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Tuohy CA, Liziewski KE, White PA, Wright WL. Evaluating adherence to American Diabetes Association standards of care in diabetes and impacts of social determinants of health on patients at two nurse practitioner-owned clinics. J Am Assoc Nurse Pract 2024; 36:399-408. [PMID: 38771202 DOI: 10.1097/jxx.0000000000001026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 04/08/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND The COVID-19 pandemic created barriers in the management of type 2 diabetes mellitus (T2DM) and worsened social determinants of health (SDOH). A New Hampshire primary care office worked to adhere to T2DM standards of care and began screening for SDOH. This project assessed adherence to quality metrics, hemoglobin A1C, and SDOH screening as telehealth utilization decreased. LOCAL PROBLEM A1C values have increased at the practice, especially since COVID-19. The practice also began screening for SDOH at every visit, but there was need to assess how needs were being documented and if/how they were addressed. METHODS A retrospective chart review of patients with T2DM was performed. Demographic data and T2DM metrics were collected and compared with previous years and compared new versus established patients. Charts were reviewed to evaluate documentation of SDOH and appropriate referral. INTERVENTIONS The practice transitioned from an increased utliization of telehealth back to prioritizing in-office visits. The practice also began routinely screening for SDOH in 2020; however, this process had not been standardized or evaluated. RESULTS Adherence to nearly all quality metrics improved. Glycemic control improved after a year of nurse practitioner (NP) care, especially in new patients. All patients were screened for SDOH, but documentation varied, and affected patients had higher A1Cs, despite receiving comparable care. CONCLUSION Nurse practitioners at this practice are adhering to American Diabetes Association guidelines, and A1C values improve under their care. Social determinants of health continue to act as unique barriers that keep patients from improving glycemic control, highlighting the need for individualized treatment of SDOH in T2DM care.
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Affiliation(s)
- Christine A Tuohy
- Wright & Associates Family Healthcare, Amherst, New Hampshire
- Wright & Associates Family Healthcare, Concord, New Hampshire
- Tan Chingfen Graduate School of Nursing, University of Massachusetts (UMass) Chan Medical School, Worcester, Massachusetts
| | - Kathryn E Liziewski
- Tan Chingfen Graduate School of Nursing, University of Massachusetts (UMass) Chan Medical School, Worcester, Massachusetts
- Beth Israel Lahey Health Primary Care, Lexington, Massachusetts
| | - Patricia A White
- Tan Chingfen Graduate School of Nursing, University of Massachusetts (UMass) Chan Medical School, Worcester, Massachusetts
| | - Wendy L Wright
- Wright & Associates Family Healthcare, Amherst, New Hampshire
- Wright & Associates Family Healthcare, Concord, New Hampshire
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Mathews M, Lyons R, Harris S, Hedden L, Choi YH, Donnan J, Green ME, Harvey E, Reichert SM, Ryan B, Sibbald S, Meredith L. Evaluation of a unique and innovative diabetes care model in primary care in Ontario, Canada: protocol for a multiple-methods study with a convergent parallel design. BMJ Open 2024; 14:e088737. [PMID: 38858140 PMCID: PMC11168156 DOI: 10.1136/bmjopen-2024-088737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 05/30/2024] [Indexed: 06/12/2024] Open
Abstract
INTRODUCTION The growth and complexity of diabetes are exceeding the capacity of family physicians, resulting in the demand for community-based, interprofessional, primary care-led transition clinics. The Primary Care Diabetes Support Programme (PCDSP) in London, Ontario, is an innovative approach to diabetes care for high-risk populations, such as medically or socially complex and unattached patients. In this study, we will employ a quadruple-aim approach to evaluate the health system impacts of the PCDSP. METHODS AND ANALYSIS We will use multiple methods through a convergent parallel design in this project across five unique studies: a case study, a patient study, a provider study, a complications study and a cost-effectiveness study. The project will be conducted in a dedicated stand-alone clinic specialising in chronic disease management, specifically focusing on diabetes care. Participants will include clinic staff, administrators, family physicians, specialists and patients with type 1 or type 2 diabetes who received care at the clinic between 2011 and 2023. The project design will define the intervention, support replication at other sites or for other chronic diseases and address each of the quadruple aims and equity. Following the execution of the five individual studies, we will build a business case by integrating the results. Data will be analysed using both qualitative (content analysis and thematic analysis) and quantitative techniques (descriptive statistics and multiple logistic regression). ETHICS AND DISSEMINATION We received approval from the research ethics boards at Western University (reference ID: 2023-1 21 766; 2023-1 22 326) and Lawson Health Research Institute (reference ID: R-23-202). A privacy review was completed by St. Joseph's Healthcare Corporation. The findings will be shared among PCDSP staff and patients, stakeholders, academic researchers and the public through stakeholder sessions, conferences, peer-reviewed publications, infographics, posters, media interviews, social media and online discussions. For the patient and provider study, all participants will be asked to provide consent and are free to withdraw from the study, without penalty, until the data are combined. Participants will not be identified in any report or presentation except in the case study, for which, given the number of PCDSP providers, we will seek explicit consent to identify them.
