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Cheng I, Kiss A, Coyle N, Verma A, Pardhan K, Hall JN, Wagner B, Thomas-Boaz W, Shadowitz S, Atzema C. Diversion of hospital admissions from the emergency department using an interprofessional team: a propensity score analysis. CAN J EMERG MED 2024:10.1007/s43678-024-00760-x. [PMID: 39186238 DOI: 10.1007/s43678-024-00760-x] [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: 01/02/2024] [Accepted: 07/28/2024] [Indexed: 08/27/2024]
Abstract
PURPOSE To examine if an ED interprofessional team ("ED1Team") could safely decrease hospital admissions among older persons. METHODS This single-center, retrospective, propensity score matched study was performed at a single ED during a control (December 2/2018-March 31/2019) and intervention (December 2/2019-March 31/2020) period. The intervention was assessed by the ED1Team, which could include an occupational therapist, physiotherapist, and social worker. We compared admission rates between period in persons age ≥ 70 years. Next, we compared visits attended by the ED1Team to (a) control period visits, and (b) intervention period visits without ED1Team attendance. SECONDARY OUTCOMES ED length-of-stay, 7-day subsequent hospital admission and mortality in discharged patients. RESULTS There were 5496 and 4876 eligible ED visits during the control and intervention periods, respectively. In the latter group, 556 (11.4%) received ED1Team assessment. After matching, there was an absolute 2.3% (p = 0.07) reduction in the admission rate between control and intervention periods. After matching the 556 ED1Team attended visits to control period visits, and to intervention period visits without the intervention, admission rates decreased by 10.0% (p = 0.006) and 13.5% (p < 0.001), respectively. For discharged patients, median ED length-of-stay decreased by 1.0 h (p < 0.001) between control and intervention periods and increased by 2.3 h (p < 0.001) compared to intervention period without the intervention. For patients discharged by the ED1Team, subsequent readmissions after 7 days were slightly higher, but mortality was not significantly different. CONCLUSION ED1Team consultation was associated with a decreased hospital admission rate in older ED patients. It was associated with a slightly longer ED length-of-stay and subsequent early hospitalizations. Given that even a small increase in freed hospital beds would release some of the pressure on an overextended healthcare system, these results suggest that upscaling of the intervention might procure systems-wide benefits.
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Affiliation(s)
- Ivy Cheng
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
- Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada.
| | | | - Natalie Coyle
- Royal Victoria Regional Health Centre, Barrie, ON, Canada
| | - Aikta Verma
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
| | - Kaif Pardhan
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
- McMaster Children's Hospital, Hamilton, ON, Canada
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Justin N Hall
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | | | - Will Thomas-Boaz
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Steven Shadowitz
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Clare Atzema
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
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Nummedal MA, King S, Uleberg O, Pedersen SA, Bjørnsen LP. Non-emergency department (ED) interventions to reduce ED utilization: a scoping review. BMC Emerg Med 2024; 24:117. [PMID: 38997631 PMCID: PMC11242019 DOI: 10.1186/s12873-024-01028-4] [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: 08/25/2023] [Accepted: 06/20/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND Emergency department (ED) crowding is a global burden. Interventions to reduce ED utilization have been widely discussed in the literature, but previous reviews have mainly focused on specific interventions or patient groups within the EDs. The purpose of this scoping review was to identify, summarize, and categorize the various types of non-ED-based interventions designed to reduce unnecessary visits to EDs. METHODS This scoping review followed the JBI Manual for Evidence Synthesis and the PRISMA-SCR checklist. A comprehensive structured literature search was performed in the databases MEDLINE and Embase from 2008 to March 2024. The inclusion criteria covered studies reporting on interventions outside the ED that aimed to reduce ED visits. Two reviewers independently screened the records and categorized the included articles by intervention type, location, and population. RESULTS Among the 15,324 screened records, we included 210 studies, comprising 183 intervention studies and 27 systematic reviews. In the primary studies, care coordination/case management or other care programs were the most commonly examined out of 15 different intervention categories. The majority of interventions took place in clinics or medical centers, in patients' homes, followed by hospitals and primary care settings - and targeted patients with specific medical conditions. CONCLUSION A large number of studies have been published investigating interventions to mitigate the influx of patients to EDs. Many of these targeted patients with specific medical conditions, frequent users and high-risk patients. Further research is needed to address other high prevalent groups in the ED - including older adults and mental health patients (who are ill but may not need the ED). There is also room for further research on new interventions to reduce ED utilization in low-acuity patients and in the general patient population.
