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Browne B, Ali K, Ford E, Tabet N. Determinants of hospital readmissions in older people with dementia: a narrative review. BMC Geriatr 2024; 24:336. [PMID: 38609878 PMCID: PMC11015733 DOI: 10.1186/s12877-024-04905-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 03/20/2024] [Indexed: 04/14/2024] Open
Abstract
INTRODUCTION Over 50% of hospitalised older people with dementia have multimorbidity, and are at an increased risk of hospital readmissions within 30 days of their discharge. Between 20-40% of these readmissions may be preventable. Current research focuses on the physical causes of hospital readmissions. However, older people with dementia have additional psychosocial factors that are likely to increase their risk of readmissions. This narrative review aimed to identify psychosocial determinants of hospital readmissions, within the context of known physical factors. METHODS Electronic databases MEDLINE, EMBASE, CINAHL and PsychInfo were searched from inception until July 2022 and followed up in February 2024. Quantitative and qualitative studies in English including adults aged 65 years and over with dementia, their care workers and informal carers were considered if they investigated hospital readmissions. An inductive approach was adopted to map the determinants of readmissions. Identified themes were described as narrative categories. RESULTS Seventeen studies including 7,194,878 participants met our inclusion criteria from a total of 6369 articles. Sixteen quantitative studies included observational cohort and randomised controlled trial designs, and one study was qualitative. Ten studies were based in the USA, and one study each from Taiwan, Australia, Canada, Sweden, Japan, Denmark, and The Netherlands. Large hospital and insurance records provided data on over 2 million patients in one American study. Physical determinants included reduced mobility and accumulation of long-term conditions. Psychosocial determinants included inadequate hospital discharge planning, limited interdisciplinary collaboration, socioeconomic inequalities among ethnic minorities, and behavioural and psychological symptoms. Other important psychosocial factors such as loneliness, poverty and mental well-being, were not included in the studies. CONCLUSION Poorly defined roles and responsibilities of health and social care professionals and poor communication during care transitions, increase the risk of readmission in older people with dementia. These identified psychosocial determinants are likely to significantly contribute to readmissions. However, future research should focus on the understanding of the interaction between a host of psychosocial and physical determinants, and multidisciplinary interventions across care settings to reduce hospital readmissions.
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Affiliation(s)
- Bria Browne
- Centre for Dementia Studies, Brighton and Sussex Medical School, The University of Sussex Brighton, Brighton, UK.
| | - Khalid Ali
- Department of Medicine, Brighton and Sussex Medical School, Brighton, UK
- Department of Elderly Care and Stroke Medicine, University Hospitals Sussex NHS Trust, Brighton, UK
| | - Elizabeth Ford
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, UK
| | - Naji Tabet
- Centre for Dementia Studies, Brighton and Sussex Medical School, The University of Sussex Brighton, Brighton, UK
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Arsenault-Lapierre G, Bui T, Godard-Sebillotte C, Kang N, Sourial N, Rochette L, Massamba V, Quesnel-Vallée A, Vedel I. Sex Differences in Healthcare Utilization in Persons Living with Dementia Between 2000 and 2017: A Population-Based Study in Quebec, Canada. J Aging Health 2024:8982643241242512. [PMID: 38554023 DOI: 10.1177/08982643241242512] [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: 04/01/2024]
Abstract
Objectives: Describe sex differences in healthcare utilization and mortality in persons with new dementia in Quebec, Canada. Methods: We conducted a repeated cohort study from 2000 to 2017 using health administrative databases. Community-dwelling persons aged 65+ with a new diagnosis of dementia were included. We measured 23 indicators of healthcare use across five care settings: ambulatory care, pharmacological care, acute hospital care, long-term care, and mortality. Clinically meaningful sex differences in age-standardized rates were determined graphically through expert consultations. Results: Women with dementia had higher rates of ambulatory care and pharmacological care, while men with dementia had higher acute hospital care, admission to long-term care, and mortality. There was no meaningful difference in visits to cognition specialists, antipsychotic prescriptions, and hospital death. Discussion: Men and women with dementia demonstrate differences in healthcare utilization and mortality. Addressing these differences will inform decision-makers, care providers and researchers and guide more equitable policy and interventions in dementia care.
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Affiliation(s)
- Genevieve Arsenault-Lapierre
- Center for Research and Expertise in Social Gerontology, Centre Intégré Universitaire de Santé et Services Sociaux Du Centre-Ouest de l'Ile de Montréal, Montreal, QC, Canada
| | - Tammy Bui
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada
| | - Claire Godard-Sebillotte
- McGill University Health Centre Research Institute, Montreal, QC, Canada
- Department of Medicine Division of Geriatrics, McGill University, Montreal, QC, Canada
| | - Nia Kang
- Department of Family Medicine, McGill University, Montreal, QC, Canada
| | - Nadia Sourial
- Department of Health Management, Evaluation and Policy, School of Public Health, Université de Montreal, Montreal, QC, Canada
- Research Center of the Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Louis Rochette
- Institut National de Santé Publique Du Québec, Montreal, QC, Canada
| | | | - Amélie Quesnel-Vallée
- Department of Equity, Ethics, and Policy, School of Population and Global Health, McGill University, Montreal, QC, Canada
- Department of Sociology, McGill University, Montreal, QC, Canada
| | - Isabelle Vedel
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada
- Department of Family Medicine, McGill University, Montreal, QC, Canada
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Kosteniuk J, Osman BA, Osman M, Quail J, Islam N, O'Connell ME, Kirk A, Stewart N, Karunanayake C, Morgan D. Rural-urban differences in use of health services before and after dementia diagnosis: a retrospective cohort study. BMC Health Serv Res 2024; 24:399. [PMID: 38553765 PMCID: PMC10981340 DOI: 10.1186/s12913-024-10817-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 03/03/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Rural-urban differences in health service use among persons with prevalent dementia are known. However, the extent of geographic differences in health service use over a long observation period, and prior to diagnosis, have not been sufficiently examined. The purpose of this study was to examine yearly rural-urban differences in the proportion of patients using health services, and the mean number of services, in the 5-year period before and 5-year period after a first diagnosis of dementia. METHODS This population-based retrospective cohort study used linked administrative health data from the Canadian province of Saskatchewan to investigate the use of five health services [family physician (FP), specialist physician, hospital admission, all-type prescription drug dispensations, and short-term institutional care admission] each year from April 2008 to March 2019. Persons with dementia included 2,024 adults aged 65 years and older diagnosed from 1 April 2013 to 31 March 2014 (617 rural; 1,407 urban). Matching was performed 1:1 to persons without dementia on age group, sex, rural versus urban residence, geographic region, and comorbidity. Differences between rural and urban persons within the dementia and control cohorts were separately identified using the Z-score test for proportions (p < 0.05) and independent samples t-test for means (p < 0.05). RESULTS Rural compared to urban persons with dementia had a lower average number of FP visits during 1-year and 2-year preindex and between 2-year and 4-year postindex (p < 0.05), a lower likelihood of at least one specialist visit and a lower average number of specialist visits during each year (p < 0.05), and a lower average number of all-type prescription drug dispensations for most of the 10-year study period (p < 0.05). Rural-urban differences were not observed in admission to hospital or short-term institutional care (p > 0.05 each year). CONCLUSIONS This study identified important geographic differences in physician services and all-type prescription drugs before and after dementia diagnosis. Health system planners and educators must determine how to use existing resources and technological advances to support care for rural persons living with dementia.
