawa, ON, K1Y 4E9, Canada.,ICES, Ottawa, Canada
| | - Michael Reaume
- Faculty of Medicine, University of Ottawa, Ottawa, Canada.,Institut du Savoir Montfort, Ottawa, Canada
| | - Emily Rhodes
- Department of Medicine, Clinical Epidemiology Program, Ottawa Hospital Research Institute, 1053 Carling Ave, Ottawa, ON, K1Y 4E9, Canada
| | | | - Denis Prud'homme
- Institut du Savoir Montfort, Ottawa, Canada.,Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
| | - Peter Tanuseputro
- Bruyère Research Institute, Ottawa, Canada. .,Department of Medicine, Clinical Epidemiology Program, Ottawa Hospital Research Institute, 1053 Carling Ave, Ottawa, ON, K1Y 4E9, Canada.
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A Case-Control Study of the Sub-Acute Care for Frail Elderly (SAFE) Unit on Hospital Readmission, Emergency Department Visits and Continuity of Post-Discharge Care. J Am Med Dir Assoc 2020; 22:544-550.e2. [PMID: 32943339 DOI: 10.1016/j.jamda.2020.07.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 07/13/2020] [Accepted: 07/15/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVES In Canada, alternate-level-of-care (ALC) beds in hospitals may be used when patients who do not require the intensity of services provided in an acute care setting are waiting to be discharged to a more appropriate care setting. However, when there is a lack of care options for patients waiting to be discharged, it contributes to prolonged hospital stays and bottlenecks in the health care system manifested as "hallway medicine." We examined the effectiveness of a function-focused transitional care program, the Sub-Acute care for Frail Elderly (SAFE) Unit, in reducing the length of stay (LOS) in hospital, as well as post-discharge acute care use and continuity of care. DESIGN Case-control study. SETTING AND PARTICIPANTS A 450-bed nursing home located in Ontario, Canada, where the SAFE Unit is based. The study population included frail, older patients aged 60 years and older who received care in the SAFE Unit between March 1, 2018, and February 28, 2019 (n = 153) to controls comprising of other hospitalized patients (n = 1773). METHODS We linked facility-level to provincial health administrative databases on hospital admissions and emergency department (ED) visits, and the Ontario Health Insurance Plan claims database for physician billings to investigated the LOS during the index hospitalization, 30-day odds of post-discharge ED visits, hospital readmission, and follow-up with family physicians. RESULTS SAFE patients had a median hospital LOS of 13 days [interquartile range (IQR): 8-19 days], with 75% having fewer than 1 day in an ALC bed. In comparison, the median LOS in the control group was 15 days (IQR: 10-24 days), with one-third of those days spent in an ALC bed (median: 5 days, IQR: 3-10 days). SAFE patients were more likely (64.1%) to be discharged home than control patients (46.3%). Both groups experienced similar 30-day odds of ED visits, hospital readmission and follow-up with a family physician. CONCLUSIONS AND IMPLICATIONS Frail older individuals in the SAFE Unit experienced shorter hospital stays, were less likely to be discharged to settings other than home and had similar 30-day acute care outcomes as control patients post-discharge.
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Webber C, Watt CL, Bush SH, Lawlor PG, Talarico R, Tanuseputro P. The occurrence and timing of delirium in acute care hospitalizations in the last year of life: A population-based retrospective cohort study. Palliat Med 2020; 34:1067-1077. [PMID: 32515283 DOI: 10.1177/0269216320929545] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Delirium is a distressing neurocognitive disorder that is common among terminally ill individuals, although few studies have described its occurrence in the acute care setting among this population. AIM To describe the prevalence of delirium in patients admitted to acute care hospitals in Ontario, Canada, in their last year of life and identify factors associated with delirium. DESIGN Population-based retrospective cohort study using linked health administrative data. Delirium was identified through diagnosis codes on hospitalization records. SETTING/PARTICIPANTS Ontario decedents (1 January 2014 to 31 December 2016) admitted to an acute care hospital in their last year of life, excluding individuals age of <18 years or >105 years at admission, those not eligible for the provincial health insurance plan between their hospitalization and death dates, and non-Ontario residents. RESULTS Delirium was recorded as a diagnosis in 8.2% of hospitalizations. The frequency of delirium-related hospitalizations increased as death approached. Delirium prevalence was higher in patients with dementia (prevalence ratio: 1.43; 95% confidence interval: 1.36-1.50), frailty (prevalence ratio: 1.67; 95% confidence interval: 1.56-1.80), or organ failure-related cause of death (prevalence ratio: 1.23; 95% confidence interval: 1.16-1.31) and an opioid prescription (prevalence ratio: 1.17; 95% confidence interval: 1.12-1.21). Prevalence also varied by age, sex, chronic conditions, antipsychotic use, receipt of long-term care or home care, and hospitalization characteristics. CONCLUSION This study described the occurrence and timing of delirium in acute care hospitals in the last year of life and identified factors associated with delirium. These findings can be used to support delirium prevention and early detection in the hospital setting.