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Affiliation(s)
- Målfrid A Nummedal
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
| | - Sarah King
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Oddvar Uleberg
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Emergency Medicine and Prehospital Care, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Sindre A Pedersen
- The Medicine and Health Library, Library Section for Research Support, Data and Analysis, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Lars Petter Bjørnsen
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Emergency Medicine and Prehospital Care, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
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Weijers J, Prins MLM, van Dam DGHA, van Nieuwkoop C, Alsma J, Haak HR, V Uffen JW, Kaasjager KAH, Kremers MNT, Nanayakkara PWB, Stassen PM, Groeneveld GH. Patients' Perspectives and Feasibility of Home Monitoring in Acute Care: The AcuteCare@Home Flash Mob Study. Telemed J E Health 2024. [PMID: 38938204 DOI: 10.1089/tmj.2024.0166] [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: 06/29/2024] Open
Abstract
Objective: To determine patients' perspectives on home monitoring at emergency department (ED) presentation and shortly after admission and compare these with their physicians' perspectives. Methods: Forty Dutch hospitals participated in this prospective flash mob study. Adult patients with acute medical conditions, treated by internal medicine specialties, presenting at the ED or admitted at the admission ward within the previous 24 h were included. The primary outcome was the proportion of patients who were able and willing to undergo home monitoring. Secondary outcomes included identifying barriers to home monitoring, patient's prerequisites, and assessing the agreement between the perspectives of patients and treating physicians. Results: On February 2, 2023, in total 665 patients [median age 69 (interquartile range: 55-78) years; 95.5% community dwelling; 29.3% Modified Early Warning Score ≥3; 29.5% clinical frailty score ≥5] were included. In total, 19.6% of ED patients were admitted and 26% of ward patients preferred home monitoring as continuation of care. Guaranteed readmission (87.8%), ability to contact the hospital 24/7 (77.3%), and a family caregiver at home (55.7%) were the most often reported prerequisites. Barriers for home monitoring were feeling too severely ill (78.8%) and inability to receive the required treatment at home (64.4%). The agreement between patients and physicians was fair (Cohens kappa coefficient 0.26). Conclusions: A substantial proportion of acutely ill patients stated that they were willing and able to be monitored at home. Guaranteed readmission, availability of a treatment team (24/7), and a home support system are needed for successful implementation of home monitoring in acute care.
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Affiliation(s)
- Jari Weijers
- Division of Acute Medicine, Department of Internal Medicine, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Manon L M Prins
- Division of Acute Medicine, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Davy G H A van Dam
- Division of Acute Medicine, Department of Internal Medicine, St Jans Gasthuis, Weert, The Netherlands
| | - Cees van Nieuwkoop
- Division of Acute Medicine, Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Jelmer Alsma
- Division of Acute Medicine, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Harm R Haak
- Division of Acute Medicine, Department of Internal Medicine, Máxima Medical Center, Veldhoven, The Netherlands
| | - Jan Willem V Uffen
- Division of Acute Medicine, Department of Internal Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Karin A H Kaasjager
- Division of Acute Medicine, Department of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marjolein N T Kremers
- Division of Acute Medicine, Department of Internal Medicine, Máxima Medical Center, Veldhoven, The Netherlands
| | - Prabath W B Nanayakkara
- Division of Acute Medicine, Department of Internal Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Patricia M Stassen
- Division of Acute Medicine, Department of Internal Medicine, School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Geert H Groeneveld
- Division of Acute Medicine, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
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Adebola O. Do we need a neurosurgical frailty index? Surg Neurol Int 2024; 15:134. [PMID: 38742014 PMCID: PMC11090588 DOI: 10.25259/sni_50_2024] [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: 01/20/2024] [Accepted: 03/06/2024] [Indexed: 05/16/2024] Open