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Affiliation(s)
- Julie Kosteniuk
- Canadian Centre for Rural and Agricultural Health, University of Saskatchewan, 104 Clinic Place, S7N 2Z4, Saskatoon, SK, Canada.
| | - Beliz Acan Osman
- Saskatchewan Health Quality Council, Atrium Building, Innovation Place, 241- 111 Research Drive, S7N 3R2, Saskatoon, SK, Canada
| | - Meric Osman
- Saskatchewan Medical Association, 2174 Airport Drive #201, S7L 6M6, Saskatoon, SK, Canada
| | - Jacqueline Quail
- Saskatchewan Health Quality Council, Atrium Building, Innovation Place, 241- 111 Research Drive, S7N 3R2, Saskatoon, SK, Canada
| | - Naorin Islam
- College of Pharmacy and Nutrition, University of Saskatchewan, 107 Wiggins Road, S7N 5E5, Saskatoon, SK, Canada
| | - Megan E O'Connell
- Department of Psychology, University of Saskatchewan, Arts 182, 9 Campus Drive, S7N 5A5, Saskatoon, SK, Canada
| | - Andrew Kirk
- Department of Medicine, University of Saskatchewan, S7N 0W8, Saskatoon, SK, Canada
| | - Norma Stewart
- College of Nursing, University of Saskatchewan, 104 Clinic Place, S7N 2Z4, Saskatoon, SK, Canada
| | - Chandima Karunanayake
- Canadian Centre for Rural and Agricultural Health, University of Saskatchewan, 104 Clinic Place, S7N 2Z4, Saskatoon, SK, Canada
| | - Debra Morgan
- Canadian Centre for Rural and Agricultural Health, University of Saskatchewan, 104 Clinic Place, S7N 2Z4, Saskatoon, SK, Canada
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Schrøder CK, Kristiansen EB, Flarup L, Christiansen CF, Thomsen RW, Kristensen PK. Preadmission morbidity and healthcare utilization among older adults with potentially avoidable hospitalizations: a Danish case-control study. Eur Geriatr Med 2024; 15:127-138. [PMID: 38015387 PMCID: PMC10876768 DOI: 10.1007/s41999-023-00887-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/17/2023] [Indexed: 11/29/2023]
Abstract
PURPOSE Examine preadmission diagnoses, medication use, and preadmission healthcare utilization among older adults prior to first potentially avoidable hospitalizations. METHODS A nationwide population-based case-control study using Danish healthcare data. All Danish adults aged ≥ 65 years who had a first potentially avoidable hospitalization from January 1995 through March 2019 (n = 725,939) were defined as cases, and 1:1 age- and sex-matched general population controls (n = 725,939). Preadmission morbidity and healthcare utilization were assessed based on a complete hospital diagnosis history within 10 years prior, and all medication use and healthcare contacts 1 year prior. Using log-binomial regression, we calculated adjusted prevalence ratios (PR) with 95% confidence intervals (CI). RESULTS Included cases and controls had a median age of 78 years and 59% were female. The burden of preadmission morbidity was higher among cases than controls. The strongest associations were observed for preadmission chronic lung disease (PR 3.8, CI 3.7-3.8), alcohol-related disease (PR 3.1, CI 3.0-3.2), chronic kidney disease (PR 2.4, CI 2.4-2.5), psychiatric disease (PR 2.2, CI 2.2-2.3), heart failure (PR 2.2, CI 2.2-2.3), and previous hospital contacts with infections (PR 2.2, CI 2.2-2.3). A high and accelerating number of healthcare contacts was observed during the months preceding the potentially avoidable hospitalization (having over 5 GP contacts 1 month prior, PR 3.0, CI 3.0-3.0). CONCLUSION A high number of healthcare contacts and preadmission morbidity and medication use, especially chronic lung, heart, and kidney disease, alcohol-related or psychiatric disease including dementia, and previous infections are strongly associated with potentially avoidable hospitalizations.
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Affiliation(s)
- Christine K Schrøder
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200, Aarhus N, Denmark.
- Department of Orthopedic Surgery, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus N, Denmark.
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark.
