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Manis DR, Katz P, Lane NE, Rochon PA, Sinha SK, Andel R, Heckman GA, Kirkwood D, Costa AP. Rates of Hospital-Based Care among Older Adults in the Community and Residential Care Facilities: A Repeated Cross-Sectional Study. J Am Med Dir Assoc 2023; 24:1341-1348. [PMID: 37549887 DOI: 10.1016/j.jamda.2023.06.024] [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: 03/22/2023] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 08/09/2023]
Abstract
OBJECTIVE We examine annual rates of emergency department (ED) visits, hospital admissions, and alternate levels of care (ALC) days (ie, the number of days that an older adult remained in hospital when they could not be safely discharged to an appropriate setting in their community) among older adults. DESIGN Repeated cross-sectional study. SETTING AND PARTICIPANTS Linked, individual-level health system administrative data on community-dwelling persons, home care recipients, residents of assisted living facilities, and residents of nursing homes aged 65 years and older in Ontario, Canada, from January 1, 2013, to December 31, 2019. METHODS We calculated rates of ED visits, hospital admissions, and ALC days per 1000 individuals per older adult population per year. We used a generalized linear model with a gaussian distribution, log link, and year fixed effects to obtain rate ratios. RESULTS There were 1,655,656 older adults in the community, 237,574 home care recipients, 42,600 older adults in assisted living facilities, and 94,055 older adults in nursing homes in 2013; there were 2,129,690 older adults in the community, 281,028 home care recipients, 56,975 older adults in assisted living facilities, and 95,925 older adults in nursing homes in 2019. Residents of assisted living facilities had the highest rates of ED visits (1260.692019 vs 1174.912013), hospital admissions (482.632019 vs 480.192013), and ALC days (1905.572019 vs 1443.032013) per 1000 individuals. Residents of assisted living facilities also had significantly higher rates of ED visits [rate ratio (RR) 3.30, 95% CI 3.20, 3.41), hospital admissions (RR 6.24, 95% CI 6.01, 6.47), and ALC days (RR 25.68, 95% CI 23.27, 28.35) relative to community-dwelling older adults. CONCLUSIONS AND IMPLICATIONS The disproportionate use of ED visits, hospital admissions, and ALC days among residents of assisted living facilities may be attributed to the characteristics of the population and fragmented licensing and regulation of the sector, including variable models of care. The implementation of interdisciplinary, after-hours, team-based approaches to home and primary care in assisted living facilities may reduce the potentially avoidable use of ED visits, hospital admissions, and ALC days among this population and optimize resource allocation in health care systems.
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Affiliation(s)
- Derek R Manis
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; ICES, Toronto, ON, Canada.
| | - Paul Katz
- Department of Geriatrics, College of Medicine, Florida State University, Tallahassee, FL, USA
| | - Natasha E Lane
- ICES, Toronto, ON, Canada; Department of Internal Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Paula A Rochon
- ICES, Toronto, ON, Canada; Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada; Women's College Research Institute, Toronto, ON, Canada; Division of Geriatric Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Samir K Sinha
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada; Division of General Internal Medicine and Geriatrics, Sinai Health and University Health Network, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; National Institute on Ageing, Toronto Metropolitan University, Toronto, ON, Canada
| | - Ross Andel
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA; Department of Neurology, Charles University, Second Faculty of Medicine and Motol University Hospital, Prague, Czech Republic; International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | - George A Heckman
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | | | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; ICES, Toronto, ON, Canada; Schlegel Research Institute for Aging, Waterloo, ON, Canada; Centre for Integrated Care, St. Joseph's Health System, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
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Zimmerman S, Sloane PD, Wretman CJ, Cao K, Silbersack J, Carder P, Thomas KS, Allen J, Butrum K, Chicotel T, Giorgio P, Hernandez M, Kales H, Katz P, Klinger JH, Kunze M, Laxton C, McNealley V, Meeks S, O'Neil K, Pace D, Resnick B, Schwartz L, Seitz D, Smetanka L, Van Haitsma K. Recommendations for Medical and Mental Health Care in Assisted Living Based on an Expert Delphi Consensus Panel: A Consensus Statement. JAMA Netw Open 2022; 5:e2233872. [PMID: 36173637 DOI: 10.1001/jamanetworkopen.2022.33872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