Abstract
Background An increasing number of elderly patients now require neurosurgical intervention, and it is sometimes unclear if the benefits of surgery outweigh the risks, especially considering the confounding factor of numerous comorbidities and often poor functional states. Historically, many patients were denied surgery on the basis of age alone. This paper examines the current selection criteria being used to determine which patients get offered neurosurgical management and attempts to show if these patients have a good outcome. Particular focus is given to the increasing insight into the need to develop a neurosurgical frailty index. Methods Using a prospective cohort study, this study observed 324 consecutive patients (n) over a 3-month period who were ≥65 years of age at the time of referral or admission to the neurosurgical department of the Royal Hallamshire Hospital. It highlights the selection model used to determine if surgical intervention was in the patient's best interest and explores the reasons why some patients did not need to have surgery or were considered unsuitable for surgery. Strengths and weaknesses of different frailty indices and indicators of functional status currently in use are discussed, and how they differ between the patients who had surgery and those who did not. Results Sixty-one (18.83%) of n were operated on in the timeframe studied. Compared to patients not operated, they were younger, less frail, and more functionally independent. The 30-day mortality of patients who had surgery was 3.28%, and despite the stringent definition of poor outcomes, 65.57% of patients had good postoperative results overall, suggesting that the present selection model for surgery produces good outcomes. The independent variables that showed the greatest correlation with outcome were emergency surgery, the American Society of Anesthesiology grade, the Glasgow Coma Scale, and modified frailty index-5. Conclusion It would be ideal to carry out future studies of similar designs with a much larger sample size with the goal of improving existing selection criteria and possibly developing a neurosurgical frailty index.
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Affiliation(s)
- Oluwaseyi Adebola
- Department of Neurosurgery, The Walton Centre, Liverpool, United Kingdom
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Harrison SL, Lang C, Eshetie TC, Crotty M, Whitehead C, Evans K, Corlis M, Wesselingh S, Caughey GE, Inacio MC. Hospitalisations and emergency department presentations by older individuals accessing long-term aged care in Australia. AUST HEALTH REV 2024; 48:182-190. [PMID: 38537302 DOI: 10.1071/ah24019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 03/06/2024] [Indexed: 04/05/2024]
Abstract
Objective The study examined emergency department (ED) presentations, unplanned hospitalisations and potentially preventable hospitalisations in older people receiving long-term care by type of care received (i.e. permanent residential aged care or home care packages in the community), in Australia in 2019. Methods A retrospective cohort study was conducted using the Registry of Senior Australians National Historical Cohort. Individuals were included if they resided in South Australia, Queensland, Victoria or New South Wales, received a home care package or permanent residential aged care in 2019 and were aged ≥65 years. The cumulative incidence of ED presentations, unplanned hospitalisations and potentially preventable hospitalisations in each of the long-term care service types were estimated during the year. Days in hospital per 1000 individuals were also calculated. Results The study included 203,278 individuals accessing permanent residential aged care (209,639 episodes) and 118,999 accessing home care packages in the community (127,893 episodes). A higher proportion of people accessing home care packages had an ED presentation (43.1% [95% confidence interval, 42.8-43.3], vs 37.8% [37.6-38.0]), unplanned hospitalisation (39.8% [39.6-40.1] vs 33.4% [33.2-33.6]) and potentially preventable hospitalisation (11.8% [11.6-12.0] vs 8.2% [8.1-8.4]) than people accessing permanent residential aged care. Individuals with home care packages had more days in hospital due to unplanned hospitalisations than those in residential care (7745 vs 3049 days/1000 individuals). Conclusions While a high proportion of older people in long-term care have ED presentations, unplanned hospitalisations and potentially preventable hospitalisations, people in the community with home care packages experience these events at a higher frequency.