| | - Eskild B Kristiansen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark
| | - Lone Flarup
- Strategisk Kvalitet, Koncern Kvalitet, Central Denmark Region, Viborg, Denmark
| | - Christian F Christiansen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark
| | - Reimar W Thomsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark
| | - Pia K Kristensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200, Aarhus N, Denmark
- Department of Orthopedic Surgery, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark
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Manis DR, Katz P, Lane NE, Rochon PA, Sinha SK, Andel R, Heckman GA, Kirkwood D, Costa AP. Rates of Hospital-Based Care among Older Adults in the Community and Residential Care Facilities: A Repeated Cross-Sectional Study. J Am Med Dir Assoc 2023; 24:1341-1348. [PMID: 37549887 DOI: 10.1016/j.jamda.2023.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 08/09/2023]
Abstract
OBJECTIVE We examine annual rates of emergency department (ED) visits, hospital admissions, and alternate levels of care (ALC) days (ie, the number of days that an older adult remained in hospital when they could not be safely discharged to an appropriate setting in their community) among older adults. DESIGN Repeated cross-sectional study. SETTING AND PARTICIPANTS Linked, individual-level health system administrative data on community-dwelling persons, home care recipients, residents of assisted living facilities, and residents of nursing homes aged 65 years and older in Ontario, Canada, from January 1, 2013, to December 31, 2019. METHODS We calculated rates of ED visits, hospital admissions, and ALC days per 1000 individuals per older adult population per year. We used a generalized linear model with a gaussian distribution, log link, and year fixed effects to obtain rate ratios. RESULTS There were 1,655,656 older adults in the community, 237,574 home care recipients, 42,600 older adults in assisted living facilities, and 94,055 older adults in nursing homes in 2013; there were 2,129,690 older adults in the community, 281,028 home care recipients, 56,975 older adults in assisted living facilities, and 95,925 older adults in nursing homes in 2019. Residents of assisted living facilities had the highest rates of ED visits (1260.692019 vs 1174.912013), hospital admissions (482.632019 vs 480.192013), and ALC days (1905.572019 vs 1443.032013) per 1000 individuals. Residents of assisted living facilities also had significantly higher rates of ED visits [rate ratio (RR) 3.30, 95% CI 3.20, 3.41), hospital admissions (RR 6.24, 95% CI 6.01, 6.47), and ALC days (RR 25.68, 95% CI 23.27, 28.35) relative to community-dwelling older adults. CONCLUSIONS AND IMPLICATIONS The disproportionate use of ED visits, hospital admissions, and ALC days among residents of assisted living facilities may be attributed to the characteristics of the population and fragmented licensing and regulation of the sector, including variable models of care. The implementation of interdisciplinary, after-hours, team-based approaches to home and primary care in assisted living facilities may reduce the potentially avoidable use of ED visits, hospital admissions, and ALC days among this population and optimize resource allocation in health care systems.
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Affiliation(s)
- Derek R Manis
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; ICES, Toronto, ON, Canada.
| | - Paul Katz
- Department of Geriatrics, College of Medicine, Florida State University, Tallahassee, FL, USA
| | - Natasha E Lane
- ICES, Toronto, ON, Canada; Department of Internal Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Paula A Rochon
- ICES, Toronto, ON, Canada; Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada; Women's College Research Institute, Toronto, ON, Canada; Division of Geriatric Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Samir K Sinha
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada; Division of General Internal Medicine and Geriatrics, Sinai Health and University Health Network, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; National Institute on Ageing, Toronto Metropolitan University, Toronto, ON, Canada
| | - Ross Andel
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA; Department of Neurology, Charles University, Second Faculty of Medicine and Motol University Hospital, Prague, Czech Republic; International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | - George A Heckman
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | | | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; ICES, Toronto, ON, Canada; Schlegel Research Institute for Aging, Waterloo, ON, Canada; Centre for Integrated Care, St. Joseph's Health System, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
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Nguyen OT, Katoju S, Pons EE, Motwani K, Daniels GM, Reed AC, Alfred J, Feller DB, Hong YR. Predictors of intent to utilize the emergency department among a free clinic's patients. Am J Emerg Med 2023; 71:25-30. [PMID: 37327708 PMCID: PMC10527010 DOI: 10.1016/j.ajem.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 05/26/2023] [Accepted: 06/04/2023] [Indexed: 06/18/2023] Open
Abstract
OBJECTIVE Primary care use helps reduce utilization of more expensive modes of care, such as the emergency department (ED). Although most studies have investigated this association among patients with insurance, few have done so for patients without insurance. We used data from a free clinic network to assess the association between free clinic use and intent to use the ED. METHODS Data were collected from a free clinic network's electronic health records on adult patients from January 2015 to February 2020. Our outcome was whether patients reported themselves as 'very likely' to visit the ED if the free clinics were unavailable. The independent variable was frequency of free clinic use. Using a multivariable logistic regression model, we controlled for other factors, such as patient demographic factors, social determinants of health, health status, and year effect. RESULTS Our sample included 5008 visits. When controlling for other factors, higher odds of expressing ED interest were observed for patients who are non-Hispanic Black, older, not married, lived with others, had lower education, were homeless, had personal transportation, lived in rural areas, and had a higher comorbidity burden. In sensitivity analyses, higher odds were observed for dental, gastrointestinal, genitourinary, musculoskeletal, or respiratory conditions. CONCLUSIONS In the free clinic space, several patient demographic, social determinants of health and medical conditions were independently associated with greater odds of reporting intent on visiting the ED. Additional interventions that improve access and use of free clinics (e.g., dental) may keep patients without insurance from the ED.
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Affiliation(s)
- Oliver T Nguyen
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA; Department of Community Health & Family Medicine, University of Florida, Gainesville, FL, USA.
| | - SriVarsha Katoju
- Department of Community Health & Family Medicine, University of Florida, Gainesville, FL, USA
| | - Erick E Pons
- Department of Community Health & Family Medicine, University of Florida, Gainesville, FL, USA; College of Medicine, Ohio State University, Columbus, OH, USA
| | - Kartik Motwani
- Department of Community Health & Family Medicine, University of Florida, Gainesville, FL, USA
| | - Gabriel M Daniels
- Department of Community Health & Family Medicine, University of Florida, Gainesville, FL, USA; Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Austin C Reed
- Department of Community Health & Family Medicine, University of Florida, Gainesville, FL, USA; Department of Emergency Medicine, University of Florida, Gainesville, FL, USA
| | - Joanne Alfred
- Department of Community Health & Family Medicine, University of Florida, Gainesville, FL, USA; Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - David B Feller
- Department of Community Health & Family Medicine, University of Florida, Gainesville, FL, USA
| | - Young-Rock Hong
- Department of Health Services Research, Management, and Policy, Gainesville, FL, USA
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Hovsepian VE, McHugh MD, Kutney-Lee A. Electronic Health Record Usability and Postsurgical Outcomes Among Older Adults With Dementia. Am J Geriatr Psychiatry 2023; 31:491-500. [PMID: 36878739 PMCID: PMC10257739 DOI: 10.1016/j.jagp.2023.02.004] [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: 10/27/2022] [Revised: 02/06/2023] [Accepted: 02/06/2023] [Indexed: 02/14/2023]
Abstract
INTRODUCTION Electronic health record (EHR) usability, defined as the extent to which the system can be used to complete tasks, can influence patient outcomes. The aim of this study is to assess the relationship between EHR usability and postsurgical outcomes of older adults with dementia including 30-day readmission, 30-day mortality, and length of stay (LOS). METHODS A cross-sectional analysis of linked American Hospital Association, Medicare claims data, and nurse survey data was conducted using logistic regression and negative binominal models. RESULTS The dementia population who received care in hospitals with better EHR usability were less likely to die within 30 days of their admission following surgery compared to hospitals with poorer EHR usability (OR: 0.79, 95% CI: 0.68-0.91, p = 0.001). EHR usability was not associated with readmission or LOS. DISCUSSION Better nurse reported EHR usability has the potential to reduce mortality rates among older adults with dementia in hospitals.