IMPORTANCE Assisted living (AL) is the largest provider of residential long-term care in the US, and the morbidity of AL residents has been rising. However, AL is not a health care setting, and concern has been growing about residents' medical and mental health needs. No guidance exists to inform this care. OBJECTIVE To identify consensus recommendations for medical and mental health care in AL and determine whether they are pragmatic. EVIDENCE REVIEW A Delphi consensus statement study was conducted in 2021; as a separate effort, the extent to which the recommendations are reflected in practice was examined in data obtained from 2016 to 2021 (prepandemic). In the separate effort, data were from a 7-state study (Arkansas, Louisiana, New Jersey, New York, Oklahoma, Pennsylvania, Texas). The 19 Delphi panelists constituted nationally recognized experts in medical, nursing, and mental health needs of and care for older adults; dementia care; and AL and long-term care management, advocacy, regulation, and education. One invitee was unavailable and nominated an alternate. The primary outcome was identification of recommended practices based on consensus ratings of importance. Panelists rated 183 items regarding importance to care quality and feasibility. FINDINGS Consensus identified 43 recommendations in the areas of staff and staff training, nursing and related services, resident assessment and care planning, policies and practices, and medical and mental health clinicians and care. To determine the pragmatism of the recommendations, their prevalence was examined in the 7-state study and found that most were in practice. The items reflected the tenets of AL, the role of AL in providing dementia care, the need for pragmatism due to the diversity of AL, and workforce needs. CONCLUSIONS AND RELEVANCE In this consensus statement, 43 recommendations important to medical and mental health care in AL were delineated that are highly pragmatic as a guide for practice and policy.
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Affiliation(s)
- Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill
- School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill
| | - Philip D Sloane
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill
- Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill
| | | | - Kevin Cao
- School of Medicine, University of Illinois Chicago, Chicago
| | - Johanna Silbersack
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill
| | | | | | - Josh Allen
- Allen Flores Consulting Group, Searcy, Arkansas
| | | | - Tony Chicotel
- California Advocates for Nursing Home Reform, Berkeley
| | | | | | - Helen Kales
- Department of Psychiatry, University of Michigan, Ann Arbor
| | - Paul Katz
- Department of Geriatrics, College of Medicine, Florida State University, Tallahassee
| | | | - Margo Kunze
- American Assisted Living Nurses Association, Belmar, New Jersey
| | | | | | - Suzanne Meeks
- Department of Psychological & Brain Sciences, University of Louisville, Louisville, Kentucky
| | | | | | | | - Lindsay Schwartz
- Workforce & Quality Innovations, LLC, Bear Creek, North Carolina
| | - Dallas Seitz
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Lori Smetanka
- National Consumer Voice for Quality Long-Term Care, Washington, DC
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Manis DR, Poss JW, Jones A, Rochon PA, Bronskill SE, Campitelli MA, Perez R, Stall NM, Rahim A, Babe G, Tarride JÉ, Abelson J, Costa AP. Rates of health services use among residents of retirement homes in Ontario: a population-based cohort study. CMAJ 2022; 194:E730-E738. [PMID: 35636759 PMCID: PMC9259419 DOI: 10.1503/cmaj.211883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Because there are no standardized reporting systems specific to residents of retirement homes in North America, little is known about the health of this distinct population of older adults. We evaluated rates of health services use by residents of retirement homes relative to those of residents of long-term care homes and other populations of older adults. METHODS We conducted a retrospective cohort study using population health administrative data from 2018 on adults 65 years or older in Ontario. We matched the postal codes of individuals to those of licensed retirement homes to identify residents of retirement homes. Outcomes included rates of hospital-based care and physician visits. RESULTS We identified 54 733 residents of 757 retirement homes (mean age 86.7 years, 69.0% female) and 2 354 385 residents of other settings. Compared to residents of long-term care homes, residents of retirement homes had significantly higher rates per 1000 person months of emergency department visits (10.62 v. 4.48, adjusted relative rate [RR] 2.61, 95% confidence interval [CI] 2.55 to 2.67), hospital admissions (5.42 v. 2.08, adjusted RR 2.77, 95% CI 2.71 to 2.82), alternate level of care (ALC) days (6.01 v. 2.96, adjusted RR 1.51, 95% CI 1.48 to 1.54), and specialist physician visits (6.27 v. 3.21, adjusted RR 1.64, 95% CI 1.61 to 1.68), but a significantly lower rate of primary care visits (16.71 v. 108.47, adjusted RR 0.13, 95% CI 0.13 to 0.14). INTERPRETATION Residents of retirement homes are a distinct population with higher rates of hospital-based care. Our findings can help to inform policy debates about the need for more coordinated primary and supportive health care in privately operated congregate care homes.