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Affiliation(s)
- Colleen Webber
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,ICES uOttawa, Ottawa, ON, Canada
| | - Christine L Watt
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Shirley H Bush
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Peter G Lawlor
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - Peter Tanuseputro
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,ICES uOttawa, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
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Ouvrard C, Meillon C, Dartigues JF, Ávila-Funes JA, Amieva H. Do Individual and Geographical Deprivation Have the Same Impact on the Risk of Dementia? A 25-Year Follow-up Study. J Gerontol B Psychol Sci Soc Sci 2020; 75:218-227. [PMID: 29077923 DOI: 10.1093/geronb/gbx130] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 09/26/2017] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To determine the impact of both individual psychosocioeconomic precariousness and geographical deprivation on risk of dementia in older adults followed-up for 25 years. METHOD The sample consisted of 3,431 participants aged 65 years or over from the PAQUID cohort study. Individual psychosocioeconomic precariousness was measured computing eight economic and psychosocial indicators. Geographical deprivation was assessed by the FDep99 index, consisting of four community socioeconomic variables. For both measures, the fourth quartile of the distribution was considered as the more precarious or deprived category, while the first quartile was considered as the less precarious or deprived one. Clinical dementia diagnosis was assessed all along study follow-up. The association between individual psychosocioeconomic precariousness, geographical deprivation and risk of dementia was assessed using illness-death regression models adjusted for age, sex, depression, psychotropic drug consumption, comorbidities, disability, and body mass index, while accounting for death as a competing event. RESULTS The risk of dementia was higher for the more psychosocioeconomic precarious participants (HR = 1.51; 95% CI: 1.24-1.84). No increased risk of dementia was found for those living in communities with high index of deprivation. DISCUSSION Psychosocioeconomic precariousness, but not geographical deprivation, is associated with a higher risk of dementia.
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Affiliation(s)
- Camille Ouvrard
- Inserm, Bordeaux Population Health Research Center, team Psychoepidemiology of aging and chronic diseases, University of Bordeaux, France
| | - Céline Meillon
- Inserm, Bordeaux Population Health Research Center, team Psychoepidemiology of aging and chronic diseases, University of Bordeaux, France
| | - Jean-François Dartigues
- Inserm, Bordeaux Population Health Research Center, team Psychoepidemiology of aging and chronic diseases, University of Bordeaux, France
| | - José Alberto Ávila-Funes
- Inserm, Bordeaux Population Health Research Center, team Psychoepidemiology of aging and chronic diseases, University of Bordeaux, France.,Department of Geriatrics, National Institute of Medical Sciences and Nutrition "Salvador Zubiran", Mexico City, Mexico
| | - Hélène Amieva
- Inserm, Bordeaux Population Health Research Center, team Psychoepidemiology of aging and chronic diseases, University of Bordeaux, France
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Cost-effectiveness of Investment in End-of-Life Home Care to Enable Death in Community Settings. Med Care 2020; 58:665-673. [PMID: 32520768 DOI: 10.1097/mlr.0000000000001320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Many people with terminal illness prefer to die in home-like settings-including care homes, hospices, or palliative care units-rather than an acute care hospital. Home-based palliative care services can increase the likelihood of death in a community setting, but the provision of these services may increase costs relative to usual care. OBJECTIVE The aim of this study was to estimate the incremental cost per community death for persons enrolled in end-of-life home care in Ontario, Canada, who died between 2011 and 2015. METHODS Using a population-based cohort of 50,068 older adults, we determined the total cost of care in the last 90 days of life, as well as the incremental cost to achieve an additional community death for persons enrolled in end-of-life home care, in comparison with propensity score-matched individuals under usual care (ie, did not receive home care services in the last 90 days of life). RESULTS Recipients of end-of-life home care were nearly 3 times more likely to experience a community death than individuals not receiving home care services, and the incremental cost to achieve an additional community death through the provision of end-of-life home care was CAN$995 (95% confidence interval: -$547 to $2392). CONCLUSION Results suggest that a modest investment in end-of-life home care has the potential to improve the dying experience of community-dwelling older adults by enabling fewer deaths in acute care hospitals.
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Hagarty AM, Bush SH, Talarico R, Lapenskie J, Tanuseputro P. Severe pain at the end of life: a population-level observational study. BMC Palliat Care 2020; 19:60. [PMID: 32354364 PMCID: PMC7193354 DOI: 10.1186/s12904-020-00569-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/24/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pain is a prevalent symptom at the end of life and negatively impacts quality of life. Despite this, little population level data exist that describe pain frequency and associated factors at the end of life. The purpose of this study was to explore the prevalence of clinically significant pain at the end of life and identify predictors of increased pain. METHODS Retrospective population-level cohort study of all decedents in Ontario, Canada, from April 1, 2011 to March 31, 2015 who received a home care assessment in the last 30 days of life (n = 20,349). Severe daily pain in the last 30 days of life using linked Ontario health administrative databases. Severe pain is defined using a validated pain scale combining pain frequency and intensity: daily pain of severe intensity. RESULTS Severe daily pain was reported in 17.2% of 20,349 decedents. Increased risk of severe daily pain was observed in decedents who were female, younger and functionally impaired. Those who were cognitively impaired had a lower risk of reporting pain. Disease trajectory impacted pain; those who died of a terminal illness (i.e. cancer) were more likely to experience pain than those with frailty (odds ratio 1.66). CONCLUSION Pain is a common fear of those contemplating end of life, but severe pain is reported in less than 1 in 5 of our population in the last month of life. Certain subpopulations may be more likely to report severe pain at the end of life and may benefit from earlier palliative care referral and intervention.
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Affiliation(s)
- A Meaghen Hagarty
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, ON, K1Y4E9, Canada
| | - Robert Talarico
- Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, ON, K1Y4E9, Canada.,ICES, Population Health and Primary Care, Ottawa, Ontario, Canada
| | - Julie Lapenskie
- Bruyère Research Institute, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, ON, K1Y4E9, Canada
| | - Peter Tanuseputro
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada. .,Bruyère Research Institute, Ottawa, Ontario, Canada. .,Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, ON, K1Y4E9, Canada. .,ICES, Population Health and Primary Care, Ottawa, Ontario, Canada.
