Primary health care and hospital interactions: effects for hospital length of stay

Measuring hospital spatial accessibility using the enhanced two-step floating catchment area method to assess the impact of spatial accessibility to hospital and non-hospital care on the length of hospital stay

Background

Optimal healthcare access improves the health status and decreases health inequalities. Many studies demonstrated the importance of spatial access to healthcare facilities in health outcomes, particularly using the enhanced two-step floating catchment area (E2SFCA) method. The study objectives were to build a hospital facility access indicator at a fine geographic scale, and then to assess the impact of spatial accessibility to inpatient hospital and non-hospital care services on the length of hospital stay (LOS).

Methods

Data concerning older adults (≥75 years) living in the Nord administrative region of France were used. Hospital spatial accessibility was computed with the E2SFCA method, and the LOS score was calculated from the French national hospital activity and patient discharge database. The relationship between LOS and spatial accessibility to inpatient hospital care and to three non-hospital care types (general practitioners, physiotherapists, and home-visiting nurses) was analyzed with linear regression models.

Results

The mean number (standard deviation) of beds per 10,000 inhabitants was 19.0 (10.69) in Medical, Surgical and Obstetrics (MCO) facilities and 5.58 (2.19) in Postoperative and Rehabilitation Care (SSR) facilities, highlighting important variations within the region. Accessibility to hospital services was higher in large urban areas, despite the dense population and higher demand. In 2014, the mean LOS scores were 0.26 for MCO and 0.85 for SSR, but their geographical repartition was non-homogeneous. The linear regression analysis revealed a strong negative and significant association between LOS and non-hospital care accessibility.

Conclusions

This is the first study to measure spatial accessibility to inpatient hospital care in France using the E2SFCA method, and to investigate the relationship between healthcare utilization (LOS score) and spatial accessibility to inpatient hospital care facilities and three types of non-hospital care services. Our findings might help to make decisions about deploying additional beds and to identify the best locations for non-hospital care services. They might also contribute to improve access, and to ensure the best coordination and sustainability of inpatient and outpatient services, in order to better cover the population’s healthcare needs. International studies using multiple consensual indicators of healthcare outcomes and accessibility and sophisticated modeling methods are needed.

Efficiency of fine scale and spatial regression in modelling associations between healthcare service spatial accessibility and their utilization

BACKGROUND

Healthcare accessibility, a key public health issue, includes potential (spatial accessibility) and realized access (healthcare utilization) dimensions. Moreover, the assessment of healthcare service potential access and utilization should take into account the care provided by primary and secondary services. Previous studies on the relationship between healthcare spatial accessibility and utilization often used conventional statistical methods without addressing the scale effect and spatial processes. This study investigated the impact of spatial accessibility to primary and secondary healthcare services on length of hospital stay (LOS), and the efficiency of using a geospatial approach to model this relationship.

METHODS

This study focused on the ≥ 75-year-old population of the Nord administrative region of France. Inpatient hospital spatial accessibility was computed with the E2SFCA method, and then the LOS was calculated from the French national hospital activity and patient discharge database. Ordinary least squares (OLS), spatial autoregressive (SAR), and geographically weighted regression (GWR) were used to analyse the relationship between LOS and spatial accessibility to inpatient hospital care and to three primary care service types (general practitioners, physiotherapists, and home-visiting nurses). Each model performance was assessed with measures of goodness of fit. Spatial statistical methods to reduce or eliminate spatial autocorrelation in the residuals were also explored.

RESULTS

GWR performed best (highest R2 and lowest Akaike information criterion). Depending on global model (OLS and SAR), LOS was negatively associated with spatial accessibility to general practitioners and physiotherapists. GWR highlighted local patterns of spatial variation in LOS estimates. The distribution of areas in which LOS was positively or negatively associated with spatial accessibility varied when considering accessibility to general practitioners and physiotherapists.