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Affiliation(s)
- Derek R Manis
- Centre for Health Economics and Policy Analysis (Manis, Tarride, Abelson, Costa), and Department of Health Research Methods, Evidence, and Impact (Manis, Jones, Tarride, Abelson, Costa), Department of Medicine (Costa), McMaster University; Programs for Assessment of Technology in Health (Tarride), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; ICES Central (Manis, Rochon, Bronskill, Campitelli, Perez, Rahim, Babe, Costa), Toronto, Ont.; School of Population and Public Health (Poss), University of Waterloo, Waterloo, Ont.; Women's College Research Institute (Rochon, Bronskill, Stall); Institute for Health Policy, Management & Evaluation (Rochon, Bronskill, Stall), and Division of Geriatric Medicine (Rochon), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Bronskill); Division of General Internal Medicine and Geriatrics (Stall), Sinai Health and University Health Network; National Institute on Ageing, Ryerson University (Stall), Toronto, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont
| | - Jeffrey W Poss
- Centre for Health Economics and Policy Analysis (Manis, Tarride, Abelson, Costa), and Department of Health Research Methods, Evidence, and Impact (Manis, Jones, Tarride, Abelson, Costa), Department of Medicine (Costa), McMaster University; Programs for Assessment of Technology in Health (Tarride), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; ICES Central (Manis, Rochon, Bronskill, Campitelli, Perez, Rahim, Babe, Costa), Toronto, Ont.; School of Population and Public Health (Poss), University of Waterloo, Waterloo, Ont.; Women's College Research Institute (Rochon, Bronskill, Stall); Institute for Health Policy, Management & Evaluation (Rochon, Bronskill, Stall), and Division of Geriatric Medicine (Rochon), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Bronskill); Division of General Internal Medicine and Geriatrics (Stall), Sinai Health and University Health Network; National Institute on Ageing, Ryerson University (Stall), Toronto, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont
| | - Aaron Jones
- Centre for Health Economics and Policy Analysis (Manis, Tarride, Abelson, Costa), and Department of Health Research Methods, Evidence, and Impact (Manis, Jones, Tarride, Abelson, Costa), Department of Medicine (Costa), McMaster University; Programs for Assessment of Technology in Health (Tarride), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; ICES Central (Manis, Rochon, Bronskill, Campitelli, Perez, Rahim, Babe, Costa), Toronto, Ont.; School of Population and Public Health (Poss), University of Waterloo, Waterloo, Ont.; Women's College Research Institute (Rochon, Bronskill, Stall); Institute for Health Policy, Management & Evaluation (Rochon, Bronskill, Stall), and Division of Geriatric Medicine (Rochon), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Bronskill); Division of General Internal Medicine and Geriatrics (Stall), Sinai Health and University Health Network; National Institute on Ageing, Ryerson University (Stall), Toronto, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont
| | - Paula A Rochon
- Centre for Health Economics and Policy Analysis (Manis, Tarride, Abelson, Costa), and Department of Health Research Methods, Evidence, and Impact (Manis, Jones, Tarride, Abelson, Costa), Department of Medicine (Costa), McMaster University; Programs for Assessment of Technology in Health (Tarride), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; ICES Central (Manis, Rochon, Bronskill, Campitelli, Perez, Rahim, Babe, Costa), Toronto, Ont.; School of Population and Public Health (Poss), University of Waterloo, Waterloo, Ont.; Women's College Research Institute (Rochon, Bronskill, Stall); Institute for Health Policy, Management & Evaluation (Rochon, Bronskill, Stall), and Division of Geriatric Medicine (Rochon), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Bronskill); Division of General Internal Medicine and Geriatrics (Stall), Sinai Health and University Health Network; National Institute on Ageing, Ryerson University (Stall), Toronto, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont
| | - Susan E Bronskill