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Affiliation(s)
- Maria Mathews
- Department of Family Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Rhiannon Lyons
- Department of Family Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Stewart Harris
- Department of Family Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
- Primary Care Diabetes Support Program, St. Joseph's Health Care London, London, Ontario, Canada
| | - Lindsay Hedden
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Yun-Hee Choi
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Jennifer Donnan
- School of Pharmacy, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Michael E Green
- Departments of Family Medicine and Public Health Sciences, School of Medicine, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Elisabeth Harvey
- Primary Care Diabetes Support Program, St. Joseph's Health Care London, London, Ontario, Canada
- School of Nursing, Faculty of Health Sciences, University of Western Ontario, London, Ontario, Canada
| | - Sonja M Reichert
- Department of Family Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
- Primary Care Diabetes Support Program, St. Joseph's Health Care London, London, Ontario, Canada
| | - Bridget Ryan
- Department of Family Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Shannon Sibbald
- School of Health Studies, Faculty of Health Sciences, University of Western Ontario, London, Ontario, Canada
| | - Leslie Meredith
- Department of Family Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
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Aldahmashi H, Maneze D, Molloy L, Salamonson Y. Nurses' adoption of diabetes clinical practice guidelines in primary care and the impacts on patient outcomes and safety: An integrative review. Int J Nurs Stud 2024; 154:104747. [PMID: 38531197 DOI: 10.1016/j.ijnurstu.2024.104747] [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: 11/28/2023] [Revised: 02/26/2024] [Accepted: 02/29/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Complications related to diabetes mellitus impose substantial health and economic burdens to individuals and society. While clinical practice guidelines improve diabetes management in primary care settings, the variability in adherence to these guidelines persist. Hence, there is a need to comprehensively review existing evidence regarding factors influencing nurses' adherence to implementation of clinical practice guidelines to improve clinical care and patient safety. OBJECTIVE This integrative review seeks to investigate nurses' adherence to clinical guidelines for diabetes management in primary healthcare settings and to explore factors influencing effective implementation, focusing on the role of nurses and impacts on patient outcomes. METHODS A comprehensive search was conducted in March 2023 across six electronic databases. The search targeted studies that examined the use of Type 2 diabetes mellitus guidelines by nurses in primary healthcare settings with a focus on clinical management outcomes related to diabetes care or patient safety. Included studies were classified using the Effective Practice and Organisation of Care taxonomy, synthesised narratively and presented thematically. Reporting of the review adhered to PRISMA guidelines. (PROSPERO ID CRD42023394311). RESULTS The review included ten studies conducted between 2000 and 2020, and the results were categorised into three themes. These were: (i) Implementation strategies to promote clinical practice guidelines adherence, including health professional development, reminders for clinicians, patient-mediated interventions, health information systems, role expansion, and comprehensive package-of-care. A multifaceted educational approach emerged as the most effective strategy. (ii) Impact of guidelines adherence: These strategies consistently improved clinical management, lowering HbA1c levels, improving blood pressure and lipid profiles, and enhancing patient self-care engagement, along with increased nurses' adherence to diabetes clinical guidelines. (iii) The role of nurses in guideline implementation, enabling independent practice within multidisciplinary teams. Their roles encompassed patient education, collaborative practice with fellow healthcare professionals, program planning and execution, and comprehensive documentation review. Nurse-led interventions were effective in improving patient outcomes, underscoring the necessity of empowering nurses with greater autonomy in providing primary diabetes care. CONCLUSION Implementing a diverse range of strategies, focusing on comprehensive education for healthcare providers, is paramount for enhancing guideline adherence in diabetes care, to improve clinical management towards optimal patient health outcomes. Tailoring these strategies to meet local needs adds relevance to the guidelines. Empowering nurses to take a leading role in primary care not only enhances patient safety but also promotes quality of care, resulting in improved overall outcomes. TWEETABLE ABSTRACT In primary care, empowering nurses with diabetes guideline education and tailoring strategies to local needs enhance guideline adherence and improve patient outcomes.
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Affiliation(s)
- Hadwan Aldahmashi
- School of Nursing, University of Wollongong, Wollongong, Sydney, Australia; College of Applied Medical Sciences, University of Hafr Albatin, Saudi Arabia.
| | - Della Maneze
- School of Nursing, University of Wollongong, Wollongong, Sydney, Australia; School of Nursing and Midwifery, Western Sydney University, Australia; Australian Centre for Integration of Oral Health, Australia.
| | - Luke Molloy
- School of Nursing, University of Wollongong, Wollongong, Sydney, Australia.
| | - Yenna Salamonson
- School of Nursing, University of Wollongong, Wollongong, Sydney, Australia; Australian Centre for Integration of Oral Health, Australia.