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Affiliation(s)
- Vaneh E Hovsepian
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing (VEH, MDM, AK-L), Philadelphia, PA; The Leonard Davis Institute of Health Economics, University of Pennsylvania (VEH, MDM), Philadelphia, PA.
| | - Matthew D McHugh
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing (VEH, MDM, AK-L), Philadelphia, PA; The Leonard Davis Institute of Health Economics, University of Pennsylvania (VEH, MDM), Philadelphia, PA
| | - Ann Kutney-Lee
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing (VEH, MDM, AK-L), Philadelphia, PA; Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center (AK-L), Philadelphia, PA
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Seeley A, Glogowska M, Hayward G. 'Frailty as an adjective rather than a diagnosis'-identification of frailty in primary care: a qualitative interview study. Age Ageing 2023; 52:afad095. [PMID: 37366329 PMCID: PMC10294554 DOI: 10.1093/ageing/afad095] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Indexed: 06/28/2023] Open
Abstract
INTRODUCTION In 2017, NHS England introduced proactive identification of frailty into the General Practitioners (GP) contract. There is currently little information as to how this policy has been operationalised by front-line clinicians, their working understanding of frailty and impact of recognition on patient care. We aimed to explore the conceptualisation and identification of frailty by multidisciplinary primary care clinicians in England. METHODS Qualitative semi-structured interviews were conducted with primary care staff across England including GPs, physician associates, nurse practitioners, paramedics and pharmacists. Thematic analysis was facilitated through NVivo (Version 12). RESULTS Totally, 31 clinicians participated. Frailty was seen as difficult to define, with uncertainty about its value as a medical diagnosis. Clinicians conceptualised frailty differently, dependant on job-role, experience and training. Identification of frailty was most commonly informal and opportunistic, through pattern recognition of a frailty phenotype. Some practices had embedded population screening and structured reviews. Visual assessment and continuity of care were important factors in recognition. Most clinicians were familiar with the electronic frailty index, but described poor accuracy and uncertainty as to how to interpret and use this tool. There were different perspectives amongst professional groups as to whether frailty should be more routinely identified, with concerns of capacity and feasibility in the current climate of primary care workload. CONCLUSIONS Concepts of frailty in primary care differ. Identification is predominantly ad hoc and opportunistic. A more cohesive approach to frailty, relevant to primary care, together with better diagnostic tools and resource allocation, may encourage wider recognition.
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Affiliation(s)
- Anna Seeley
- Address correspondence to: Anna Seeley. Tel: 01865 617855.
| | - Margaret Glogowska
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Wong WWL, Lee L, Walker S, Lee C, Patel T, Hillier LM, Costa AP, Sinha SK. Cost-utility analysis of a multispecialty interprofessional team dementia care model in Ontario, Canada. BMJ Open 2023; 13:e064882. [PMID: 37076160 PMCID: PMC10124186 DOI: 10.1136/bmjopen-2022-064882] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/21/2023] Open
Abstract
OBJECTIVES To examine the cost-effectiveness of Multi-specialty INterprofessional Team (MINT) Memory Clinic care in comparison to the provision of usual care. DESIGN Using a Markov-based state transition model, we performed a cost-utility (costs and quality-adjusted life years, QALY) analysis of MINT Memory Clinic care and usual care not involving MINT Memory Clinics. SETTING A primary care-based Memory Clinic in Ontario, Canada. PARTICIPANTS The analysis included data from a sample of 229 patients assessed in the MINT Memory Clinic between January 2019 and January 2021. PRIMARY OUTCOME MEASURES Effectiveness as measured in QALY, costs (in Canadian dollars) and the incremental cost-effectiveness ratio calculated as the incremental cost per QALY gained between MINT Memory Clinics versus usual care. RESULTS MINT Memory Clinics were found to be less expensive ($C51 496 (95% Crl $C4806 to $C119 367) while slightly improving quality of life (+0.43 (95 Crl 0.01 to 1.24) QALY) compared with usual care. The probabilistic analysis showed that MINT Memory Clinics were the superior treatment compared with usual care 98% of the time. Variation in age was found to have the greatest impact on cost-effectiveness as patients may benefit from the MINT Memory Clinics more if they receive care beginning at a younger age. CONCLUSION Multispecialty interprofessional memory clinic care is less costly and more effective compared with usual care and early access to care significantly reduces care costs over time. The results of this economic evaluation can inform decision-making and improvements to health system design, resource allocation and care experience for persons living with dementia. Specifically, widespread scaling of MINT Memory Clinics into existing primary care systems may assist with improving quality and access to memory care services while decreasing the growing economic and social burden of dementia.
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Affiliation(s)
- William W L Wong
- School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
| | - Linda Lee
- Centre for Family Medicine Family Health Team, Kitchener, Ontario, Canada
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
- Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada
| | - Sasha Walker
- Centre for Family Medicine Family Health Team, Kitchener, Ontario, Canada
| | - Catherine Lee
- Centre for Family Medicine Family Health Team, Kitchener, Ontario, Canada
| | - Tejal Patel
- School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
- Centre for Family Medicine Family Health Team, Kitchener, Ontario, Canada
- Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada
| | | | - Andrew P Costa
- Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada
- Departments of Clinical Epidemiology & Biostatistics, and Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Samir K Sinha
- Departments of Medicine, Family and Community Medicine and the Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- National Institute on Ageing, Toronto Metropolitan University, Toronto, Ontario, Canada
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Payen A, Godard-Sebillotte C, Sourial N, Soula J, Verloop D, Defebvre MM, Dupont C, Dambre D, Lamer A, Beuscart JB. The impact of including a medication review in an integrated care pathway: A pilot study. Br J Clin Pharmacol 2023; 89:1036-1045. [PMID: 36164674 DOI: 10.1111/bcp.15543] [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: 11/23/2021] [Revised: 08/09/2022] [Accepted: 08/31/2022] [Indexed: 12/01/2022] Open
Abstract
AIM The objective of the present study was to measure the impact of the intervention of combining a medication review with an integrated care approach on potentially inappropriate medications (PIMs) and hospital readmissions in frail older adults. METHODS A cohort of hospitalized older adults enrolled in the French PAERPA integrated care pathway (the exposed cohort) was matched retrospectively with hospitalized older adults not enrolled in the pathway (unexposed cohort) between January 1st, 2015, and December 31st, 2018. The study was an analysis of French health administrative database. The inclusion criteria for exposed patients were admission to an acute care department in a general hospital, age 75 years or over, at least three comorbidities or the prescription of diuretics or oral anticoagulants, discharge alive and performance of a medication review. RESULTS For the study population (n = 582), the mean ± standard deviation age was 82.9 ± 4.9 years, and 380 (65.3%) were women. Depending on the definition used, the overall median number of PIMs ranged from 2 [0;3] on admission to 3 [0;3] at discharge. The intervention was not associated with a significant difference in the mean number of PIMs. Patients in the exposed cohort were half as likely to be readmitted to hospital within 30 days of discharge relative to patients in the unexposed cohort. CONCLUSION Our results show that a medication review was not associated with a decrease in the mean number of PIMs. However, an integrated care intervention including the medication review was associated with a reduction in the number of hospital readmissions at 30 days.
