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Mitsutake S, Ishizaki T, Yano S, Tsuchiya-Ito R, Jin X, Watanabe T, Uda K, Livingstone I, Tamiya N. Characteristics associated with hospitalization within 30 days of geriatric intermediate care facility admission. Geriatr Gerontol Int 2021; 21:1010-1017. [PMID: 34549493 PMCID: PMC9290842 DOI: 10.1111/ggi.14278] [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: 05/16/2021] [Revised: 08/14/2021] [Accepted: 08/31/2021] [Indexed: 11/29/2022]
Abstract
AIM To identify facility-level characteristics associated with hospitalization within 30 days after admission to a geriatric intermediate care facility (GICF) (30-day hospitalization) in Japan. METHODS This retrospective cohort study used nationwide long-term care insurance claims data and a national survey of long-term geriatric care facilities. The study population was residents admitted to GICFs between October 2016 and February 2018. The outcome variable was 30-day hospitalization. The independent variables were facility-level characteristics such as level of healthcare professionals. RESULTS The final sample for analysis comprised 282 991 residents of mean age ± SD, 85.8 ± 7.2 years, of whom 12 814 (4.5%) experienced 30-day hospitalization. In a multivariable logistic generalized estimating equation model adjusted for facility- and resident-level characteristics, and clustering GICFs, the odds of 30-day hospitalization were 0.906 times lower (95% confidence interval [CI] 0.857-0.958) among residents in a GICF with dental hygienist than in those in a facility without. Furthermore, the risk of 30-day hospitalization was lower among residents who had been admitted to a GICF with higher staffing levels of pharmacists (adjusted odds ratio [aOR] 0.941, 95% CI 0.899-0.985), registered nurses (aOR 0.931, 95% CI 0.880-0.986), care workers (aOR 0.920, 95% CI 0.879-0.964) and speech-language pathologists (aOR 0.926, 95% CI 0.874-0.982) than in those who had been admitted to a GICF with fewer of these healthcare professionals. CONCLUSIONS Transitional care including dental hygienist or higher staffing levels of pharmacists, registered nurses, care workers and speech-language pathologists may be a more effective way to prevent 30-day hospitalization. Geriatr Gerontol Int 2021; 21: 1010-1017.
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Affiliation(s)
- Seigo Mitsutake
- Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan
| | - Tatsuro Ishizaki
- Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan
| | - Shohei Yano
- Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan.,The Salvation Army Booth Memorial Hospital, Tokyo, Japan
| | - Rumiko Tsuchiya-Ito
- Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan.,Research Department, Institute for Health Economics and Policy, Association for Health Economics Research and Social Insurance and Welfare, Tokyo, Japan
| | - Xueying Jin
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Taeko Watanabe
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Kazuaki Uda
- Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan.,Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | | | - Nanako Tamiya
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan.,Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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Maeda K, Koga T, Akagi J. Nutritional variables predict chances of returning home and activities of daily living in post-acute geriatric care. Clin Interv Aging 2018; 13:151-157. [PMID: 29416323 PMCID: PMC5790089 DOI: 10.2147/cia.s154129] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Little is known about the association between malnutrition and the chances of returning home from post-acute facilities in older adult patients. This study aimed to understand whether malnutrition and malnutrition-related factors would be determinants for returning home and activities of daily living (ADL) at discharge after post-acute care. Methods Patients aged ≥65 years living at home before the onset of an acute disease and admitted to a post-acute ward were enrolled (n=207) in this prospective observational study. Malnutrition was defined based on the criteria of the European Society for Clinical Nutrition and Metabolism. Nutritional parameters included the nutritional intake at the time of admission and oral conditions evaluated by the Oral Health Assessment Tool (OHAT). The Barthel Index was used to assess daily activities. A Cox regression analysis of the length of stay was performed. Multivariable linear regression analyses to determine associations between malnutrition, returning home, and ADL at discharge were performed, after adjusting the variables of acute care setting. Results The mean patient age was 84.7±6.7 years; 38% were men. European Society for Clinical Nutrition and Metabolism-defined malnutrition was observed in 129 (62.3%) patients, and 118 (57.0%) of all patients returned home. Multivariable regression analyses showed that malnutrition was a negative predictor of returning home (hazard ratio: 0.517 [0.351–0.761], p=0.001), and an increase in the nutritional intake (kcal/kg/d) was a positive predictor of the Barthel Index at discharge (coefficient: 0.34±0.15, p=0.021). The OHAT was not associated with returning home and ADL. Conclusion Malnutrition and nutritional intake are associated with returning home and ADL at discharge, respectively, after post-acute care. Further studies investigating the effects of a nutritional intervention for post-acute patients would be necessary.