CONCLUSIONS

Our findings suggest that spatial regressions could be useful for analysing the relationship between healthcare spatial accessibility and utilization. In our case study, hospitalization of elderly people was shorter in areas with better accessibility to general practitioners and physiotherapists. This may be related to the presence of effective community healthcare services. GWR performed better than LOS and SAR. The identification by GWR of how these relationships vary spatially could bring important information for public healthcare policies, hospital decision-making, and healthcare resource allocation.

The Reshaping Care for Older People programme and changes in unscheduled hospital care: Analysis of routinely collected hospital data

OBJECTIVE

This study examines mean length of stay (LOS) and rates of emergency bed days during the course of the Reshaping Care for Older People (RCOP) programme in Glasgow City.

METHODS

An ecological small-area study design was used. Standardised monthly rates of bed days and LOS were calculated, between April 2011 and March 2015, for residents of Glasgow City aged 65 years and over. Multilevel negative binomial models for the square root of each outcome nested by datazone were created, adjusting for sex, 5-year age group, area-level deprivation, season, month and month squared. Relative index of inequality (RII) and slope index of inequality (SII) were calculated for each year and the trend was examined.

RESULTS

The rate of bed days first rose then fell during the study period, while LOS first fell then rose. Relative risk (RR) of an additional bed day was greater for males (RR=1.14 (1.12, 1.16)) and increased with increasing age group. There was no gender difference in LOS. Bed days per head of population first increased then fell; for 12-month period RR=1.01 (0.98, 1.05) and for 12-month period squared, RR=0.999 (0.999, 0.999). RII and SII for rate of bed days per head of population were significant, though not for LOS. SII for bed days per head of population did not change significantly over time, while RII reduced at the 87% level of confidence.

CONCLUSIONS

The results suggest a reduction in secondary care use by older people during the RCOP programme, and a possible reduction in socioeconomic inequalities in bed days in the longer term.

Barriers to information exchange during older patients' transfer: nurses' experiences

AIMS AND OBJECTIVES

To describe nurses' experiences of barriers that influence their information exchange during the transfer of older patients between hospital and home care.

BACKGROUND

The successful transfer of an older patient across health organisations requires good communication and coordination between providers. Despite an increased focus on the need for cooperation among providers across healthcare organisations, researchers still report problems in the exchange of information between the hospitals and the healthcare systems in the municipalities.

DESIGN

A qualitative study using focus group methodology.

METHODS

Three focus group interviews using topic guides were conducted and interpreted. The study included registered nurses (n = 14) from hospital and home care. The data were analysed through content analysis.

RESULTS

Three main themes were identified: barriers associated with the nurse, barriers associated with interpersonal processes and barriers associated with the organisation. These themes included several subthemes.

CONCLUSIONS

The findings highlight the challenges that nurses encounter in ensuring a successful information exchange during older patients' transfer through the healthcare system. The barriers negatively influence the nurses' information exchange and may put the patients in a vulnerable and exposed situation. In order for nurses to conduct a successful exchange of information, it is critical that hospital and home care systems facilitate this through adequate resources, clear missions and responsibilities, and understandable policies.

RELEVANCE TO CLINICAL PRACTICE

Recognition of the barriers that affect nurses' exchange of information is important to ensure patient safety and successful transitions. The barriers described here should help both nurses in practice and their leaders to be more attentive to the prerequisites needed to achieve a satisfactory nursing information exchange and enhance informational continuity.

Does long-term care use within primary health care reduce hospital use among older people in Norway? A national five-year population-based observational study

Background

Population ageing may threaten the sustainability of future health care systems. Strengthening primary health care, including long-term care, is one of several measures being taken to handle future health care needs and budgets. There is limited and inconsistent evidence on the effect of long-term care on hospital use. We explored the relationship between the total use of long-term care within public primary health care in Norway and the use of hospital beds when adjusting for various effect modifiers and confounders.

Methods

This national population-based observational study consists of all Norwegians (59% women) older than 66 years (N = 605676) (13.2% of total population) in 2002-2006. The unit of analysis was defined by municipality, age and sex. The association between total number of recipients of long-term care per 1000 inhabitants (LTC-rate) and hospital days per 1000 inhabitants (HD-rate) was analysed in a linear regression model. Modifying and confounding effects of socioeconomic, demographic and geographic variables were included in the final model. We defined a difference in hospitalization rates of more than 1000 days per 1000 inhabitants as clinically important.