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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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Menéndez Torre EL, Pujante Alarcón P, Basterra-Gortari FJ, Rojo-Martínez G, Santos Mata MÁ. Survey of Spanish hospitals on diabetes care resources. ENDOCRINOL DIAB NUTR 2023; 70:526-531. [PMID: 37863667 DOI: 10.1016/j.endien.2023.10.002] [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] [Received: 02/21/2023] [Revised: 05/09/2023] [Accepted: 05/09/2023] [Indexed: 10/22/2023]
Abstract
INTRODUCTION The quality of diabetes care varies from region to region. The objective of this study is to analyze the characteristics of care in different hospitals in Spain through a specific survey assessing different aspects of care for both children and adults. MATERIALS AND METHODS Cross-sectional observational voluntary survey study, sent to the heads of the Endocrinology and Pediatric Endocrinology Departments or Units in public hospitals with more than 150 beds, during the first semester of 2021. A total of 105 responses were obtained, 55.5% of the 189 requested, which corresponded to a population served of 31,782,409 people, representing almost 80% of the total population served. RESULTS Patients with diabetes under 15 years of age are cared for by Pediatric Departments, but only 58% of them have a specific Diabetes Education Unit for children, and in 72% of the cases, there is one single nurse dedicated to these tasks, and not always full-time. Those over 15 years of age are attended by specialists in Endocrinology and Nutrition in 94.3 % of hospitals. There are Therapeutic Education Units in Diabetes in practically all hospitals (94.3%). However, Diabetes Day Hospitals exist in only 32 centres and cover 40.3% of the population, since in 22 provinces there are none. Virtual and telematic consultations, as well as retinography, are available in more than 70% of cases, but access to a Diabetic Foot Unit only in 54% of centres. Monographic technological consultations on diabetes have become widespread, but access to mental health specialists with diabetes training remains limited (24% of centres), and interdisciplinary (32%) or interlevel (12%) committees are very scarce. CONCLUSION Diabetes care in Spain shows great variability from one region to another, and some deficiencies have been detected that affect a large part of the population, such as access to Diabetic Foot Units, as well as mental health specialists with specific training. The presence of multidisciplinary and mixed committees between levels of care remains scarce.
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Affiliation(s)
- Edelmiro Luis Menéndez Torre
- Servicio de Endocrinología y Nutrición, Hospital Universitario Central de Asturias, Oviedo, Spain; Departamento de Medicina, Universidad de Oviedo, Oviedo, Spain.
| | - Pedro Pujante Alarcón
- Servicio de Endocrinología y Nutrición, Hospital Universitario Central de Asturias, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain; CIBER de Enfermedades Raras (CIBERER), Oviedo, Spain
| | | | - Gemma Rojo-Martínez
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Regional Universitario de Málaga, Málaga, Spain; Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain; CIBER de Diabetes y Enfermedades Metabólicas (CIBERDEM), Málaga, Spain
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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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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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9
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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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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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Koné AP, Scharf D, Tan A. Multimorbidity and Complexity Among Patients with Cancer in Ontario: A Retrospective Cohort Study Exploring the Clustering of 17 Chronic Conditions with Cancer. Cancer Control 2023; 30:10732748221150393. [PMID: 36631419 PMCID: PMC9841838 DOI: 10.1177/10732748221150393] [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] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Multimorbidity is a concern for people living with cancer, as over 90% have at least one other condition. Multimorbidity complicates care coming from multiple providers who work within separate, siloed systems. Information describing high-risk and high-cost disease combinations has potential to improve the experience, outcome, and overall cost of care by informing comprehensive care management frameworks. This study aimed to identify disease combinations among people with cancer and other conditions, and to assess the health burden associated with those combinations to help healthcare providers more effectively prioritize and coordinate care. METHODS We used a population-based retrospective cohort design including adults with a cancer diagnosis between March-2003 and April-2013, followed-up until March 2018. We used observed disease combinations defined by level of multimorbidity and partitive (k-means) clusters, ie groupings of similar diseases based on the prevalence of each condition. We assessed disease combination-associated health burden through health service utilization, including emergency department visits, primary care visits and hospital admissions during the follow-up period. RESULTS 549,248 adults were included in the study. Anxiety, diabetes mellitus, hypertension, and osteoarthritis co-occurred with cancer 1.1 to 5.3 times more often than expected by chance. Disease combinations varied by cancer type and age but were similar between sexes. The largest partitive cluster included cancer and anxiety, with at least 25% of individuals also having osteoarthritis. Cancer also tended to co-occur with hypertension (8.0%) or osteoarthritis (6.2%). There were differences between clusters in healthcare utilization, regardless of the number of disease combinations or clustering approach used. CONCLUSION Researchers, clinicians, policymakers, and other stakeholders can use the clustering information presented here to improve the healthcare system for people with cancer multimorbidity by developing cluster-specific care management and clinical guidelines for common disease combinations.
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Affiliation(s)
- Anna Péfoyo Koné
- Department of Health Sciences, Lakehead University, Thunder Bay, ON, Canada,Behavioural Research and Northern Community Health Evaluative Services (BRANCHES), Thunder Bay, ON, Canada,Health System Performance Network (HSPN), Toronto, ON, Canada,Centre for Education and Research on Aging and Health (CERAH), Thunder Bay, ON, Canada,Centre for Rural and Northern Health Research (CRaNHR), Thunder Bay, ON, Canada,Anna P. Kone, Department of Health Sciences, Lakehead University, Thunder bay, ON P7B5E1, Canada.