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Shaver NS, Lapenskie J, Smith GA, Hsu AT, Liddy C, Tanuseputro P. How Often, Where, and by Which Specialty Do Long-Term Care Home Residents Receive Specialist Physician Care? A Retrospective Cohort Study. J Appl Gerontol 2020; 40:837-846. [PMID: 32028821 DOI: 10.1177/0733464819901255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
This retrospective cohort study describes the rates, location, and determinants of specialist physician visits among 257,216 long-term care (LTC) residents across 648 LTC homes in Ontario, Canada, between 2007 and 2016. Visit rates in the last year of life were calculated for a sub-cohort of residents who died in LTC between 2013 and 2016. Visits were measured per resident-year using physician billings. Over 10 years, the rate of visits to specialists outside the LTC home was consistently higher than within LTC (2.99 vs. 1.55 visits/resident-year). Residents were less likely to receive specialist care if they were older, had dementia, or lived in urban LTC homes. From 12 months before death to the last week of life, rates of specialist visits increased by 246% and 56% inside and outside of LTC, respectively. Improving access to physician specialist care in LTC homes may reduce burdensome transitions and improve resident quality of life.
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Affiliation(s)
- Nicole S Shaver
- Bruyère Research Institute, Ottawa, ON, Canada.,Queen's University, Kingston, ON, Canada
| | - Julie Lapenskie
- Bruyère Research Institute, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, ON, Canada
| | - Glenys A Smith
- Ottawa Hospital Research Institute, ON, Canada.,ICES uOttawa, ON, Canada
| | - Amy T Hsu
- Bruyère Research Institute, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, ON, Canada.,ICES uOttawa, ON, Canada
| | - Clare Liddy
- Bruyère Research Institute, Ottawa, ON, Canada.,ICES uOttawa, ON, Canada
| | - Peter Tanuseputro
- Bruyère Research Institute, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, ON, Canada.,ICES uOttawa, ON, Canada.,Department of Medicine, University of Ottawa, ON, Canada
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Zygmunt A, Tanuseputro P, James P, Lima I, Tuna M, Kendall CE. Neighbourhood-level marginalization and avoidable mortality in Ontario, Canada: a population-based study. Canadian Journal of Public Health 2019; 111:169-181. [PMID: 31828730 DOI: 10.17269/s41997-019-00270-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 10/09/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine the impact of neighbourhood marginalization on avoidable mortality (AM) from preventable and treatable causes of death. METHODS All premature deaths between 1993 and 2014 (N = 691,453) in Ontario, Canada, were assigned to quintiles of neighbourhood marginalization using the four dimensions of the Ontario Marginalization Index: dependency, ethnic concentration, material deprivation, and residential instability. We conducted two multivariate logistic regressions to examine the association between neighbourhood marginalization, first with AM compared with non-AM as the outcome, and second with AM from preventable causes compared with treatable causes as the outcome. All models were adjusted for decedent age, sex, urban/rural location, and level of comorbidity. RESULTS A total of 463,015 deaths were classified as AM and 228,438 deaths were classified as non-AM. Persons living in the most materially deprived (OR, 1.24; 95% CI, 1.22 to 1.27) and residentially unstable neighbourhoods (OR, 1.13; 95% CI, 1.11 to 1.15) had greater odds of AM, particularly from preventable causes. Those living in the most dependent (OR, 0.91; 95% CI, 0.89 to 0.93) and ethnically concentrated neighbourhoods (OR, 0.93; 95% CI, 0.91 to 0.93) had lower odds of AM, although when AM occurred, it was more likely to arise from treatable causes. CONCLUSION Different marginalization dimensions have unique associations with AM. By identifying how different aspects of neighbourhood marginalization influence AM, these results may have important implications for future public health efforts to reduce inequities in avoidable deaths.
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Affiliation(s)
- Austin Zygmunt
- School of Epidemiology and Public Health, University of Ottawa, Room 101, 600 Peter Morand Crescent, Ottawa, Ontario, K1G 5Z3, Canada.