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Affiliation(s)
- Stephanie L Harrison
- Registry of Senior Australians, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia; and Allied Health and Human Performance, University of South Australia, Adelaide, SA, Australia
| | - Catherine Lang
- Registry of Senior Australians, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
| | - Tesfahun C Eshetie
- Registry of Senior Australians, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia; and Allied Health and Human Performance, University of South Australia, Adelaide, SA, Australia; and UniSA Clinical & Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Maria Crotty
- Southern Adelaide Local Health Network, SA Health, Adelaide, SA, Australia; and College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Craig Whitehead
- Southern Adelaide Local Health Network, SA Health, Adelaide, SA, Australia; and College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Keith Evans
- Registry of Senior Australians, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
| | - Megan Corlis
- Australian Nursing and Midwifery Federation SA Branch, Adelaide, SA, Australia
| | - Steve Wesselingh
- Registry of Senior Australians, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia; and National Health and Medical Research Council, ACT, Australia
| | - Gillian E Caughey
- Registry of Senior Australians, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia; and Allied Health and Human Performance, University of South Australia, Adelaide, SA, Australia
| | - Maria C Inacio
- Registry of Senior Australians, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia; and Allied Health and Human Performance, University of South Australia, Adelaide, SA, Australia
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Punchik B, Kolushev-Ivshin I, Kagan E, Lerner E, Velikiy N, Marciano S, Freud T, Golan R, Cohn-Schwartz E, Press Y. The outcomes of treatment for homebound adults with complex medical conditions in a hospital-at-home unit in the southern district of Israel. Isr J Health Policy Res 2024; 13:8. [PMID: 38355553 PMCID: PMC10865532 DOI: 10.1186/s13584-024-00595-y] [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: 07/26/2023] [Accepted: 02/08/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND A model of hospital-at-home services called the Home Care Unit ("the unit") has been implemented in the southern region of the Clalit Healthcare Services in Israel. The aim of the present study was to characterize this service model. METHODS A retrospective cross-over study. included homebound patients 65 years of age and above who were treated for at least one month in the framework of the unit, between 2013 and 2020. We compared the hospitalization rate, the number of hospital days, the number of emergency room visits, and the cost of hospitalization for the six-month period prior to admission to the unit, the period of treatment in the unit, and the six-month period following discharge from the unit. RESULTS The study included 623 patients with a mean age of 83.7 ± 9.2 years with a mean Mini-mental State Examination (MMSE) score of 12.0 ± 10.2, a mean Charlson Comorbidity Index (CCI) of 3.7 ± 2.2 and a Barthel Index score of 23.9 ± 25.1. The main indications for admission to the unit were various geriatric syndromes (56.7%), acute functional decline (21.2%), and heart failure (12%). 22.8% died during the treatment period and 63.4% were discharged to ongoing treatment by their family doctor after their condition stabilized. Compared to the six months prior to admission to the unit there was a significant decrease (per patient per month) in the treatment period in the number of days of hospitalization (2.84 ± 4.35 vs. 1.7 ± 3.8 days, p < 0.001) and in the cost of hospitalization (1606 ± 2170 vs. 1066 ± 2082 USD, p < 0.001). CONCLUSIONS Treatment of homebound adults with a high disease burden in the setting of a hospital-at-home unit can significantly reduce the number of hospital days and the cost of hospitalization. This model of service for homebound patients with multiple medical problems maintained a high level of care while reducing costs. The results support the widespread adoption of this service in the community to enable the healthcare system to respond to the growing population of elderly patients with medical complexity.
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Affiliation(s)
- Boris Punchik
- Geriatric Unit, The Haim Doron Division of Community Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, PO Box 653, 84105, Beer-Sheva, Israel.
- Home Care Unit, Clalit Health Services, South District, Beer-Sheva, Israel.