| | - Deborah Scharf
- Department of Health Sciences, Lakehead University, Thunder Bay, ON, Canada,Behavioural Research and Northern Community Health Evaluative Services (BRANCHES), Thunder Bay, ON, Canada,Department of Psychology, Lakehead University, Thunder Bay, ON, Canada
| | - Amy Tan
- Division of Palliative Care and Dept of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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13
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Cai CX, Kim M, Lundeen EA, Benoit SR. Differences in receipt of recommended eye examinations by comorbidity status and healthcare utilization among nonelderly adults with diabetes. J Diabetes 2022; 14:749-757. [PMID: 36285845 PMCID: PMC9705799 DOI: 10.1111/1753-0407.13328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 08/27/2022] [Accepted: 09/30/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND To evaluate the effect of diabetes comorbidities by baseline healthcare utilization on receipt of recommended eye examinations. METHODS Retrospective analysis of 310 691 nonelderly adults with type 2 diabetes in the IBM MarketScan Commercial Database from 2016 to 2019. Patients were grouped based on diabetes-concordant (related) or -discordant (unrelated) comorbidities. Logistic regression was used to estimate the prevalence ratio (PR) for eye examinations by comorbidity status, healthcare utilization, and an interaction between comorbidities and utilization, controlling for age, sex, region, and major eye disease. RESULTS Prevalence of biennial eye examinations varied by the four comorbidity groups: 43.5% (diabetes only), 52.7% (concordant + discordant comorbidities), 48.0% (concordant comorbidities only), and 45.3% (discordant comorbidities only). In the lowest healthcare utilization tertile, the concordant-only and concordant + discordant groups had lower prevalence of examinations compared to diabetes only (PR 0.95 [95% CI 0.92-0.98] and PR 0.91 [95% CI 0.88-0.95], respectively). In the medium utilization tertile, the discordant-only and concordant + discordant groups had lower prevalence of examinations (PR 0.89 [0.83-0.95] and PR 0.94 [0.90-0.98], respectively). In the highest utilization tertile, the concordant-only and concordant + discordant groups had higher prevalence of examinations. CONCLUSIONS Among patients with low healthcare utilization, having comorbid conditions is associated with lower prevalence of eye examinations. Among those with medium healthcare utilization, patients with diabetes-discordant comorbidities are particularly vulnerable. This study highlights populations of diabetes patients who would benefit from increased assistance in receiving vision-preserving eye examinations.
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Affiliation(s)
- Cindy X. Cai
- Wilmer Eye Institute, Johns Hopkins HospitalBaltimoreMarylandUSA
| | - Minchul Kim
- Center for Outcomes Research, Department of Internal MedicineUniversity of Illinois College of Medicine PeoriaPeoriaIllinoisUSA
| | - Elizabeth A. Lundeen
- Division of Diabetes TranslationNational Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and PreventionAtlantaGeorgiaUSA
| | - Stephen R. Benoit
- Division of Diabetes TranslationNational Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and PreventionAtlantaGeorgiaUSA
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14
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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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15
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Truong DH, Bedimo R, Malone M, Wukich DK, Oz OK, Killeen AL, Lavery LA. Meta-Analysis: Outcomes of Surgical and Medical Management of Diabetic Foot Osteomyelitis. Open Forum Infect Dis 2022; 9:ofac407. [PMID: 36147596 PMCID: PMC9487605 DOI: 10.1093/ofid/ofac407] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/06/2022] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND The aim of this study was to evaluate clinical outcomes in the published literature on medical and surgical management of diabetic foot osteomyelitis (DFO). METHODS A PubMed and Google Scholar search of articles relating to DFO was performed over the dates of January 1931 to January 2020. Articles that involved Charcot arthropathy, case reports, small case series, review articles, commentaries, nonhuman studies, and non-English articles were excluded. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool was used to rate the bias of each study. A meta-analysis was performed using random-effects and inverse variance methods. The search yielded 1192 articles. After review and the removal of articles that did not meet inclusion criteria, 28 articles remained. Eighteen articles were related to the medical management of DFO and 13 articles were related to surgical management. Three articles looked at a combination of medical and surgical management and were included in both groups. Heterogeneity was evaluated using Cochran Q, I 2, τ2, and τ. RESULTS The average success rate was 68.2% (range, 17.0%-97.3%) for medical treatment and 85.7% (range, 65.0%-98.8%) for surgical and medical treatment. There were significant inconsistencies in accounting for peripheral arterial disease and peripheral neuropathy. There was significant heterogeneity in outcomes between studies. However, there was a high rate of successful treatment and a wide range between patients with medical treatment and combined surgical and medical treatment. CONCLUSIONS Additional properly designed prospective studies with gold-standard references for diagnosing osteomyelitis are needed to help determine whether medical management of DFO can be successful without surgical intervention.