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, Canada.,ICES uOttawa, The Ottawa Hospital, Civic Campus 1053 Carling Avenue, Ottawa, Canada.,CT Lamont Primary Health Care Research Group, Bruyère Research Institute, Ottawa, Canada.,Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Canada
| | - Paul James
- ICES uOttawa, The Ottawa Hospital, Civic Campus 1053 Carling Avenue, Ottawa, Canada.,Department of Medicine, University Health Network, University of Toronto, Toronto, Canada
| | - Isac Lima
- Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, Canada.,ICES uOttawa, The Ottawa Hospital, Civic Campus 1053 Carling Avenue, Ottawa, Canada
| | - Meltem Tuna
- Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, Canada.,ICES uOttawa, The Ottawa Hospital, Civic Campus 1053 Carling Avenue, Ottawa, Canada
| | - Claire E Kendall
- Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, Canada.,ICES uOttawa, The Ottawa Hospital, Civic Campus 1053 Carling Avenue, Ottawa, Canada.,CT Lamont Primary Health Care Research Group, Bruyère Research Institute, Ottawa, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
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HCV-infected individuals have higher prevalence of comorbidity and multimorbidity: a retrospective cohort study. BMC Infect Dis 2019; 19:712. [PMID: 31438873 PMCID: PMC6706878 DOI: 10.1186/s12879-019-4315-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 07/24/2019] [Indexed: 02/07/2023] Open
Abstract
Background Almost 1% of Canadians are hepatitis C (HCV)-infected. The liver-specific complications of HCV are established but the extra-hepatic comorbidity, multimorbidity, and its relationship with HCV treatment, is less well known. We describe the morbidity burden for people with HCV and the relationship between multimorbidity and HCV treatment uptake and cure in the pre- and post-direct acting antiviral (DAA) era. Methods We linked adults with HCV at The Ottawa Hospital Viral Hepatitis Program as of April 1, 2017 to provincial health administrative data and matched on age and sex to 5 Ottawa-area residents for comparison. We used validated algorithms to identify the prevalence of mental and physical health comorbidities, as well as multimorbidity (2+ comorbidities). We calculated direct age- and sex-standardized rates of comorbidity and comparisons were made by interferon-based and interferon-free, DAA HCV treatments. Results The mean age of the study population was 54.5 years (SD 11.4), 65% were male. Among those with HCV, 4% were HIV co-infected, 26% had liver cirrhosis, 47% received DAA treatment, and 57% were cured of HCV. After accounting for age and sex differences, the HCV group had greater multimorbidity (prevalence ratio (PR) 1.38, 95% confidence interval (CI) 1.20 to 1.58) and physical-mental health multimorbidity (PR 2.71, 95% CI 2.29–3.20) compared to the general population. Specifically, prevalence ratios for people with HCV were significantly higher for diabetes, renal failure, cancer, asthma, chronic obstructive pulmonary disease, substance use disorder, mood and anxiety disorders and liver failure. HCV treatment and cure were not associated with multimorbidity, but treatment prevalence was significantly lower among middle-aged individuals with substance use disorders despite no differences in prevalence of cure among those treated. Conclusion People with HCV have a higher prevalence of comorbidity and multimorbidity compared to the general population. While HCV treatment was not associated with multimorbidity, people with substance use disorder were less likely to be treated. Our results point to the need for integrated, comprehensive models of care delivery for people with HCV. Electronic supplementary material The online version of this article (10.1186/s12879-019-4315-6) contains supplementary material, which is available to authorized users.
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Multimorbidity, healthcare utilization and socioeconomic status: A register-based study in Denmark. PLoS One 2019; 14:e0214183. [PMID: 31369580 PMCID: PMC6675513 DOI: 10.1371/journal.pone.0214183] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 07/10/2019] [Indexed: 12/11/2022] Open
Abstract
Background People with multimorbidity have reduced functional capacity, lower quality of life, higher mortality rates and use healthcare resources more intensively than healthy people or those with a single chronic condition. Multimorbidity was defined as the coexistence of two or more chronic conditions in the same person. The aim of this study was to explore associations between multimorbidity and use of healthcare services and the impact of socioeconomic status on utilization of hospitalizations and bed days. Methods The study population included all individuals aged 16 years and older who lived in the Capital Region of Denmark on January 1st, 2012. Data on chronic conditions, use of healthcare services and demographics were obtained from Danish national administrative and health registries. Zero-inflated models were used to calculate anticipated annual use of hospitalizations and bed days. Findings The study population comprised 1,397,173 individuals; the prevalence of multimorbidity was 22%. Prevalence was inversely related to educational attainment. For people with multimorbidity, utilization of hospitalizations and bed days increased approximately linearly with the number of chronic conditions. However, a steep increase in utilization of bed days was observed between five and six or more chronic conditions. An educational gradient in hospitalization rates and use of bed days was observed regardless of the number of chronic conditions. Educational attainment was strongly associated with healthcare utilization. Conclusion Multimorbidity was associated with a significant increase in utilization of all healthcare services in Denmark. In addition, a socioeconomic gradient was observed in utilization of hospitalizations and bed days.
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Jani BD, Hanlon P, Nicholl BI, McQueenie R, Gallacher KI, Lee D, Mair FS. Relationship between multimorbidity, demographic factors and mortality: findings from the UK Biobank cohort. BMC Med 2019; 17:74. [PMID: 30967141 PMCID: PMC6456941 DOI: 10.1186/s12916-019-1305-x] [Citation(s) in RCA: 107] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 03/11/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Multimorbidity is associated with higher mortality, but the relationship with cancer and cardiovascular mortality is unclear. The influence of demographics and type of condition on the relationship of multimorbidity with mortality remains unknown. We examine the relationship between multimorbidity (number/type) and cause of mortality and the impact of demographic factors on this relationship. METHODS Data source: the UK Biobank; 500,769 participants; 37-73 years; 53.7% female. Exposure variables: number and type of long-term conditions (LTCs) (N = 43) at baseline, modelled separately. Cox regression models were used to study the impact of LTCs on all-cause/vascular/cancer mortality during median 7-year follow-up. All-cause mortality regression models were stratified by age/sex/socioeconomic status. RESULTS All-cause mortality is 2.9% (14,348 participants). Of all deaths, 8350 (58.2%) were cancer deaths and 2985 (20.8%) vascular deaths. Dose-response relationship is observed between the increasing number of LTCs and all-cause/cancer/vascular mortality. A strong association is observed between cardiometabolic multimorbidity and all three clinical outcomes; non-cardiometabolic multimorbidity (excluding cancer) is associated with all-cause/vascular mortality. All-cause mortality risk for those with ≥ 4 LTCs was nearly 3 times higher than those with no LTCs (HR 2.79, CI 2.61-2.98); for ≥ 4 cardiometabolic conditions, it was > 3 times higher (HR 3.20, CI 2.56-4.00); and for ≥ 4 non-cardiometabolic conditions (excluding cancer), it was 50% more (HR 1.50, CI 1.36-1.67). For those with ≥ 4 LTCs, morbidity combinations that included cardiometabolic conditions, chronic kidney disease, cancer, epilepsy, chronic obstructive pulmonary disease, depression, osteoporosis and connective tissue disorders had the greatest impact on all-cause mortality. In the stratified model by age/sex, absolute all-cause mortality was higher among the 60-73 age group with an increasing number of LTCs; however, the relative effect size of the increasing number of LTCs on higher mortality risk was larger among those 37-49 years, especially men. While socioeconomic status was a significant predictor of all-cause mortality, mortality risk with increasing number of LTCs remained constant across different socioeconomic gradients. CONCLUSIONS Multimorbidity is associated with higher all-cause/cancer/vascular mortality. Type, as opposed to number, of LTCs may have an important role in understanding the relationship between multimorbidity and mortality. Multimorbidity had a greater relative impact on all-cause mortality in middle-aged as opposed to older populations, particularly males, which deserves exploration.