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Affiliation(s)
- Anaïs Payen
- University of Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
| | | | - Nadia Sourial
- Department of Health Management, Evaluation and Policy, School of Public Health, University of Montreal, Montreal, Québec, Canada
| | - Julien Soula
- University of Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
| | - David Verloop
- Agence Régionale de Santé Hauts-de-France, Lille, France
| | | | - Corinne Dupont
- Agence Régionale de Santé Hauts-de-France, Lille, France
| | - Delphine Dambre
- Service de Médecine Polyvalente, Centre Hospitalier de Saint-Amand-les-Eaux, Saint-Amand-les-Eaux, France
| | - Antoine Lamer
- University of Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
| | - Jean-Baptiste Beuscart
- University of Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
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11
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Lautamatti E, Mattila K, Suominen S, Sillanmäki L, Sumanen M. A named GP increases self-reported access to health care services. BMC Health Serv Res 2022; 22:1262. [PMID: 36261827 PMCID: PMC9580200 DOI: 10.1186/s12913-022-08660-5] [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] [Received: 04/14/2022] [Accepted: 10/04/2022] [Indexed: 11/18/2022] Open
Abstract
Background Continuity of care strengthens health promotion and decreases mortality, although the mechanisms of these effects are still unclear. In recent decades, continuity of care and accessibility of health care services have both decreased in Finland. Objectives The aim of the study was to investigate whether a named and assigned GP representing continuity of care is associated with the use of primary and hospital health care services and to create knowledge on the state of continuity of care in a changing health care system in Finland. Methods The data are part of the Health and Social Support (HeSSup) mail survey based on a random Finnish working age population sample of 64,797 individuals drawn in 1998 and follow-up surveys in 2003 and 2012. The response rate in 1998 was 40% (n = 25,898). Continuity of care was derived from the 2003 and 2012 data sets, other variables from the 2012 survey (n = 11,924). The principal outcome variables were primary health care and hospital service use reported by participants. The association of the explanatory variables (gender, age, education, reported chronic diseases, health status, smoking, obesity, NYHA class of any functional limitation, depressive mood and continuity of care) with the outcome variables was analysed by binomial logistic regression analysis. Results A named and assigned GP was independently and significantly associated with more frequent use of primary and hospital care in the adjusted logistic regression analysis (ORs 1.53 (95% CI 1.35–1.72) and 1.19 (95% CI 1.08–1.32), p < 0.001). Conclusion A named GPs is associated with an increased use of primary care and hospital services. A named GP assures access to health care services especially to the chronically ill population. The results depict the state of continuity of care in Finland. All benefits of continuity of care are not enabled although it still assures treatment of population in the most vulnerable position.
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Affiliation(s)
- Emmi Lautamatti
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland. .,Centre for General Practice, Pirkanmaa Hospital District, Tampere, Finland.
| | - Kari Mattila
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Sakari Suominen
- School of Health Sciences, University of Skövde, Skövde, Sweden.,Department of Public Health and Clinical Research Centre, University of Turku, Turku University Hospital, Turku, Finland
| | - Lauri Sillanmäki
- Turku University Hospital and University of Turku, Turku, Finland.,Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Markku Sumanen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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12
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Yang S, Zhou M, Liao J, Ding X, Hu N, Kuang L. Association between Primary Care Utilization and Emergency Room or Hospital Inpatient Services Utilization among the Middle-Aged and Elderly in a Self-Referral System: Evidence from the China Health and Retirement Longitudinal Study 2011-2018. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph191912979. [PMID: 36232279 PMCID: PMC9564952 DOI: 10.3390/ijerph191912979] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/28/2022] [Accepted: 10/02/2022] [Indexed: 05/09/2023]
Abstract
With rapid economic growth and aging, hospital inpatient and emergency services utilization has grown rapidly, and has emphasized an urgent requirement to adjust and optimize the structure of health service utilization. Studies have shown that primary care is an effective way to reduce inpatient and emergency room (ER) service utilization. This study aims to examine whether middle-aged and elderly individuals who selected primary care outpatient services in the last month had less ER and hospital inpatient service utilization than those who selected hospitals outpatient services via the self-referral system. Data were obtained from four waves of the nationally representative China Health and Retirement Longitudinal Study (CHARLS). We pooled respondents who had outpatient visits and were aged 45 years and above. We used logistic regressions to explore the association between types of outpatient and ER visits or hospitalization, and then used zero-truncated negative binomial regression to examine the impact of outpatient visit types on the number of hospitalizations and the length of hospitalization days. A trend test was used to explore the trend of outpatient visit types and the ER or hospital inpatient services utilization with the increase in outpatient visits. Among the 7544 respondents in CHARLS, those with primary care outpatient visits were less likely to have ER visits (adjusted OR = 0.141, 95% CI: 0.101-0.194), hospitalization (adjusted OR = 0.623, 95% CI: 0.546-0.711), and had fewer hospitalization days (adjusted IRR = 0.886, 95% CI: 0.81-0.969). The trend test showed that an increase in the number of total outpatient visits was associated with a lower hospitalizations (p = 0.006), but a higher odds of ER visits (p = 0.023). Our findings suggest that policy makers need to adopt systematic policies that focus on restructuring and balancing the structure of resources and service utilization in the three-tier healthcare system.