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Affiliation(s)
- Keisuke Maeda
- Palliative Care Center, Aichi Medical University, Aichi, Japan.,Department of Nutrition and Dysphagia Rehabilitation, Tamana Regional Health Medical Center, Kumamoto, Japan
| | - Takayuki Koga
- Department of Swallowing and Nutritional Therapy, Tamana Regional Health Medical Center, Kumamoto, Japan
| | - Junji Akagi
- Department of Surgery, Tamana Regional Health Medical Center, Kumamoto, Japan
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3
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Mitsutake S, Ishizaki T, Teramoto C, Tsuchiya-Ito R, Shimizu S, Ito H. [The associations between readmission within 30 days and the medical institute factors among older patients receiving home medical care]. Nihon Ronen Igakkai Zasshi 2018; 55:612-623. [PMID: 30542027 DOI: 10.3143/geriatrics.55.612] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
AIM To improve preventive strategies for readmission within 30 days after discharge among older patients receiving home medical care services, we examined the associations between readmission within 30 days and the medical institute factors among patients over 75 years of age. METHODS All patients over 75 years of age receiving home medical care services and who had been admitted to hospital or clinic and discharged between September 2013 and July 2014 in Tokyo, Japan, were participants of this study (n=7,213). The primary outcome was readmission within 30 days after discharge. We performed generalized estimating equations (GEEs) using a model with logit link and binominal sampling distribution to examine the associations of sociodemographic variables, the prevalence of chronic diseases and medical institute factors with readmission within 30 days. RESULTS Approximately 11.2% of the patients receiving home medical care services who had been discharged were readmitted within 30 days after discharge. Men, cancer patients, and emergency admission were positively associated with readmission within 30 days according to the GEEs. The rate of readmission within 30 days was lower in patients receiving home medical care services at home care support clinics/hospitals after discharge (adjusted odds ratio [aOR] = 0.205, p value < 0.001) and in patients discharged from hospitals with over 200 beds (aOR = 0.447, p value < 0.001, vs. clinics) than in others. CONCLUSION Home care support clinics/hospitals, which can provide home medical care services around the clock, may help reduce the rate of readmission within 30 days.
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Affiliation(s)
| | | | - Chie Teramoto
- Tokyo Metropolitan Institute of Gerontology
- Graduate School of Medicine, University of Tokyo
| | - Rumiko Tsuchiya-Ito
- Tokyo Metropolitan Institute of Gerontology
- Dia foundation for research on Ageing Societies
| | | | - Hideki Ito
- Tokyo Metropolitan Institute of Gerontology
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4
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Nishida Y, Wakabayashi H, Maeda K, Nishioka S. Nutritional status is associated with the return home in a long-term care health facility. J Gen Fam Med 2017; 19:9-14. [PMID: 29340260 PMCID: PMC5763026 DOI: 10.1002/jgf2.142] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 09/27/2017] [Indexed: 12/02/2022] Open
Abstract
Background The purpose of this study was to determine the association between nutritional status and the return home of older people living in a long‐term care health facility (LCHF). Methods A nested case control study was performed in 116 people ≥65 years of age in a single LCHF. Nutritional status was assessed using the Mini Nutritional Assessment Short Form (MNA‐SF) and activities of daily living by the Functional Independence Measure (FIM). The return home, duration of rehabilitation, and the family wanting the patient to return home were obtained from clinical records. Multivariate logistic regression analysis was used to assess whether malnutrition had independent effects on the return home. Results The participants included 36 males and 80 females with a mean age of 82 years. Thirty‐seven people returned home while 79 did not. The MNA‐SF showed that 80 subjects were malnourished. Sixty‐six of the participants received rehabilitation for longer than 1 hour per week, while 50 received rehabilitation for <1 hour. The proportion of subjects with malnutrition who returned home was significantly lower (P = .003) than in participants who did not return home. Multivariate logistic regression analysis showed that malnutrition (adjusted odds ratio [AOR], 0.23; 95% confidence interval [CI], 0.08‐0.65; P = .006), total FIM score (AOR, 1.03; 95% CI, 1.01‐1.06; P = .012), and the family wanting the patient to return home (AOR, 9.46; 95% CI, 3.19‐28.12; P < .001) were independently associated with the return home. Conclusions Nutritional status is associated with the return home in older people living in LCHF.