Results

Thirty-one percent of women and eighteen percent of men were long-term care users. Men had higher HD-rates than women. The crude association between LTC-rate and HD-rate was weakly negative. We identified two effect modifiers (age and sex) and two strong confounders (travel time to hospital and mortality). Age and sex stratification and adjustments for confounders revealed a positive statistically significant but not clinically important relationship between LTC-rates and hospitalization for women aged 67-79 years and all men. For women 80 years and over there was a weak but negative relationship which was neither statistically significant nor clinically important.

Conclusions

We found a weak positive adjusted association between LTC-rates and HD-rates. Opposite to common belief, we found that increased volume of LTC by itself did not reduce pressure on hospitals. There still is a need to study integrated care models for the elderly in the Norwegian setting and to explore further why municipalities far away from hospital achieve lower use of hospital beds.

Patients' length of stay in women hospital and its associated clinical and non-clinical factors, tehran, iran

BACKGROUND

Length of Stay (LOS) is an appropriate hospital indicator to evaluate hospital resource utilization rate, efficiency, and quality of services delivered. In this survey, we aimed to study hospital LOS and determine its association with clinical and non-clinical factors in Women Hospital in Tehran.

METHODS

In this cross-sectional study, we reviewed all 3421 charts of patients admitted in Oncology, Surgery and Obstetrics units in 2008. We used a data collection sheet and conducted interviews to collect the following data: distance from living area, medical insurance coverage types, admission and discharge months, days and times, inpatient units, final diagnoses and the number of diagnostic tests.

RESULTS

The overall median of the LOS in the studied hospital was 50.8 hours. The medians were 48.5, 54.4, and 94.2 hours in the Obstetrics, Surgical and Oncology units, respectively. Results showed that the associated factors with the LOS were patient admissions on Thursdays, admitting by residents, the number of performed diagnostic tests (p<0.001), suffering from neoplastic diseases (p=0.005) and spouse jobs.

CONCLUSION

Among the associated factors, policy makers and managers can only change the admission days and the number of diagnostic tests to decrease the LOS. Further researches are needed to find other factors associated with LOS.

Cultural diversity between hospital and community nurses: implications for continuity of care

Introduction

Health care systems and nurses need to take into account the increasing number of people who need post-hospital nursing care in their homes. Nurses have taken a pivotal role in discharge planning for frail patients. Despite considerable effort and focus on how to undertake hospital discharge successfully, the problem of ensuring continuity of care remains.

Challenges

In this paper, we highlight and discuss three challenges that seem to be insufficiently articulated when hospital and community nurses interact during discharge planning. These three challenges are: how local practices circumvent formal structures, how nurses' different perspectives influence their assessment of patients' need for post-hospital care, and how nurses have different understanding of what it means to be ‘ready to be discharged’.

Discussion

We propose that nurses need to discuss these challenges and their implications for nursing care so as to be ready to face changing demands for health care in future.

Coordinating health care: lessons from Norway

OBJECTIVE

What influences the coordination of care between general practitioners and hospitals? In this paper, general practitioner satisfaction with hospital-GP interaction is revealed, and related to several background variables.

METHOD

A questionnaire was sent to all general practitioners in Norway (3388), asking their opinion on the interaction and coordination of health care in their district. A second questionnaire was sent to all the somatic hospitals in Norway (59) regarding formal routines and structures. The results were analysed using ordinary least squares regression.

RESULTS

General practitioners tend to be less satisfied with the coordination of care when their primary hospital is large and cost-effective with a high share of elderly patients. Together with the degree to which the general practitioner is involved in arenas where hospital physicians and general practitioners interact, these factors turned out to be good predictors of general practitioner satisfaction.

IMPLICATION

To improve coordination between general practitioners and specialists, one should focus upon the structural traits within the hospitals in different regions as well as creating common arenas where the physicians can interact.