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Affiliation(s)
- Bhautesh Dinesh Jani
- General Practice and Primary Care, Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, 1 Horselethill Road, Glasgow, G12 9LX, UK
| | - Peter Hanlon
- General Practice and Primary Care, Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, 1 Horselethill Road, Glasgow, G12 9LX, UK
| | - Barbara I Nicholl
- General Practice and Primary Care, Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, 1 Horselethill Road, Glasgow, G12 9LX, UK
| | - Ross McQueenie
- General Practice and Primary Care, Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, 1 Horselethill Road, Glasgow, G12 9LX, UK
| | - Katie I Gallacher
- General Practice and Primary Care, Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, 1 Horselethill Road, Glasgow, G12 9LX, UK
| | - Duncan Lee
- School of Mathematics and Statistics, University of Glasgow, Glasgow, UK
| | - Frances S Mair
- General Practice and Primary Care, Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, 1 Horselethill Road, Glasgow, G12 9LX, UK.
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Park S, Kim B, Kwon E. The Role of Senior Housing in Hospitalizations Among Vulnerable Older Adults With Multiple Chronic Conditions: A Longitudinal Perspective. THE GERONTOLOGIST 2018; 58:932-941. [PMID: 28575200 DOI: 10.1093/geront/gnx046] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Indexed: 11/14/2022] Open
Abstract
Background and Objectives This study focuses on vulnerable elders (i.e., those with moderate or low incomes who live alone) and examines to what extent a senior housing environment moderates the effects of multiple chronic conditions (MCCs) on hospitalization over time. Research Design and Methods Data came from six waves (2002-2012) of the Health Retirement Study (N = 1,401 individuals, 3,705 observations). Mixed-effect multinomial logistic regression modeling estimated the effects of senior housing on changes in hospitalization. Results Vulnerable elders with MCCs were more likely to be hospitalized at both moderate and heavy levels at baseline. Consistent with the environment docility hypothesis, findings show that older individuals with MCCs who live in a senior housing environment have fewer hospitalizations over time. Discussions and Implications As one of the first efforts to build empirical knowledge on health care use among vulnerable elders in senior housing, our findings underscore the importance of continued research into these environments as a possible alternative to existing models.
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Affiliation(s)
- Sojung Park
- George Warren Brown School of Social Work at Washington University in One Brookings Drive, Saint Louis, Missouri
| | - BoRin Kim
- University of New Hampshire, Durham, UK
| | - Eunsun Kwon
- Center for Social Science, Seoul National University, Gwanak-gu, South Korea
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Mondor L, Cohen D, Khan AI, Wodchis WP. Income inequalities in multimorbidity prevalence in Ontario, Canada: a decomposition analysis of linked survey and health administrative data. Int J Equity Health 2018. [PMID: 29941034 DOI: 10.1186/s12939‐018‐0800‐6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The burden of multimorbidity is a growing clinical and health system problem that is known to be associated with socioeconomic status, yet our understanding of the underlying determinants of inequalities in multimorbidity and longitudinal trends in measured disparities remains limited. METHODS We included all adult respondents from four cycles of the Canadian Community Health Survey (CCHS) (between 2005 to 2011/12), linked at the individual-level to health administrative data in Ontario, Canada (pooled n = 113,627). Multimorbidity was defined at each survey response as having ≥2 (of 17) high impact chronic conditions, based on claims data. Using a decomposition method of the Erreygers-corrected concentration index (CErreygers), we measured household income inequality and the contribution of the key determinants of multimorbidity (including socio-demographic, socio-economic, lifestyle and health system factors) to these disparities. Differences over time are described. We tested for statistically significant changes to measured inequality using the slope index (SII) and relative index of inequality (RII) with a 2-way interaction on pooled data. RESULTS Multimorbidity prevalence in 2011/12 was 33.5% and the CErreygers was - 0.085 (CI: -0.108 to - 0.062), indicating a greater prevalence among lower income groups. In decomposition analyses, income itself accounted more than two-thirds (69%) of this inequality. Age (21.7%), marital status (15.2%) and physical inactivity (10.9%) followed, and the contribution of these factors increased from baseline (2005 CCHS survey) with the exception of age. Other lifestyle factors, including heavy smoking and obesity, had minimal contribution to measured inequality (1.8 and 0.4% respectively). Tests for trends (SII/RII) across pooled survey data were not statistically significant (p = 0.443 and 0.405, respectively), indicating no change in inequalities in multimorbidity prevalence over the study period. CONCLUSIONS A pro-rich income gap in multimorbidity has persisted in Ontario from 2005 to 2011/12. These empirical findings suggest that to advance equality in multimorbidity prevalence, policymakers should target chronic disease prevention and control strategies focused on older adults, non-married persons and those that are physically inactive, in addition to addressing income disparities directly.