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Affiliation(s)
- David H Truong
- Surgical Service, Podiatry Section, Veterans Affairs North Texas Health Care System, Dallas, Texas, USA
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Roger Bedimo
- Medical Service, Infectious Disease Section, Veterans Affairs North Texas Health Care System, Dallas, Texas, USA
- Department of Infectious Disease, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Matthew Malone
- Infectious Disease and Microbiology, School of Medicine, Western Sydney University, Campbelltown, Australia
- South West Sydney Limb Preservation and Wound Research Academic Unit, South Western Sydney Local Health District, Sydney, Australia
| | - Dane K Wukich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Orhan K Oz
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Amanda L Killeen
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Lawrence A Lavery
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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16
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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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17
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Income inequalities and risk of early rehospitalization for diabetes, hypertension, and heart failure in the Canadian working age population. Can J Diabetes 2021; 46:561-568. [DOI: 10.1016/j.jcjd.2021.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 05/19/2021] [Accepted: 08/13/2021] [Indexed: 11/19/2022]
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18
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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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19
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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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20
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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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21
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Gupta N, Sheng Z. Reduced Risk of Hospitalization With Stronger Community Belonging Among Aging Canadians Living With Diabetes: Findings From Linked Survey and Administrative Data. Front Public Health 2021; 9:670082. [PMID: 34055729 PMCID: PMC8160117 DOI: 10.3389/fpubh.2021.670082] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 04/19/2021] [Indexed: 11/28/2022] Open
Abstract
Background: Social isolation has been identified as a substantial health concern in aging populations, associated with adverse chronic disease outcomes and health inequalities; however, little is known about the interconnections between social capital, diabetes management, and hospital burdens. This study aimed to assess the role of community belonging with the risk of potentially avoidable hospitalization among aging adults living with diabetes in Canada. Methods: The study leveraged a novel resource available through Statistics Canada's Social Data Linkage Environment: the Canadian Community Health Survey linked to administrative health records from the hospital Discharge Abstract Database. A population-representative sample of 13,580 community-dwelling adults aged 45 and over with diabetes was identified. Multiple logistic regression was used to assess the association of individuals' sense of community belonging with the risk of diabetes-related hospitalization over the period 2006-2012. Results: Most (69.9%) adults with diabetes reported a strong sense of belonging to their local community. Those who reported weak community belonging were significantly more likely to have been hospitalized for diabetes (χ2 = 13.82; p < 0.05). The association between weak community attachment and increased risk of diabetes hospitalization remained significant [adjusted OR: 1.80 (95%CI: 1.12-2.90)] after controlling for age, education, and other sociodemographic and behavioral factors. Conclusion: The COVID-19 pandemic has resurfaced attention to the need to better address social capital and diabetes care in public health strategies. While the causal pathways are unclear, this national study highlighted that deficits in social attachments may place adults with diabetes at greater risk of acute complications leading to hospitalization.
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Affiliation(s)
- Neeru Gupta
- Department of Sociology, University of New Brunswick, Fredericton, NB, Canada
| | - Zihao Sheng
- Department of Economics, Dalhousie University, Halifax, NS, Canada
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22
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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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23
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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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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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25
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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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26
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Thavam T, Devlin RA, Thind A, Zaric GS, Sarma S. The impact of the diabetes management incentive on diabetes-related services: evidence from Ontario, Canada. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2020; 21:1279-1293. [PMID: 32676753 DOI: 10.1007/s10198-020-01216-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 06/25/2020] [Indexed: 06/11/2023]
Abstract
Financial incentives have been introduced in several countries to improve diabetes management. In Ontario, the most populous province in Canada, a Diabetes Management Incentive (DMI) was introduced to family physicians practicing in patient enrollment models in 2006. This paper examines the impact of the DMI on diabetes-related services provided to individuals with diabetes in Ontario. Longitudinal health administrative data were obtained for adults diagnosed with diabetes and their family physicians. The study population consisted of two groups: DMI group (patients enrolled with a family physician exposed to DMI for 3 years), and comparison group (patients affiliated with a family physician ineligible for DMI throughout the study period). Diabetes-related services was measured using the Diabetic Management Assessment (DMA) billing code claimed by patient's physician. The impact of DMI on diabetes-related services was assessed using difference-in-differences regression models. After adjusting for patient- and physician-level characteristics, patient fixed-effects and patient-specific time trend, we found that DMI increased the probability of having at least one DMA fee code claimed by patient's physician by 9.3% points, and the probability of having at least three DMA fee codes claimed by 2.1% points. Subgroup analyses revealed the impact of DMI was slightly larger in males compared to females. We found that Ontario's DMI was effective in increasing the diabetes-related services provided to patients diagnosed with diabetes in Ontario. Financial incentives for physicians help improve the provision of targeted diabetes-related services.
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Affiliation(s)
- Thaksha Thavam
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, N6A 5C1, Canada
| | - Rose Anne Devlin
- Department of Economics, University of Ottawa, Ottawa, ON, Canada
| | - Amardeep Thind
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, N6A 5C1, Canada
| | - Gregory S Zaric
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, N6A 5C1, Canada
- Ivey School of Business, University of Western Ontario, London, ON, Canada
| | - Sisira Sarma
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, N6A 5C1, Canada.
- ICES, Toronto, ON, Canada.
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27
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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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30
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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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31
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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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Malik FS, Stafford JM, Reboussin BA, Klingensmith GJ, Dabelea D, Lawrence JM, Mayer-Davis E, Saydah S, Corathers S, Pihoker C. Receipt of recommended complications and comorbidities screening in youth and young adults with type 1 diabetes: Associations with metabolic status and satisfaction with care. Pediatr Diabetes 2020; 21:349-357. [PMID: 31797506 PMCID: PMC7597528 DOI: 10.1111/pedi.12948] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 10/26/2019] [Accepted: 11/01/2019] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES This study sought to: (a) assess the prevalence of diabetes complications and comorbidities screening as recommended by the American Diabetes Association (ADA) for youth and young adults (YYAs) with type 1 diabetes (T1D), (b) examine the association of previously measured metabolic status related to diabetes complications with receipt of recommended clinical screening, and (c) examine the association of satisfaction with diabetes care with receipt of recommended clinical screening. METHODS The study included 2172 SEARCH for Diabetes in Youth participants with T1D (>10 years old, diabetes duration >5 years). Mean participant age was 17.7 ± 4.3 years with a diabetes duration of 8.1 ± 1.9 years. Linear and multinomial regression models were used to evaluate associations. RESULTS Sixty percent of participants reported having three or more hemoglobin A1c (HbA1c) measurements in the past year. In terms of diabetes complications screening, 93% reported having blood pressure measured, 81% having an eye examination, 71% having lipid levels checked, 64% having a foot exam, and 63% completing albuminuria screening in accordance with ADA recommendations. Youth known to have worse glycemic control in the past had higher odds of not meeting HbA1c screening criteria (OR 1.11, 95% CI = 1.05, 1.17); however, after adjusting for race/ethnicity, this was no longer statistically significant. Greater satisfaction with diabetes care was associated with increased odds of meeting screening criteria for most of the ADA-recommended measures. CONCLUSIONS Efforts should be made to improve diabetes complications screening efforts for YYAs with T1D, particularly for those at higher risk for diabetes complications.