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Affiliation(s)
- Yuri Nishida
- Department of Nutrition Care and Food Service Long-term Care Health Facilities Sayama-no-satoIwamuro, Osakasayama Japan
| | - Hidetaka Wakabayashi
- Department of Rehabilitation Medicine Yokohama City University Medical Center Yokohama, Kanagawa Japan
| | - Keisuke Maeda
- Department of Nutrition and Dysphagia Rehabilitation Palliative Care Center Aichi Medical University Nagakute Aichi Japan
| | - Shinta Nishioka
- Department of Clinical Nutrition and Food Service Nagasaki Rehabilitation Hospital Nagasaki Japan
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5
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Nakanishi M, Shindo Y, Niimura J. Discharge Destination of Dementia Patients Who Undergo Intermediate Care at a Facility. J Am Med Dir Assoc 2016; 17:92.e1-7. [DOI: 10.1016/j.jamda.2015.10.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 09/28/2015] [Accepted: 10/23/2015] [Indexed: 11/25/2022]
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6
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Castellano Vela E, Gómez Pajares F, Rochina Puchades A, Gil Egea M. Factores asociados a mejoría funcional y nueva institucionalización en enfermos con intervención rehabilitadora en una unidad de media-larga estancia. Rev Clin Esp 2010; 210:1-10. [DOI: 10.1016/j.rce.2009.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2008] [Accepted: 06/29/2009] [Indexed: 10/20/2022]
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7
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Kauffman T. Physiotherapy and the generational conflict. Physiother Theory Pract 2009. [DOI: 10.3109/09593989609036436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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8
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Tamiya N, Kobayashi Y, Murakami S, Sasaki J, Yoshizawa K, Otaki J, Kano K. Factors related to home discharge of cerebrovascular disease patients: 1-year follow-up interview survey of caregivers of hospitalized patients in 53 acute care hospitals in Japan. Arch Gerontol Geriatr 2005; 33:109-21. [PMID: 15374027 DOI: 10.1016/s0167-4943(01)00100-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2000] [Revised: 02/27/2001] [Accepted: 03/07/2001] [Indexed: 11/16/2022]
Abstract
In Japan, many disabled elderly people remain hospitalized for long periods. Cerebrovascular diseases (CVD) are the most causes responsible for such disability. To examine the predictors of home discharge in CVD patients, we performed a 1-year follow-up interview of the main caregivers of patients hospitalized with a CVD event. The initial cohort consisted of CVD patients hospitalized in all the second level emergency and general hospitals in Ibaraki Prefecture in February 1992 (N=888 patients in 53 hospitals). In the following year, we performed an interview survey of the main caregivers of these CVD patients. The survey items included the characteristics of the patients (including medical and socioeconomic conditions), caregivers, and family members. The final study population included the main caregivers of 187 home patients and 90 institutionalized patients. We compared these two groups in terms of predictors of discharge to home. The results of multiple logistic regression analysis showed that the following seven factors were related to home discharge; better baseline activities of daily living (ADL), larger improvement in ADL, larger family size, spouse as the caregiver, caregiver without a full-time job, better economic status of the caregiver, and sources of the patient's income. Our study indicated that the caregiver's conditions were closely related to home discharge of the CVD patients. More attention should, therefore, be centered on the caregiver's well-being and economic aspects as well as the patient's conditions in order to encourage home discharge of stroke patients.
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Affiliation(s)
- N Tamiya
- Department of Hygiene and Public Health, Teikyo University School of Medicine, 2-11-1 Kaga Itabashi, Tokyo 173-8605, Japan.