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Affiliation(s)
- Luke Mondor
- Institute for Clinical Evaluative Sciences (ICES), G1 06 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.,Health System Performance Research Network (HSPRN), 155 College St 4th Floor, Toronto, ON, M5T 3M6, Canada
| | - Deborah Cohen
- Health System Performance Research Network (HSPRN), 155 College St 4th Floor, Toronto, ON, M5T 3M6, Canada.,School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON, K1G Z53, Canada
| | - Anum Irfan Khan
- Health System Performance Research Network (HSPRN), 155 College St 4th Floor, Toronto, ON, M5T 3M6, Canada.,Institute of Health Policy, Management, and Evaluation (IHPME), University of Toronto, 155 College St 4th Floor, Toronto, ON, M5T 3M6, Canada
| | - Walter P Wodchis
- Institute for Clinical Evaluative Sciences (ICES), G1 06 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada. .,Health System Performance Research Network (HSPRN), 155 College St 4th Floor, Toronto, ON, M5T 3M6, Canada. .,Institute of Health Policy, Management, and Evaluation (IHPME), University of Toronto, 155 College St 4th Floor, Toronto, ON, M5T 3M6, Canada. .,Institute for Better Health, Trillium Health Partners, 100 Queensway West, Mississauga, ON, L5B 1B8, Canada.
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Mondor L, Cohen D, Khan AI, Wodchis WP. Income inequalities in multimorbidity prevalence in Ontario, Canada: a decomposition analysis of linked survey and health administrative data. Int J Equity Health 2018; 17:90. [PMID: 29941034 PMCID: PMC6019796 DOI: 10.1186/s12939-018-0800-6] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 06/11/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The burden of multimorbidity is a growing clinical and health system problem that is known to be associated with socioeconomic status, yet our understanding of the underlying determinants of inequalities in multimorbidity and longitudinal trends in measured disparities remains limited. METHODS We included all adult respondents from four cycles of the Canadian Community Health Survey (CCHS) (between 2005 to 2011/12), linked at the individual-level to health administrative data in Ontario, Canada (pooled n = 113,627). Multimorbidity was defined at each survey response as having ≥2 (of 17) high impact chronic conditions, based on claims data. Using a decomposition method of the Erreygers-corrected concentration index (CErreygers), we measured household income inequality and the contribution of the key determinants of multimorbidity (including socio-demographic, socio-economic, lifestyle and health system factors) to these disparities. Differences over time are described. We tested for statistically significant changes to measured inequality using the slope index (SII) and relative index of inequality (RII) with a 2-way interaction on pooled data. RESULTS Multimorbidity prevalence in 2011/12 was 33.5% and the CErreygers was - 0.085 (CI: -0.108 to - 0.062), indicating a greater prevalence among lower income groups. In decomposition analyses, income itself accounted more than two-thirds (69%) of this inequality. Age (21.7%), marital status (15.2%) and physical inactivity (10.9%) followed, and the contribution of these factors increased from baseline (2005 CCHS survey) with the exception of age. Other lifestyle factors, including heavy smoking and obesity, had minimal contribution to measured inequality (1.8 and 0.4% respectively). Tests for trends (SII/RII) across pooled survey data were not statistically significant (p = 0.443 and 0.405, respectively), indicating no change in inequalities in multimorbidity prevalence over the study period. CONCLUSIONS A pro-rich income gap in multimorbidity has persisted in Ontario from 2005 to 2011/12. These empirical findings suggest that to advance equality in multimorbidity prevalence, policymakers should target chronic disease prevention and control strategies focused on older adults, non-married persons and those that are physically inactive, in addition to addressing income disparities directly.
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Affiliation(s)
- Luke Mondor
- Institute for Clinical Evaluative Sciences (ICES), G1 06 2075 Bayview Ave, Toronto, ON M4N 3M5 Canada
- Health System Performance Research Network (HSPRN), 155 College St 4th Floor, Toronto, ON M5T 3M6 Canada
| | - Deborah Cohen
- Health System Performance Research Network (HSPRN), 155 College St 4th Floor, Toronto, ON M5T 3M6 Canada
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON K1G Z53 Canada
| | - Anum Irfan Khan
- Health System Performance Research Network (HSPRN), 155 College St 4th Floor, Toronto, ON M5T 3M6 Canada
- Institute of Health Policy, Management, and Evaluation (IHPME), University of Toronto, 155 College St 4th Floor, Toronto, ON M5T 3M6 Canada
| | - Walter P. Wodchis
- Institute for Clinical Evaluative Sciences (ICES), G1 06 2075 Bayview Ave, Toronto, ON M4N 3M5 Canada
- Health System Performance Research Network (HSPRN), 155 College St 4th Floor, Toronto, ON M5T 3M6 Canada
- Institute of Health Policy, Management, and Evaluation (IHPME), University of Toronto, 155 College St 4th Floor, Toronto, ON M5T 3M6 Canada
- Institute for Better Health, Trillium Health Partners, 100 Queensway West, Mississauga, ON L5B 1B8 Canada
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Lund Jensen N, Pedersen HS, Vestergaard M, Mercer SW, Glümer C, Prior A. The impact of socioeconomic status and multimorbidity on mortality: a population-based cohort study. Clin Epidemiol 2017; 9:279-289. [PMID: 28546772 PMCID: PMC5436773 DOI: 10.2147/clep.s129415] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Multimorbidity (MM) is more prevalent among people of lower socioeconomic status (SES), and both MM and SES are associated with higher mortality rates. However, little is known about the relationship between SES, MM, and mortality. This study investigates the association between educational level and mortality, and to what extent MM modifies this association. METHODS We followed 239,547 individuals invited to participate in the Danish National Health Survey 2010 (mean follow-up time: 3.8 years). MM was assessed by using information on drug prescriptions and diagnoses for 39 long-term conditions. Data on educational level were provided by Statistics Denmark. Date of death was obtained from the Civil Registration System. Information on lifestyle factors and quality of life was collected from the survey. The main outcomes were overall and premature mortality (death before the age of 75). RESULTS Of a total of 12,480 deaths, 6,607 (9.5%) were of people with low educational level (LEL) and 1,272 (2.3%) were of people with high educational level (HEL). The mortality rate was higher among people with LEL compared with HEL in groups of people with 0-1 disease (hazard ratio: 2.26, 95% confidence interval: 2.00-2.55) and ≥4 diseases (hazard ratio: 1.14, 95% confidence interval: 1.04-1.24), respectively (adjusted model). The absolute number of deaths was six times higher among people with LEL than those with HEL in those with ≥4 diseases. The 1-year cumulative mortality proportions for overall death in those with ≥4 diseases was 5.59% for people with HEL versus 7.27% for people with LEL, and 1-year cumulative mortality proportions for premature death was 2.93% for people with HEL versus 4.04% for people with LEL. Adjusting for potential mediating factors such as lifestyle and quality of life eliminated the statistical association between educational level and mortality in people with MM. CONCLUSION Our study suggests that LEL is associated with higher overall and premature mortality and that the association is affected by MM, lifestyle factors, and quality of life.