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Affiliation(s)
- Faisal S. Malik
- Department of Pediatrics, University of Washington, Seattle, WA
| | - Jeanette M. Stafford
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC
| | - Beth A. Reboussin
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC
| | | | - Dana Dabelea
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO
| | - Jean M. Lawrence
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Elizabeth Mayer-Davis
- Departments of Nutrition and Medicine, University of North Carolina, Chapel Hill, NC
| | - Sharon Saydah
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Georgia
| | - Sarah Corathers
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
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Petrosyan Y, Kuluski K, Barnsley J, Liu B, Wodchis WP. Evaluating quality of overall care among older adults with diabetes with comorbidities in Ontario, Canada: a retrospective cohort study. BMJ Open 2020; 10:e033291. [PMID: 32034022 PMCID: PMC7044838 DOI: 10.1136/bmjopen-2019-033291] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES This study aimed to: (1) explore whether the quality of overall care for older people with diabetes is differentially affected by types and number of comorbid conditions and (2) examine the association between process of care measures and the likelihood of all-cause hospitalisations. DESIGN A population-based, retrospective cohort study. SETTING The province of Ontario, Canada. PARTICIPANTS We identified 673 197 Ontarians aged 65 years and older who had diabetes comorbid with hypertension, chronic ischaemic heart disease, osteoarthritis or depression on 1 April 2010. MAIN OUTCOME MEASURES The study outcome was the likelihood of having at least one hospital admission in each year, during the study period, from 1 April 2010 to 3 March 2014. Process of care measures specific to older adults with diabetes and these comorbidities, developed by means of a Delphi panel, were used to assess the quality of care. A generalised estimating equations approach was used to examine associations between the process of care measures and the likelihood of hospitalisations. RESULTS The study findings suggest that patients are at risk of suboptimal care with each additional comorbid condition, while the incidence of hospitalisations and number of prescribed drugs markedly increased in patients with 2 versus 1 selected comorbid condition, especially in those with discordant comorbidities. The median continuity of care score was higher among patients with diabetes-concordant conditions compared with those with diabetes-discordant conditions, and it declined with additional comorbid conditions in both groups. Greater continuity of care was associated with lower hospital utilisation for older diabetes patients with both concordant and discordant conditions. CONCLUSIONS There is a need for focusing on improving continuity of care and prioritising treatment in older adults with diabetes with any multiple conditions but especially in those with diabetes-discordant conditions (eg, depression).
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Affiliation(s)
- Yelena Petrosyan
- Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kerry Kuluski
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Institute for Better Health, Trillium Health Partners, Toronto, Ontario, Canada
| | - Jan Barnsley
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Barbara Liu
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Walter P Wodchis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Institute for Better Health, Trillium Health Partners, Toronto, Ontario, Canada
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Polenick CA, Leggett AN, Webster NJ, Han BH, Zarit SH, Piette JD. Multiple Chronic Conditions in Spousal Caregivers of Older Adults With Functional Disability: Associations With Caregiving Difficulties and Gains. J Gerontol B Psychol Sci Soc Sci 2020; 75:160-172. [PMID: 29029293 PMCID: PMC6909432 DOI: 10.1093/geronb/gbx118] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 08/23/2017] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVES Multiple chronic conditions (MCCs) are common and have harmful consequences in later life. Along with managing their own health, many aging adults care for an impaired partner. Spousal caregiving may be more stressful when caregivers have MCCs, particularly those involving complex management. Yet, little is known about combinations of conditions that are most consequential for caregiving outcomes. METHOD Using a U.S. sample of 359 spousal caregivers and care recipients from the 2011 National Aging Trends Study and National Study of Caregiving, we examined three categories of MCCs based on similarity of management strategies (concordant only, discordant only, and both concordant and discordant) and their associations with caregiving difficulties and gains. We also considered gender differences. RESULTS Relative to caregivers without MCCs, caregivers with discordant MCCs reported fewer gains, whereas caregivers with both concordant and discordant MCCs reported greater emotional and physical difficulties. Wives with discordant MCCs only reported a trend for greater physical difficulties. Caregivers with concordant MCCs did not report more difficulties or gains. DISCUSSION Spousal caregivers with MCCs involving discordant management strategies appear to be at risk for adverse care-related outcomes and may benefit from support in maintaining their own health as well as their caregiving responsibilities.