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Affiliation(s)
- Siman Yang
- Department of Health Administration, School of Public Health, Sun Yat-Sen University, Guangzhou 510080, China
| | - Mengping Zhou
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, 17177 Stockholm, Sweden
| | - Jingyi Liao
- Department of Health Administration, School of Public Health, Sun Yat-Sen University, Guangzhou 510080, China
| | - Xinxin Ding
- Department of Health Administration, School of Public Health, Sun Yat-Sen University, Guangzhou 510080, China
| | - Nan Hu
- Department of Biostatistics, FIU Robert Stempel College of Public Health and Social Work, Miami, FL 33199, USA
- Department of Family and Preventive Medicine and Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
- Correspondence: (N.H.); (L.K.)
| | - Li Kuang
- Department of Health Administration, School of Public Health, Sun Yat-Sen University, Guangzhou 510080, China
- Correspondence: (N.H.); (L.K.)
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13
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Chao YH, Huang WY, Tang CH, Pan YA, Chiou JY, Ku LJE, Wei JCC. Effects of continuity of care on hospitalizations and healthcare costs in older adults with dementia. BMC Geriatr 2022; 22:724. [PMID: 36056303 PMCID: PMC9438333 DOI: 10.1186/s12877-022-03407-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 08/25/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction People with dementia have high rates of hospitalization, and a share of these hospitalizations might be avoidable with appropriate ambulatory care, also known as potentially preventable hospitalization (PAH). This study investigates the associations between continuity of care and healthcare outcomes in the following year, including all-cause hospitalization, PAHs, and healthcare costs in patients with dementia. Methods This is a longitudinal retrospective cohort study of 69,658 patients with dementia obtained from the Taiwan National Health Insurance Research Database. The Continuity of Care Index (COCI) was calculated to measure the continuity of dementia-related visits across physicians. The PAHs were classified into five types as defined by the Medicare Ambulatory Care Indicators for the Elderly (MACIEs). Logistic regression models were used to examine the effect of COCI on all-cause hospitalizations and PAHs, while generalized linear models were used to analyze the effect of COCI on outpatient, hospitalization, and total healthcare costs. Results The high COCI group was significantly associated with a lower likelihood of all-cause hospitalization than the low COCI group (OR = 0.848, 95%CI: 0.821–0.875). The COCI had no significant effect on PAHs but was associated with lower outpatient costs (exp(β) = 0.960, 95%CI: 0.941 ~ 0.979), hospitalization costs (exp(β) = 0.663, 95%CI: 0.614 ~ 0.717), total healthcare costs (exp(β) = 0.962, 95%CI: 0.945–0.980). Conclusion Improving continuity of care for dementia-related outpatient visits is recommended to reduce hospitalization and healthcare costs, although there was no statistically significant effect of continuity of care found on PAHs.
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Affiliation(s)
- Yung-Hsiang Chao
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Wen-Yen Huang
- Department of Public Health, College of Medicine, National Cheng Kung University, No.1, University Road, Tainan City, 701, Taiwan
| | - Chia-Hong Tang
- Department of Public Health, College of Medicine, National Cheng Kung University, No.1, University Road, Tainan City, 701, Taiwan.,Department of Psychiatric, Tainan Hospital, Ministry of Health and Welfare, Tainan City, Taiwan
| | - Yu-An Pan
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Jeng-Yuan Chiou
- School of Health Policy and Management, Chung Shan Medical University, Taichung, Taiwan
| | - Li-Jung Elizabeth Ku
- Department of Public Health, College of Medicine, National Cheng Kung University, No.1, University Road, Tainan City, 701, Taiwan.
| | - James Cheng-Chung Wei
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan.,Department of Allergy, Immunology & Rheumatology, Chung Shan Medical University Hospital, Taichung, Taiwan
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14
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Dyer SM, Suen J, Williams H, Inacio MC, Harvey G, Roder D, Wesselingh S, Kellie A, Crotty M, Caughey GE. Impact of relational continuity of primary care in aged care: a systematic review. BMC Geriatr 2022; 22:579. [PMID: 35836118 PMCID: PMC9281225 DOI: 10.1186/s12877-022-03131-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 05/06/2022] [Indexed: 11/21/2022] Open
Abstract
Background Greater continuity of care has been associated with lower hospital admissions and patient mortality. This systematic review aims to examine the impact of relational continuity between primary care professionals and older people receiving aged care services, in residential or home care settings, on health care resource use and person-centred outcomes. Methods Systematic review of five databases, four trial registries and three grey literature sources to October 2020. Included studies (a) aimed to increase relational continuity with a primary care professional, (b) focused on older people receiving aged care services (c) included a comparator and (d) reported outcomes of health care resource use, quality of life, activities of daily living, mortality, falls or satisfaction. Cochrane Collaboration or Joanna Briggs Institute criteria were used to assess risk of bias and GRADE criteria to rate confidence in evidence and conclusions. Results Heterogeneity in study cohorts, settings and outcome measurement in the five included studies (one randomised) precluded meta-analysis. None examined relational continuity exclusively with non-physician providers. Higher relational continuity with a primary care physician probably reduces hospital admissions (moderate certainty evidence; high versus low continuity hazard ratio (HR) 0.94; 95% confidence interval (CI) 0.92–0.96, n = 178,686; incidence rate ratio (IRR) 0.99, 95%CI 0.76–1.27, n = 246) and emergency department (ED) presentations (moderate certainty evidence; high versus low continuity HR 0.90, 95%CI 0.89–0.92, n = 178,686; IRR 0.91, 95%CI 0.72–1.15, n = 246) for older community-dwelling aged care recipients. The benefit of providing on-site primary care for relational continuity in residential settings is uncertain (low certainty evidence, 2 studies, n = 2,468 plus 15 care homes); whilst there are probably lower hospitalisations and may be fewer ED presentations, there may also be an increase in reported mortality and falls. The benefit of general practitioners’ visits during hospital admission is uncertain (very low certainty evidence, 1 study, n = 335). Conclusion Greater relational continuity with a primary care physician probably reduces hospitalisations and ED presentations for community-dwelling aged care recipients, thus policy initiatives that increase continuity may have cost offsets. Further studies of approaches to increase relational continuity of primary care within aged care, particularly in residential settings, are needed. Review registration CRD42021215698. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03131-2.