- Siaal Research Center for Family Medicine and Primary Care, The Haim Doron Division of Community Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
| | - Ilona Kolushev-Ivshin
- Siaal Research Center for Family Medicine and Primary Care, The Haim Doron Division of Community Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Department of Epidemiology, Biostatistics and Community Health Science, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ella Kagan
- Geriatric Unit, The Haim Doron Division of Community Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, PO Box 653, 84105, Beer-Sheva, Israel
- Home Care Unit, Clalit Health Services, South District, Beer-Sheva, Israel
| | - Ella Lerner
- Geriatric Unit, The Haim Doron Division of Community Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, PO Box 653, 84105, Beer-Sheva, Israel
- Home Care Unit, Clalit Health Services, South District, Beer-Sheva, Israel
| | - Natalia Velikiy
- Home Care Unit, Clalit Health Services, South District, Beer-Sheva, Israel
- Department of Geriatrics, Soroka Medical Center, Beer-Sheva, Israel
| | - Suzann Marciano
- Home Care Unit, Clalit Health Services, South District, Beer-Sheva, Israel
| | - Tamar Freud
- Siaal Research Center for Family Medicine and Primary Care, The Haim Doron Division of Community Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Rachel Golan
- Department of Epidemiology, Biostatistics and Community Health Science, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ella Cohn-Schwartz
- Department of Epidemiology, Biostatistics and Community Health Science, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Yan Press
- Geriatric Unit, The Haim Doron Division of Community Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, PO Box 653, 84105, Beer-Sheva, Israel
- Siaal Research Center for Family Medicine and Primary Care, The Haim Doron Division of Community Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Department of Geriatrics, Soroka Medical Center, Beer-Sheva, Israel
- Center for Multidisciplinary Research in Aging, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Elias TCN, Jacklin C, Bowen J, Lasserson DS, Pendlebury ST. Care pathways in older patients seen in a multidisciplinary same day emergency care (SDEC) unit. Age Ageing 2024; 53:afad257. [PMID: 38275098 PMCID: PMC10811520 DOI: 10.1093/ageing/afad257] [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: 05/01/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Same day emergency care (SDEC) services are being advocated in the UK for frail, older patients in whom hospitalisation may be associated with harm but there are few data on the 'ambulatory pathway'. We therefore determined the patient pathways pre- and post-first assessment in a SDEC unit focussed on older people. METHODS In consecutive patients, we prospectively recorded follow-up SDEC service reviews (face-to-face, telephone, Hospital-at-Home domiciliary visits), outpatient referrals (e.g. to specialist clinics, imaging, and community/voluntary/social services), and hospital admissions <30 days. In the first 67 patients, we also recorded healthcare interactions (except GP attendances) in the 180 days pre- and post-first assessment. RESULTS Among 533 patients (mean/SD age = 75.0/17.5 years, 246, 46% deemed frail) assessed in an SDEC unit, 210 were admitted within 30 days (152 immediately). In the 381(71%) remaining initially ambulatory, there were 587 SDEC follow-up reviews and 747 other outpatient referrals (mean = 3.5 per patient) with only 34 (9%) patients being discharged with no further follow-up. In the subset (n = 67), the number of 'healthcare days' was greater in the 180 days post- versus pre-SDEC assessment (mean/SD = 26/27 versus 13/22 days, P = 0.003) even after excluding hospital admission days, with greater healthcare days in frail versus non-frail patients. DISCUSSION AND CONCLUSION SDEC assessment in older, frail patients was associated with a 2-fold increase in frequency of healthcare interactions with complex care pathways involving multiple services. Our findings have implications for the development of admission-avoidance models including cost-effectiveness and optimal delivery of the multi-dimensional aspects of acute geriatric care in the ambulatory setting.