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Affiliation(s)
- Courtney A Polenick
- Department of Psychiatry, University of Michigan, Ann Arbor
- Program for Positive Aging, University of Michigan, Ann Arbor
| | - Amanda N Leggett
- Department of Psychiatry, University of Michigan, Ann Arbor
- Program for Positive Aging, University of Michigan, Ann Arbor
| | - Noah J Webster
- Institute for Social Research, University of Michigan, Ann Arbor
| | - Benjamin H Han
- Department of Medicine, New York University
- Department of Population Health, New York University
| | - Steven H Zarit
- Department of Human Development and Family Studies, The Pennsylvania State University, University Park
| | - John D Piette
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor
- Department of Veterans Affairs, HSR&D Center for Clinical Management Research (CCMR), Ann Arbor, MI
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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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Gupta N, Sheng Z. A population-based study of the association between food insecurity and potentially avoidable hospitalization among persons with diabetes using linked survey and administrative data. Int J Popul Data Sci 2019; 4:1102. [PMID: 32935031 PMCID: PMC7482516 DOI: 10.23889/ijpds.v4i1.1102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Studies have found food insecurity to be more prevalent among persons with diabetes mellitus. Other research using areal-based measures of socioeconomic status have pointed to a social gradient in diabetes hospitalizations, but without accounting for individuals’ health status. Linking person-level data from health surveys to population-based hospital records enables profiling of the role of food insecurity with hospital morbidity, focusing on the high-risk diabetic population. Objective This national study aims to assess the association between income-related household food insecurity and potentially avoidable hospital admissions among community-dwelling persons living with diagnosed diabetes. Methods We use three cycles of the Canadian Community Health Survey (2007, 2008, and 2011) linked to multiple years of hospital records from the Discharge Abstract Database (2005/06 to 2012/13), covering 12 of Canada’s 13 provinces and territories. We apply multiple logistic regression for testing the association of household food insecurity with the risk of hospitalization for diabetes and common comorbid ambulatory care sensitive conditions among persons aged 12 and over living with diabetes. Analysis Data linkage allowed us to analyze inpatient hospital records among 10,260 survey respondents with diabetes; 590 respondents had been hospitalized at least once for diabetes or a common comorbid chronic physical or mental illness. The regression results indicated that the odds of experiencing a preventable hospital admission were significantly higher among persons with diabetes who were food insecure compared to their counterparts who were food secure (OR=1.66 [95%CI=1.24-2.23]), after controlling for age, sex and other characteristics. Conclusion We found food insecurity to significantly increase the odds of hospital admission for ambulatory care sensitive conditions among Canadians living with diabetes. These results reinforce the need to consider food insecurity in public health and clinical strategies to reduce the hospital burden of diabetes and other nutrition-related chronic diseases, from primary prevention to post-discharge care.
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Affiliation(s)
- N Gupta
- Department of Sociology, University of New Brunswick, PO Box 4400, Fredericton, New Brunswick E3B 5A3, Canada
| | - Z Sheng
- Department of Sociology, University of New Brunswick, PO Box 4400, Fredericton, New Brunswick E3B 5A3, Canada
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Kendzerska T, Nickerson JW, Hsu AT, Gershon AS, Talarico R, Mulpuru S, Pakhale S, Tanuseputro P. End-of-life care in individuals with respiratory diseases: a population study comparing the dying experience between those with chronic obstructive pulmonary disease and lung cancer. Int J Chron Obstruct Pulmon Dis 2019; 14:1691-1701. [PMID: 31534323 PMCID: PMC6681558 DOI: 10.2147/copd.s210916] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 07/10/2019] [Indexed: 12/25/2022] Open
Abstract
Purpose Among individuals with COPD and/or lung cancer, to describe end-of-life health service utilization, costs, and place of death; to identify predictors of home palliative care use, and to assess benefits associated with palliative care use. Patients and methods We conducted a retrospective population-based study using provincial linked health administrative data (Ontario, Canada) between 2010 and 2015. We examined health care use in the last 90 days of life in adults 35 years and older with physician-diagnosed COPD and/or lung cancer identified using a validated algorithm and the Ontario Cancer Registry, respectively. Four mutually exclusive groups were considered: (i) COPD only, (ii) lung cancer only, (iii) COPD and lung cancer, and (iv) neither COPD nor lung cancer. Multivariable generalized linear models were employed. Results Of 445,488 eligible deaths, 34% had COPD only, 4% had lung cancer only, 5% had both and 57% had neither. Individuals with COPD only received less palliative care (20% vs 57%) than those with lung cancer only. After adjustment, people with lung cancer only were far more likely to receive palliative care (OR=4.22, 4.08–4.37) compared to those with neither diagnosis, while individuals with COPD only were less likely to receive palliative care (OR=0.82, 0.81–0.84). Home palliative care use was associated with reduced death and fewer days in acute care, and less cost, regardless of the diagnosis. Conclusion Although individuals with lung cancer were much more likely to receive palliative care than those with COPD, both populations were underserviced. Results suggest greater involvement of palliative care may improve the dying experience of these populations and reduce costs.