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Affiliation(s)
- Suzanne M Dyer
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, Australia.
| | - Jenni Suen
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, Australia
| | | | - Maria C Inacio
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, Australia.,Allied Health and Human Performance, University of South Australia, Adelaide, Australia
| | - Gillian Harvey
- College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - David Roder
- Allied Health and Human Performance, University of South Australia, Adelaide, Australia.,South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Steve Wesselingh
- South Australian Health and Medical Research Institute, Adelaide, Australia
| | | | - Maria Crotty
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, Australia
| | - Gillian E Caughey
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, Australia.,Allied Health and Human Performance, University of South Australia, Adelaide, Australia
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15
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Borson S. Perspective on Goldfarb et al., Design and Development of a Community-Based, Interdisciplinary, Collaborative Dementia Care Program. Am J Geriatr Psychiatry 2022; 30:661-663. [PMID: 35067418 DOI: 10.1016/j.jagp.2021.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 12/29/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Soo Borson
- Department of Clinical Family Medicine, University of Southern California Keck School of Medicine, Professor Emerita of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98195.
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16
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Shawaqfeh B, Hughes CM, McGuinness B, Barry HE. A systematic review of interventions to reduce anticholinergic burden in older people with dementia in primary care. Int J Geriatr Psychiatry 2022; 37:10.1002/gps.5722. [PMID: 35524704 PMCID: PMC9320938 DOI: 10.1002/gps.5722] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/20/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE This systematic review aimed to assess the types and effectiveness of interventions that sought to reduce anticholinergic burden (ACB) in people with dementia (PwD) in primary care. METHODS One trial registry and eight electronic databases were systematically searched to identify eligible English language studies from inception until December 2021. To be eligible for inclusion, studies had to be randomised controlled trials (RCTs) or non-randomised studies (NRS), including controlled before-and-after studies and interrupted time-series studies, of interventions to reduce ACB in PwD aged ≥65 years (either community-dwelling or care home residents). All outcomes were to be considered. Quality was to be assessed using the Cochrane Risk of Bias tool for RCTs and ROBINS-I tool for NRS. If data could not be pooled for meta-analysis, a narrative synthesis was to be conducted. RESULTS In total, 1880 records were found, with 1594 records remaining after removal of duplicates. Following title/abstract screening, 13 full-text articles were assessed for eligibility. None of these studies met the inclusion criteria for this review. Reasons for exclusion were incorrect study design, ineligible study population, lack of focus on reducing ACB, and studies conducted outside the primary care setting. CONCLUSIONS This 'empty' systematic review highlights the lack of interventions to reduce ACB in PwD within primary care, despite this being highlighted as a priority area for research in recent clinical guidance. Future research should focus on development and testing of interventions to reduce ACB in this patient population through high-quality clinical trials.
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17
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Leniz J, Gulliford M, Higginson IJ, Bajwah S, Yi D, Gao W, Sleeman KE. Primary care contacts, continuity, identification of palliative care needs, and hospital use: a population-based cohort study in people dying with dementia. Br J Gen Pract 2022; 72:BJGP.2021.0715. [PMID: 35817583 PMCID: PMC9282808 DOI: 10.3399/bjgp.2021.0715] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/02/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Reducing hospital admissions among people dying with dementia is a policy priority. AIM To explore associations between primary care contacts, continuity of primary care, identification of palliative care needs, and unplanned hospital admissions among people dying with dementia. DESIGN AND SETTING This was a retrospective cohort study using the Clinical Practice Research Datalink linked with hospital records and Office for National Statistics data. Adults (>18 years) who died between 2009 and 2018 with a diagnosis of dementia were included in the study. METHOD The association between GP contacts, Herfindahl-Hirschman Index continuity of care score, palliative care needs identification before the last 90 days of life, and multiple unplanned hospital admissions in the last 90 days was evaluated using random-effects Poisson regression. RESULTS In total, 33 714 decedents with dementia were identified: 64.1% (n = 21 623) female, mean age 86.6 years (SD 8.1), mean comorbidities 2.2 (SD 1.6). Of these, 1894 (5.6%) had multiple hospital admissions in the last 90 days of life (increase from 4.9%, 95% confidence interval [CI] = 4.2 to 5.6 in 2009 to 7.1%, 95% CI = 5.7 to 8.4 in 2018). Participants with more GP contacts had higher risk of multiple hospital admissions (incidence risk ratio [IRR] 1.08, 95% CI = 1.05 to 1.11). Higher continuity of care scores (IRR 0.79, 95% CI = 0.68 to 0.92) and identification of palliative care needs (IRR 0.66, 95% CI = 0.56 to 0.78) were associated with lower frequency of these admissions. CONCLUSION Multiple hospital admissions among people dying with dementia are increasing. Higher continuity of care and identification of palliative care needs are associated with a lower risk of multiple hospital admissions in this population, and might help prevent these admissions at the end of life.
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Affiliation(s)
- Javiera Leniz
- NIHR clinician scientist and honorary consultant in palliative medicine, Cicely Saunders Institute for Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London
| | - Martin Gulliford
- Department of Population Health Sciences, Faculty of Life Science & Medicine, King's College London, London
| | - Irene J Higginson
- NIHR clinician scientist and honorary consultant in palliative medicine, Cicely Saunders Institute for Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London
| | - Sabrina Bajwah
- NIHR clinician scientist and honorary consultant in palliative medicine, Cicely Saunders Institute for Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London
| | - Deokhee Yi
- NIHR clinician scientist and honorary consultant in palliative medicine, Cicely Saunders Institute for Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London
| | - Wei Gao
- NIHR clinician scientist and honorary consultant in palliative medicine, Cicely Saunders Institute for Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London
| | - Katherine E Sleeman
- NIHR clinician scientist and honorary consultant in palliative medicine, Cicely Saunders Institute for Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London
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18
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Continuity of GP care for patients with dementia: impact on prescribing and the health of patients. Br J Gen Pract 2022; 72:e91-e98. [PMID: 35074796 PMCID: PMC8803082 DOI: 10.3399/bjgp.2021.0413] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 11/03/2021] [Indexed: 12/31/2022] Open
Abstract
Background Higher continuity of GP care (CGPC), that is, consulting the same doctor consistently, can improve doctor–patient relationships and increase quality of care; however, its effects on patients with dementia are mostly unknown. Aim To estimate the associations between CGPC and potentially inappropriate prescribing (PIP), and with the incidence of adverse health outcomes (AHOs) in patients with dementia. Design and setting A retrospective cohort study with 1 year of follow-up anonymised medical records from 9324 patients with dementia, aged ≥65 years living in England in 2016. Method CGPC measures include the Usual Provider of Care (UPC), Bice–Boxerman Continuity of Care (BB), and Sequential Continuity (SECON) indices. Regression models estimated associations with PIPs and survival analysis with incidence of AHOs during the follow-up adjusted for age, sex, deprivation level, 14 comorbidities, and frailty. Results The highest quartile (HQ) of UPC (highest continuity) had 34.8% less risk of delirium (odds ratio [OR] 0.65, 95% confidence interval [CI] = 0.51 to 0.84), 57.9% less risk of incontinence (OR 0.42, 95% CI = 0.31 to 0.58), and 9.7% less risk of emergency admissions to hospital (OR 0.90, 95% CI = 0.82 to 0.99) compared with the lowest quartile. Polypharmacy and PIP were identified in 81.6% (n = 7612) and 75.4% (n = 7027) of patients, respectively. The HQ had fewer prescribed medications (HQ: mean 8.5, lowest quartile (LQ): mean 9.7, P<0.01) and had fewer PIPs (HQ: mean 2.1, LQ: mean 2.5, P<0.01), including fewer loop diuretics in patients with incontinence, drugs that can cause constipation, and benzodiazepines with high fall risk. The BB and SECON measures produced similar findings. Conclusion Higher CGPC for patients with dementia was associated with safer prescribing and lower rates of major adverse events. Increasing continuity of care for patients with dementia may help improve treatment and outcomes.