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Affiliation(s)
- Nikoline Lund Jensen
- Research Unit for General Practice.,Section for General Medical Practice, Department of Public Health, Aarhus University, Aarhus, Denmark
| | | | - Mogens Vestergaard
- Research Unit for General Practice.,Section for General Medical Practice, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Stewart W Mercer
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland
| | - Charlotte Glümer
- Research Centre for Prevention and Health, The Capital Region of Denmark, Glostrup, Denmark
| | - Anders Prior
- Research Unit for General Practice.,Section for General Medical Practice, Department of Public Health, Aarhus University, Aarhus, Denmark
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Laberge M, Wodchis WP, Barnsley J, Laporte A. Hospitalizations for ambulatory care sensitive conditions across primary care models in Ontario, Canada. Soc Sci Med 2017; 181:24-33. [DOI: 10.1016/j.socscimed.2017.03.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 03/02/2017] [Accepted: 03/18/2017] [Indexed: 01/13/2023]
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Mondor L, Maxwell CJ, Hogan DB, Bronskill SE, Gruneir A, Lane NE, Wodchis WP. Multimorbidity and healthcare utilization among home care clients with dementia in Ontario, Canada: A retrospective analysis of a population-based cohort. PLoS Med 2017; 14:e1002249. [PMID: 28267802 PMCID: PMC5340355 DOI: 10.1371/journal.pmed.1002249] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 02/02/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND For community-dwelling older persons with dementia, the presence of multimorbidity can create complex clinical challenges for both individuals and their physicians, and can contribute to poor outcomes. We quantified the associations between level of multimorbidity (chronic disease burden) and risk of hospitalization and risk of emergency department (ED) visit in a home care cohort with dementia and explored the role of continuity of physician care (COC) in modifying these relationships. METHODS AND FINDINGS A retrospective cohort study using linked administrative and clinical data from Ontario, Canada, was conducted among 30,112 long-stay home care clients (mean age 83.0 ± 7.7 y) with dementia in 2012. Multivariable Fine-Gray regression models were used to determine associations between level of multimorbidity and 1-y risk of hospitalization and 1-y risk of ED visit, accounting for multiple competing risks (death and long-term care placement). Interaction terms were used to assess potential effect modification by COC. Multimorbidity was highly prevalent, with 35% (n = 10,568) of the cohort having five or more chronic conditions. In multivariable analyses, risk of hospitalization and risk of ED visit increased monotonically with level of multimorbidity: sub-hazards were 88% greater (sub-hazard ratio [sHR] = 1.88, 95% CI: 1.72-2.05, p < 0.001) and 63% greater (sHR = 1.63; 95% CI: 1.51-1.77, p < 0.001), respectively, among those with five or more conditions, relative to those with dementia alone or with dementia and one other condition. Low (versus high) COC was associated with an increased risk of both hospitalization and ED visit in age- and sex-adjusted analyses only (sHR = 1.11, 95% CI: 1.07-1.16, p < 0.001, for hospitalization; sHR = 1.07, 95% CI: 1.03-1.11, p = 0.001, for ED visit) but did not modify associations between multimorbidity and outcomes (Wald test for interaction, p = 0.566 for hospitalization and p = 0.637 for ED visit). The main limitations of this study include use of fixed (versus time-varying) covariates and focus on all-cause rather than cause-specific hospitalizations and ED visits, which could potentially inform interventions. CONCLUSIONS Older adults with dementia and multimorbidity pose a particular challenge for health systems. Findings from this study highlight the need to reshape models of care for this complex population, and to further investigate health system and other factors that may modify patients' risk of health outcomes.