- Centre for Health Economics and Policy Analysis (Manis, Tarride, Abelson, Costa), and Department of Health Research Methods, Evidence, and Impact (Manis, Jones, Tarride, Abelson, Costa), Department of Medicine (Costa), McMaster University; Programs for Assessment of Technology in Health (Tarride), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; ICES Central (Manis, Rochon, Bronskill, Campitelli, Perez, Rahim, Babe, Costa), Toronto, Ont.; School of Population and Public Health (Poss), University of Waterloo, Waterloo, Ont.; Women's College Research Institute (Rochon, Bronskill, Stall); Institute for Health Policy, Management & Evaluation (Rochon, Bronskill, Stall), and Division of Geriatric Medicine (Rochon), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Bronskill); Division of General Internal Medicine and Geriatrics (Stall), Sinai Health and University Health Network; National Institute on Ageing, Ryerson University (Stall), Toronto, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont
| | - Michael A Campitelli
- Centre for Health Economics and Policy Analysis (Manis, Tarride, Abelson, Costa), and Department of Health Research Methods, Evidence, and Impact (Manis, Jones, Tarride, Abelson, Costa), Department of Medicine (Costa), McMaster University; Programs for Assessment of Technology in Health (Tarride), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; ICES Central (Manis, Rochon, Bronskill, Campitelli, Perez, Rahim, Babe, Costa), Toronto, Ont.; School of Population and Public Health (Poss), University of Waterloo, Waterloo, Ont.; Women's College Research Institute (Rochon, Bronskill, Stall); Institute for Health Policy, Management & Evaluation (Rochon, Bronskill, Stall), and Division of Geriatric Medicine (Rochon), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Bronskill); Division of General Internal Medicine and Geriatrics (Stall), Sinai Health and University Health Network; National Institute on Ageing, Ryerson University (Stall), Toronto, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont
| | - Richard Perez
- Centre for Health Economics and Policy Analysis (Manis, Tarride, Abelson, Costa), and Department of Health Research Methods, Evidence, and Impact (Manis, Jones, Tarride, Abelson, Costa), Department of Medicine (Costa), McMaster University; Programs for Assessment of Technology in Health (Tarride), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; ICES Central (Manis, Rochon, Bronskill, Campitelli, Perez, Rahim, Babe, Costa), Toronto, Ont.; School of Population and Public Health (Poss), University of Waterloo, Waterloo, Ont.; Women's College Research Institute (Rochon, Bronskill, Stall); Institute for Health Policy, Management & Evaluation (Rochon, Bronskill, Stall), and Division of Geriatric Medicine (Rochon), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Bronskill); Division of General Internal Medicine and Geriatrics (Stall), Sinai Health and University Health Network; National Institute on Ageing, Ryerson University (Stall), Toronto, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont
| | - Nathan M Stall
- Centre for Health Economics and Policy Analysis (Manis, Tarride, Abelson, Costa), and Department of Health Research Methods, Evidence, and Impact (Manis, Jones, Tarride, Abelson, Costa), Department of Medicine (Costa), McMaster University; Programs for Assessment of Technology in Health (Tarride), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; ICES Central (Manis, Rochon, Bronskill, Campitelli, Perez, Rahim, Babe, Costa), Toronto, Ont.; School of Population and Public Health (Poss), University of Waterloo, Waterloo, Ont.; Women's College Research Institute (Rochon, Bronskill, Stall); Institute for Health Policy, Management & Evaluation (Rochon, Bronskill, Stall), and Division of Geriatric Medicine (Rochon), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Bronskill); Division of General Internal Medicine and Geriatrics (Stall), Sinai Health and University Health Network; National Institute on Ageing, Ryerson University (Stall), Toronto, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont
| | - Ahmad Rahim
- Centre for Health Economics and Policy Analysis (Manis, Tarride, Abelson, Costa), and Department of Health Research Methods, Evidence, and Impact (Manis, Jones, Tarride, Abelson, Costa), Department of Medicine (Costa), McMaster University; Programs for Assessment of Technology in Health (Tarride), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; ICES Central (Manis, Rochon, Bronskill, Campitelli, Perez, Rahim, Babe, Costa), Toronto, Ont.; School of Population and Public Health (Poss), University of Waterloo, Waterloo, Ont.; Women's College Research Institute (Rochon, Bronskill, Stall); Institute for Health Policy, Management & Evaluation (Rochon, Bronskill, Stall), and Division of Geriatric Medicine (Rochon), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Bronskill); Division of General Internal Medicine and Geriatrics (Stall), Sinai Health and University Health Network; National Institute on Ageing, Ryerson University (Stall), Toronto, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont