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19
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Nguyen HQ, Borson S, Khang P, Langer‐Gould A, Wang SE, Carrol J, Lee JS. Dementia diagnosis and utilization patterns in a racially diverse population within an integrated health care delivery system. ALZHEIMER'S & DEMENTIA: TRANSLATIONAL RESEARCH & CLINICAL INTERVENTIONS 2022; 8:e12279. [PMID: 35310534 PMCID: PMC8918121 DOI: 10.1002/trc2.12279] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 01/18/2022] [Accepted: 02/11/2022] [Indexed: 11/18/2022]
Abstract
Introduction In an effort to identify improvement opportunities for earlier dementia detection and care within a large, integrated health care system serving diverse Medicare Advantage (MA) beneficiaries, we examined where, when, and by whom Alzheimer's disease and related dementias (ADRD) diagnoses are recorded as well as downstream health care utilization and life care planning. Methods Patients 65 years and older, continuously enrolled in the Kaiser Foundation health plan for at least 2 years, and with a first ADRD diagnosis between January 1, 2015, and December 31, 2018, comprised the incident cohort. Electronic health record data were used to identify site and source of the initial diagnosis (clinic vs hospital‐based, provider type), health care utilization in the year before and after diagnosis, and end‐of‐life care. Results ADRD prevalence was 5.5%. A total of 25,278 individuals had an incident ADRD code (rate: 1.2%) over the study period—nearly half during a hospital‐based encounter. Hospital‐diagnosed patients had higher comorbidities, acute care use before and after diagnosis, and 1‐year mortality than clinic‐diagnosed individuals (36% vs 11%). Many decedents (58%‐72%) received palliative care or hospice. Of the 55% diagnosed as outpatients, nearly two‐thirds were diagnosed by dementia specialists; when used, standardized cognitive assessments indicated moderate stage ADRD. Despite increases in advance care planning and visits to dementia specialists in the year after diagnosis, acute care use also increased for both clinic‐ and hospital‐diagnosed cohorts. Discussion Similar to other MA plans, ADRD is under‐diagnosed in this health system, compared to traditional Medicare, and diagnosed well beyond the early stages, when opportunities to improve overall outcomes are presumed to be better. Dementia specialists function primarily as consultants whose care does not appear to mitigate acute care use. Strategic targets for ADRD care improvement could focus on generating pragmatic evidence on the value of proactive detection and tracking, care planning, and the role of specialists in chronic care management.
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Affiliation(s)
- Huong Q. Nguyen
- Department of Research and Evaluation Kaiser Permanente Southern California Pasadena California USA
| | - Soo Borson
- School of Medicine Department of Psychiatry and Behavioral Sciences University of Washington Seattle Washington USA
- University of Southern California Keck School of Medicine Department of Family Medicine Los Angeles California USA
| | - Peter Khang
- Los Angeles Medical Center Department of Geriatrics Palliative and Continuing Care Kaiser Permanente Southern California Pasadena California USA
| | - Annette Langer‐Gould
- Los Angeles Medical Center Department of Neurology Kaiser Permanente Southern California Pasadena California USA
| | - Susan E. Wang
- West Los Angeles Medical Center Department of Geriatrics Palliative and Continuing Care Kaiser Permanente Southern California Pasadena California USA
| | - Jarrod Carrol
- Los Angeles Medical Center Department of Neurology Kaiser Permanente Southern California Pasadena California USA
| | - Janet S. Lee
- Department of Research and Evaluation Kaiser Permanente Southern California Pasadena California USA
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20
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Hovsepian V, Bilazarian A, Schlak AE, Sadak T, Poghosyan L. The Impact of Ambulatory Dementia Care Models on Hospitalization of Persons Living With Dementia: A Systematic Review. Res Aging 2021; 44:560-572. [PMID: 34957873 PMCID: PMC9429825 DOI: 10.1177/01640275211053239] [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: 11/17/2022]
Abstract
This systematic review presents an overview of the existing dementia care models in various ambulatory care settings under three categories (i.e., home- and community-based care models, partnership between health systems and community-based resources, and consultation models) and their impact on hospitalization among Persons Living with Dementia (PLWD). PRISMA guidelines were applied, and our search resulted in a total of 13 studies focusing on 11 care models. Seven studies reported that utilization of dementia care models was associated with a modest reduction in hospitalization among community-residing PLWD. Only two studies reported statistically significant results. Dementia care models that were utilized in specialty ambulatory care settings such as memory care showed more promising results than traditional primary care. To develop a better understanding of how dementia care models can be improved, future studies should explore how confounders (e.g., stage of dementia) influence hospitalization.
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Affiliation(s)
- Vaneh Hovsepian
- School of Nursing, 15760Columbia University, New York, NY, USA
| | - Ani Bilazarian
- School of Nursing, 15760Columbia University, New York, NY, USA
| | - Amelia E Schlak
- School of Nursing, 15760Columbia University, New York, NY, USA
| | - Tatiana Sadak
- School of Nursing, 16181University of Washington, Seattle, WA, USA
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Amjad H, Borson S. Invigorating primary care for older adults living with dementia. J Am Geriatr Soc 2021; 69:1186-1189. [PMID: 33890295 DOI: 10.1111/jgs.17123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 02/23/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Halima Amjad
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Soo Borson
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
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