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Affiliation(s)
- Luke Mondor
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Health System Performance Research Network, Toronto, Ontario, Canada
| | - Colleen J Maxwell
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Health System Performance Research Network, Toronto, Ontario, Canada.,School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada.,School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - David B Hogan
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Division of Geriatric Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Susan E Bronskill
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Health System Performance Research Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Gruneir
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Natasha E Lane
- Health System Performance Research Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Walter P Wodchis
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Health System Performance Research Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Toronto Rehabilitation Institute, Toronto, Ontario, Canada
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Langton JM, Wong ST, Johnston S, Abelson J, Ammi M, Burge F, Campbell J, Haggerty J, Hogg W, Wodchis WP, McGrail K. Primary Care Performance Measurement and Reporting at a Regional Level: Could a Matrix Approach Provide Actionable Information for Policy Makers and Clinicians? Healthc Policy 2016; 12:33-51. [PMID: 28032823 PMCID: PMC5221710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Julia M. Langton
- Research Associate, Centre for Health Services and Policy Research, University of British, Columbia Vancouver, BC
| | - Sabrina T. Wong
- Professor, Centre for Health Services and Policy Research & School of Nursing, University of British Columbia, Vancouver, BC
| | - Sharon Johnston
- Associate Professor, Department of Family Medicine, University of Ottawa & Bruyere Research Institute, Ottawa, ON
| | - Julia Abelson
- Professor, Department of Clinical Epidemiology & Biostatistics, Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON
| | - Mehdi Ammi
- Assistant Professor, School of Public Policy & Administration, Carleton University, Ottawa, ON
| | - Fred Burge
- Professor, Faculty of Medicine, Dalhousie University, Halifax, NS
| | - John Campbell
- Professor, Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | | | - William Hogg
- Professor, Department of Family Medicine, University of Ottawa & Bruyere Research Institute, Ottawa, ON
| | - Walter P. Wodchis
- Associate Professor, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
| | - Kimberlyn McGrail
- Associate Professor, Centre for Health Services and Policy Research, University of British Columbia, Vancouver, BC
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Hopman P, Heins MJ, Korevaar JC, Rijken M, Schellevis FG. Health care utilization of patients with multiple chronic diseases in the Netherlands: Differences and underlying factors. Eur J Intern Med 2016; 35:44-50. [PMID: 27640914 DOI: 10.1016/j.ejim.2016.08.025] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 08/17/2016] [Accepted: 08/21/2016] [Indexed: 12/21/2022]
Abstract
PURPOSE To examine health care utilization of people with multiple chronic diseases in The Netherlands compared to people with a single chronic disease, and to identify subgroups of multimorbid patients according to health care utilization. METHODS All patients diagnosed with one or more chronic diseases in 2008-2009 (N=54,051) were selected from the nationwide NIVEL Primary Care Database, and data on their GP contacts and medication in 2010 were retrieved. Data on hospital admissions, household size and income were added. Chi-square-tests and multivariate regression analyses were performed to analyze differences between multimorbid patients and patients with a single chronic disease, and between subgroups of multimorbid patients derived from cluster analysis. RESULTS Multimorbid patients (37% of all patients) had more GP contacts, prescribed medications, and hospital admissions (all p<.0001) than patients with a single chronic disease. The largest cluster of multimorbid patients (57%) had a relatively low level of health care utilization, a smaller cluster (36%) had higher levels of health care utilization, and 7.6% of patients were heavy health care users (p<.0001 for all variables). The latter were older, more often female, had a lower income, lived in a smaller household, had more chronic diseases, and more often had specific chronic diseases such as COPD, diabetes and heart failure. CONCLUSIONS The majority of multimorbid patients have only slightly higher health care utilization than patients with a single chronic disease. Extensive health care utilization among multimorbid patients seems to be related to patient characteristics as well as chronic disease numbers and patterns.
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Affiliation(s)
| | | | | | | | - François G Schellevis
- NIVEL, Utrecht, The Netherlands; Department of General Practice & Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands.
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The relative impact of chronic conditions and multimorbidity on health-related quality of life in Ontario long-stay home care clients. Qual Life Res 2016; 25:2619-2632. [PMID: 27052421 DOI: 10.1007/s11136-016-1281-y] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2016] [Indexed: 12/21/2022]
Abstract
PURPOSE To examine the relative impact of 16 common chronic conditions and increasing morbidity on health-related quality of life (HRQL) in a population-based sample of home care clients in Ontario, Canada. METHODS Participants were adult clients assessed with the Resident Assessment Instrument for Home Care (RAI-HC) between January and June 2009 and diagnosed with one (or more) of 16 common chronic conditions. HRQL was evaluated using the Minimum Data Set-Health Status Index (MDS-HSI), a preference-based measure derived from items captured in the RAI-HC. Multivariable linear regression models assessed the relative impact of each condition, and increasing number of diagnoses, on MDS-HSI scores. RESULTS Mean (SD) MDS-HSI score in the study population (n = 106,159) was 0.524 (0.213). Multivariable analysis revealed a statistically significant (p < 0.05) and clinically important (difference ≥ 0.03) decrease in MDS-HSI scores associated with stroke (-0.056), osteoarthritis (-0.036), rheumatoid arthritis (-0.033) and congestive heart failure (CHF, -0.030). Differences by age and sex were observed; most notably, the negative impact associated with dementia was greater among men (-0.043) than among women (-0.019). Further, HRQL decreased incrementally with additional diagnoses. In all models, chronic conditions and number of diagnoses accounted for a relatively small proportion of the variance observed in MDS-HSI. CONCLUSION Clinically important negative effects on HRQL were observed for clients with a previous diagnosis of stroke, osteo- and rheumatoid arthritis, or CHF, as well as with increasing levels of multimorbidity. Findings provide baseline preference-based HRQL scores for home care clients with different diagnoses and may be useful for identifying, targeting and evaluating care strategies toward populations with significant HRQL impairments.
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