| | - Glenda Babe
- Centre for Health Economics and Policy Analysis (Manis, Tarride, Abelson, Costa), and Department of Health Research Methods, Evidence, and Impact (Manis, Jones, Tarride, Abelson, Costa), Department of Medicine (Costa), McMaster University; Programs for Assessment of Technology in Health (Tarride), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; ICES Central (Manis, Rochon, Bronskill, Campitelli, Perez, Rahim, Babe, Costa), Toronto, Ont.; School of Population and Public Health (Poss), University of Waterloo, Waterloo, Ont.; Women's College Research Institute (Rochon, Bronskill, Stall); Institute for Health Policy, Management & Evaluation (Rochon, Bronskill, Stall), and Division of Geriatric Medicine (Rochon), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Bronskill); Division of General Internal Medicine and Geriatrics (Stall), Sinai Health and University Health Network; National Institute on Ageing, Ryerson University (Stall), Toronto, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont
| | - Jean-Éric Tarride
- Centre for Health Economics and Policy Analysis (Manis, Tarride, Abelson, Costa), and Department of Health Research Methods, Evidence, and Impact (Manis, Jones, Tarride, Abelson, Costa), Department of Medicine (Costa), McMaster University; Programs for Assessment of Technology in Health (Tarride), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; ICES Central (Manis, Rochon, Bronskill, Campitelli, Perez, Rahim, Babe, Costa), Toronto, Ont.; School of Population and Public Health (Poss), University of Waterloo, Waterloo, Ont.; Women's College Research Institute (Rochon, Bronskill, Stall); Institute for Health Policy, Management & Evaluation (Rochon, Bronskill, Stall), and Division of Geriatric Medicine (Rochon), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Bronskill); Division of General Internal Medicine and Geriatrics (Stall), Sinai Health and University Health Network; National Institute on Ageing, Ryerson University (Stall), Toronto, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont
| | - Julia Abelson
- Centre for Health Economics and Policy Analysis (Manis, Tarride, Abelson, Costa), and Department of Health Research Methods, Evidence, and Impact (Manis, Jones, Tarride, Abelson, Costa), Department of Medicine (Costa), McMaster University; Programs for Assessment of Technology in Health (Tarride), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; ICES Central (Manis, Rochon, Bronskill, Campitelli, Perez, Rahim, Babe, Costa), Toronto, Ont.; School of Population and Public Health (Poss), University of Waterloo, Waterloo, Ont.; Women's College Research Institute (Rochon, Bronskill, Stall); Institute for Health Policy, Management & Evaluation (Rochon, Bronskill, Stall), and Division of Geriatric Medicine (Rochon), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Bronskill); Division of General Internal Medicine and Geriatrics (Stall), Sinai Health and University Health Network; National Institute on Ageing, Ryerson University (Stall), Toronto, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont
| | - Andrew P Costa
- Centre for Health Economics and Policy Analysis (Manis, Tarride, Abelson, Costa), and Department of Health Research Methods, Evidence, and Impact (Manis, Jones, Tarride, Abelson, Costa), Department of Medicine (Costa), McMaster University; Programs for Assessment of Technology in Health (Tarride), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; ICES Central (Manis, Rochon, Bronskill, Campitelli, Perez, Rahim, Babe, Costa), Toronto, Ont.; School of Population and Public Health (Poss), University of Waterloo, Waterloo, Ont.; Women's College Research Institute (Rochon, Bronskill, Stall); Institute for Health Policy, Management & Evaluation (Rochon, Bronskill, Stall), and Division of Geriatric Medicine (Rochon), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Bronskill); Division of General Internal Medicine and Geriatrics (Stall), Sinai Health and University Health Network; National Institute on Ageing, Ryerson University (Stall), Toronto, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont.
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