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Ishizaki T, Imanaka Y, Oh E, Kuwabara K, Hirose M, Hayashida K, Harada Y. Association of hospital resource use with comorbidity status and patient age among hip fracture patients in Japan. Health Policy 2004; 69:179-87. [PMID: 15212865 DOI: 10.1016/j.healthpol.2003.12.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2003] [Indexed: 11/15/2022]
Abstract
OBJECTIVES This study examined the association of resource use with comorbidity status and patient age among hip fracture patients who underwent surgical treatment. DESIGN We used a database from the Voluntary Hospitals of Japan Quality Indicator Project that involved 10 privately owned leading teaching hospitals in Japan. SETTING Four of these hospitals in Japan. PARTICIPANTS We selected 778 operable hip fracture patients aged 65 or older who were admitted to these hospitals between January 1996 and August 2000 (mean age: 80.3 +/- 7.3 years). MEASUREMENTS A linear mixed model was performed to identify factors associated with the resource use, such as total length of stay (LOS), LOS before surgery, LOS after surgery, total hospital charges, charges for diagnostic examinations, charges for surgery, and length of theater time, among operable hip fracture patients. RESULTS The mean LOS was 45.9 days, and the mean total hospital charges were US dollars 14,495.0. Results from linear mixed models revealed that higher age was significantly associated with shorter length of theater time (P < 0.01), and that the presence of comorbidity among hip fracture patients was significantly associated with longer total LOS (P < 0.01), longer LOS after surgery (P < 0.001), higher charges for diagnostic examinations (P < 0.001), and shorter length of theater time (P < 0.01). CONCLUSION These results suggest that the presence of comorbidity among operable hip fracture patients requires greater resource use during their hospital stay, but higher age is not significantly associated with greater resource use at all.
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Affiliation(s)
- Tatsuro Ishizaki
- Department of Healthcare Economics and Quality Management, School of Public Health, Kyoto University Graduate School of Medicine, Yoshida Konoe-cho, Sakyo-ku, Kyoto 606-8501 Japan.
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10
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Miralles R, Sabartés O, Ferrer M, Esperanza A, Llorach I, García-Palleiro P, Cervera AM. Development and validation of an instrument to predict probability of home discharge from a geriatric convalescence unit in Spain. J Am Geriatr Soc 2003; 51:252-7. [PMID: 12558724 DOI: 10.1046/j.1532-5415.2003.51066.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To develop and validate an instrument to predict probability of home discharge upon hospital admission. DESIGN Prospective cohort study. SETTING Geriatric convalescence unit (GCU) in Spain. PARTICIPANTS Seven hundred eighty-one patients aged 65 and older consecutively admitted to a GCU over a 4-year period. The total sample was randomized and divided into two subgroups; the first (n = 575) was used to construct the predictive instrument (development subgroup) and the second (n = 206) for the validation process (validation subgroup). MEASUREMENTS All patients were evaluated within the first 72 hours after admission. Age, sex, functional status before admission, diagnostic categories, functional status on admission, comorbidity, cognitive function, and social support were assessed. RESULTS Logistic regression analysis identified three patient characteristics as independent predictors of home discharge in the development subgroup: higher scores on functional status at admission (Barthel index), normal Mini-Mental State Examination scores, and lower scores on Social Familial Evaluation Scale. A scoring system ranging from 0 to 5 was constructed using these variables to predict probability of home discharge (PHD). Different PHD scores (0-1, 2, 3, 4, and 5) identified patients with different probabilities of returning home on discharge in the validation subgroup (36.5%, 53.6%, 60.8%, 83.3%, and 100%, respectively). PHD scores of 4 and 5 demonstrated substantially higher posttest than pretest probability, with moderate and high clinical effect value. Scores of 0 or 1 demonstrated substantially lower posttest than pretest probability. CONCLUSION A PHD instrument may be useful in identifying patients most likely to be discharged to home from the GCU. Patients with low probability of home discharge may also be identified early.