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Affiliation(s)
- Tetyana Kendzerska
- Department of Medicine, University of Ottawa, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,ICES , Ottawa, Ontario, Canada
| | - Jason W Nickerson
- Bruyère Research Institute , Ottawa, Ontario, Canada.,Centre for Health Law, Policy and Ethics, Faculty of Law, University of Ottawa, Ottawa, Ontario, Canada
| | - Amy T Hsu
- Department of Medicine, University of Ottawa, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,ICES , Ottawa, Ontario, Canada.,Bruyère Research Institute , Ottawa, Ontario, Canada
| | - Andrea S Gershon
- Department of Medicine, the Sunnybrook Health Science Center/ICES , Toronto, Ontario, Canada
| | - Robert Talarico
- Department of Medicine, University of Ottawa, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,ICES , Ottawa, Ontario, Canada
| | - Sunita Mulpuru
- Department of Medicine, University of Ottawa, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Smita Pakhale
- Department of Medicine, University of Ottawa, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Department of Medicine, University of Ottawa, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,ICES , Ottawa, Ontario, Canada.,Bruyère Research Institute , Ottawa, Ontario, Canada
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An J, Le QA, Dang T. Association between different types of comorbidity and disease burden in patients with diabetes. J Diabetes 2019; 11:65-74. [PMID: 29956479 DOI: 10.1111/1753-0407.12818] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 06/06/2018] [Accepted: 06/16/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND This study examined the association between different types of comorbidities and the quality of diabetes care, health-related quality of life (HRQoL), and total health care expenditure. METHODS Adult patients with diabetes were identified from the 2011 to 2013 Medical Expenditure Panel Survey, a nationally representative survey of the civilian non-institutionalized US population. Twenty different chronic conditions were captured and categorized as: (i) diabetes only; (ii) diabetes plus concordant (diabetes-related) comorbidity only; and (iii) diabetes plus one or more discordant (non-diabetes-related) comorbidities. Disease burden outcomes included the process of diabetes care (eye and foot examinations, HbA1c and cholesterol tests, influenza vaccination), HRQoL, and total health care expenditure. Multivariable models were used to examine associations between the type of comorbidity and outcomes. RESULTS A sample of 8292 patients with diabetes was identified, of which 11.4% had diabetes only, 40.5% had concordant comorbidity only, and 48.1% reported one or more discordant comorbidities. Patients with diabetes and either type of comorbidity received better quality of diabetes care than those without a comorbidity. However, patients with discordant comorbidity showed significantly lower HRQoL measures and higher health care expenditure than those with concordant comorbidity. Adjusted total mean annual expenditure was US$4891, $6326, and $9210 for those with diabetes only and those with diabetes with one concordant or one discordant comorbidity, respectively. CONCLUSIONS Higher disease burden in patients with diabetes was associated with discordant rather than concordant comorbidity. Future interventional studies evaluating patient-centered care models addressing different types of comorbidity are necessary to better manage these complex patients.
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Affiliation(s)
- JaeJin An
- Department of Pharmacy Practice and Administration, Western University of Health Sciences, Pomona, California, USA
| | - Quang A Le
- Department of Pharmacy Practice and Administration, Western University of Health Sciences, Pomona, California, USA
| | - Tracy Dang
- Department of Pharmacy Practice and Administration, Western University of Health Sciences, Pomona, California, USA
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Gupta N, Lavallée R, Ayles J. Effects of Pay-for-Performance for Primary Care Physicians on Preventable Diabetes-Related Hospitalization Costs Among Adults in New Brunswick, Canada: A Quasiexperimental Evaluation. Can J Diabetes 2018; 43:354-360.e1. [PMID: 30679059 DOI: 10.1016/j.jcjd.2018.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 11/15/2018] [Accepted: 11/19/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVES In New Brunswick, Canada, 13.6% of the population 35 years of age and older is living with type 1 or type 2 diabetes mellitus. To address public health and clinical challenges, pay-for-performance (P4P) for family physicians was introduced in 2010 to enable comprehensive diabetes management. This study assesses the impacts of the P4P scheme on excess health-care costs. METHODS We used a quasiexperimental study design drawing on linked population-based administrative data sets of physician billings, hospital discharge abstracts and provider and resident registrations. Prospective cohorts of patients with diabetes were identified through a validated algorithm tracing individuals' interactions with the health-care system. We applied propensity-score difference-in-differences estimation for the effects of P4P on preventable diabetes-related hospitalization costs according to patients' exposures to physicians' uptake of the incentive. RESULTS Coverage of incentivized care peaked at less than half (44%) of adults with diabetes, who tended to be younger and less often presenting comorbid conditions compared to those whose providers did not claim incentives. The introduction of P4P was attributed to significantly lower diabetes hospitalization costs among newly diagnosed patients (-0.083; p<0.01) and improved compensation for physicians. No cost avoidance was established among medium-term and longer-term patients or for hospitalizations for conditions concordant with diabetes. CONCLUSIONS The effects of New Brunswick's P4P for diabetes care are mixed. Results reflect the deficient evidence base on the effects of P4P on patient-oriented and policymaker-important health outcomes. The high risk for multiple morbidities among patients with diabetes and the heterogeneity of physician responses to performance incentives may be hindering the effectiveness of P4P in improving diabetes outcomes.
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Affiliation(s)
- Neeru Gupta
- University of New Brunswick, Department of Sociology, Fredericton, New Brunswick, Canada.
| | - René Lavallée
- Government of New Brunswick, Department of Health, Fredericton, New Brunswick, Canada
| | - James Ayles
- Government of New Brunswick, Department of Health, Fredericton, New Brunswick, Canada
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