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Affiliation(s)
- Ramón Miralles
- Geriatric Department of the Municipal Geriatric Center, and Health Services Research Unit, Municipal Institute of Medical Investigation, Instituto Municipal de Asistencia Sanitaria, Barcelona, Spain
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Watanabe M, Kono K, Miyata K, Nakaya H, Higuchi Y, Kawamura K. An investigation of the disabled elderly in a geriatric health services facility in an urban area of Japan and attitudes of their family caregiver. Asia Pac J Public Health 2000; 11:39-44. [PMID: 10829827 DOI: 10.1177/101053959901100109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We investigated characteristics of 72 clients in a geriatric health services facility (hereafter called GHSF), conditions of their family caregivers, and the factors associated with the caregivers choice of discharge destination. Most of the clients were elderly females with a low degree of independence, and dementia was observed in about 60% of them. The clients had children, but many of them lived alone before admission to the GHSF. The rate of admission from hospitals was high (54%), and that of discharge to hospitals was also high (50%). Sixty-seven percent of the clients stayed in for a period of over six months. Most of the family caregivers were daughters or daughters-in-law, and considered themselves to be healthy. Sixty-three percent of them had jobs, and most of the caregivers had no sub-caregiver to assist them. The family caregivers desired the client's home (19.4%), hospital or another GHSF (54.2%), or nursing home (26.4%) as the discharge destination from the GHSF. According to Hayashi's quantification theory type II, the factors related to the home as the discharge destination desired by client's family caregivers are as follows; caregivers used formal home public health nursing visit service before entering the GHSF, the job of the caregiver was a part-time job, the client did not show dementia, the period of care experience was shorter than one year.
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Affiliation(s)
- M Watanabe
- Department of Hygiene and Public Health, Osaka Medical College, Japan.
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Bond J, Gregson B, Smith M, Lecouturier J, Rousseau N, Rodgers H. Predicting place of discharge from hospital for patients with a stroke or hip fracture on admission. J Health Serv Res Policy 2000; 5:133-9. [PMID: 11183623 DOI: 10.1177/135581960000500303] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To determine the predictive power of patient and service characteristics on place of discharge following hospital admission for an acute stroke and for hip fracture. METHODS Prospective cohort of 440 acute stroke and 572 hip fracture patients aged 65 years or over admitted from home to six district general hospitals and associated community hospitals, three in the North and three in the South of England. RESULTS Age, marital status, living arrangements, mental health status at admission, pre-admission self-rated disability, pre-admission use of home-care services, post-admission staff assessments of functional dependency as measured by Barthel Index and of confusion as measured by the modified Crichton Royal Behavioural Rating Scale and nursing staffs' expectation of place of discharge are all significantly related to place of discharge for stroke and hip fracture participants. Logistic regression correctly predicted discharge destination for 87% of stroke patients from data available at time of admission and 83% of hip fracture patients. Of the 30% of stroke patients discharged to an institution, the model correctly predicted 73%. However, of the 19% of hip fracture patients discharged to an institution, only 28% were correctly predicted. CONCLUSIONS Data about older patients admitted to hospital with an acute condition should be routinely collected by hospital staff to inform clinical management and to permit risk-adjusted audit.
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Affiliation(s)
- J Bond
- Centre for Health Services Research, Institute for the Health of the Elderly, University of Newcastle upon Tyne, UK
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13
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Nusbaum NJ. Thoughts of a traveler. J Am Geriatr Soc 1999; 47:766-7. [PMID: 10366187 DOI: 10.1111/j.1532-5415.1999.tb01611.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ishizaki T, Kobayashi Y, Tamiya N. The role of geriatric intermediate care facilities in long-term care for the elderly in Japan. Health Policy 1998; 43:141-51. [PMID: 10177615 DOI: 10.1016/s0168-8510(97)00094-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Geriatric intermediate care facilities (GICFs) were first established in 1987 to help the hospitalized elderly return home within 3 months. Users of the GICFs are the elders who do not require hospitalization, but are mentally or physically impaired. Rather than providing unnecessary medical services, GICFs emphasize nursing care and rehabilitation so that users can carry out their daily tasks independently. Due to the limited supply of institutional and in-home services for the elderly in long-term care systems in Japan, only half of the discharged users were able to return home and a quarter stayed at GICFs for over 1 year, contrary to the initial purpose. This suggests that in addition to serving as an intermediate facility between institutions and private homes, GICFs should enlarge their role of home care supporting facilities in ways that would enable them to provide frail elderly patients at home with respite care and daycare services.
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Affiliation(s)
- T Ishizaki
- Tokyo Metropolitan Institute of Gerontology, Itabashi, Japan.
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McCormick WC, Imai Y, Rubenstein LZ. International common denominators in geriatric rehabilitation and long-term care. J Am Geriatr Soc 1995; 43:714-5. [PMID: 7775736 DOI: 10.1111/j.1532-5415.1995.tb07213.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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