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Affiliation(s)
- Tania C N Elias
- Departments of Acute Internal Medicine and Older Persons' Services, Great Western Hospital NHS Foundation Trust, Swindon SN3 6BB, UK
| | - Chloe Jacklin
- Departments of Care of the Elderly and Stroke Medicine, North Middlesex University Hospital NHS Trust, Sterling Way, London N18 1QX, UK
| | - Jordan Bowen
- Department of Acute Internal Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Daniel S Lasserson
- Department of Acute Internal Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK
- NIHR Applied Research Collaboration (ARC) West Midlands, Warwick Medical School, University of Warwick, Coventry, Warwickshire CV4 3AL, UK
- Department of Acute Medicine, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham B18 7QH, UK
| | - Sarah T Pendlebury
- Department of Acute Internal Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK
- Nuffield Department of Clinical Neurosciences, Wolfson Centre for Prevention of Stroke and Dementia, John Radcliffe Hospital, and the University of Oxford, Oxford, UK
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Knight T, Kamwa V, Atkin C, Green C, Ragunathan J, Lasserson D, Sapey E. Acute care models for older people living with frailty: a systematic review and taxonomy. BMC Geriatr 2023; 23:809. [PMID: 38053044 PMCID: PMC10699071 DOI: 10.1186/s12877-023-04373-4] [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: 12/11/2022] [Accepted: 10/03/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND The need to improve the acute care pathway to meet the care needs of older people living with frailty is a strategic priority for many healthcare systems. The optimal care model for this patient group is unclear. METHODS A systematic review was conducted to derive a taxonomy of acute care models for older people with acute medical illness and describe the outcomes used to assess their effectiveness. Care models providing time-limited episodes of care (up to 14 days) within 48 h of presentation to patients over the age of 65 with acute medical illness were included. Care models based in hospital and community settings were eligible. Searches were undertaken in Medline, Embase, CINAHL and Cochrane databases. Interventions were described and classified in detail using a modified version of the TIDIeR checklist for complex interventions. Outcomes were described and classified using the Core Outcome Measures in Effectiveness Trials (COMET) taxonomy. Risk of bias was assessed using RoB2 and ROBINS-I. RESULTS The inclusion criteria were met by 103 articles. Four classes of acute care model were identified, acute-bed based care, hospital at home, emergency department in-reach and care home models. The field is dominated by small single centre randomised and non-randomised studies. Most studies were judged to be at risk of bias. A range of outcome measures were reported with little consistency between studies. Evidence of effectiveness was limited. CONCLUSION Acute care models for older people living with frailty are heterogenous. The clinical effectiveness of these models cannot be conclusively established from the available evidence. TRIAL REGISTRATION PROSPERO registration (CRD42021279131).
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Affiliation(s)
- Thomas Knight
- Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK.
| | - Vicky Kamwa
- Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
| | - Catherine Atkin
- Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
| | - Catherine Green
- Department of Geriatric Medicine, Whiston Hospital, Mersey and West Lancashire Teaching Hospital NHS Trust, Prescot, L35 5DR, UK
| | - Janahan Ragunathan
- Department of Geriatric Medicine, Royal Bolton NHS Foundation Trust, Bolton, BL4 0JR, UK
| | - Daniel Lasserson
- Warwick Medical School, Professor of Acute and Ambulatory Care, University of Warwick, Coventry, CV4 7AL, UK
| | - Elizabeth Sapey
- Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
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9
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Chambers D, Cantrell A, Preston L, Marincowitz C, Wright L, Conroy S, Lee Gordon A. Reducing unplanned hospital admissions from care homes: a systematic review. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-130. [PMID: 37916580 DOI: 10.3310/klpw6338] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
Background Care homes predominantly care for older people with complex health and care needs, who are at high risk of unplanned hospital admissions. While often necessary, such admissions can be distressing and provide an opportunity cost as well as a financial cost. Objectives Our objective was to update a 2014 evidence review of interventions to reduce unplanned admissions of care home residents. We carried out a systematic review of interventions used in the UK and other high-income countries by synthesising evidence of effects of these interventions on hospital admissions; feasibility and acceptability; costs and value for money; and factors affecting applicability of international evidence to UK settings. Data sources We searched the following databases in December 2021 for studies published since 2014: Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews; Cumulative Index to Nursing and Allied Health Literature; Health Management Information Consortium; Medline; PsycINFO; Science and Social Sciences Citation Indexes; Social Care Online; and Social Service Abstracts. 'Grey' literature (January 2022) and citations were searched and reference lists were checked. Methods We included studies of any design reporting interventions delivered in care homes (with or without nursing) or hospitals to reduce unplanned hospital admissions. A taxonomy of interventions was developed from an initial scoping search. Outcomes of interest included measures of effect on unplanned admissions among care home residents; barriers/facilitators to implementation in a UK setting and acceptability to care home residents, their families and staff. Study selection, data extraction and risk of bias assessment were performed by two independent reviewers. We used published frameworks to extract data on intervention characteristics, implementation barriers/facilitators and applicability of international evidence. We performed a narrative synthesis grouped by intervention type and setting. Overall strength of evidence for admission reduction was assessed using a framework based on study design, study numbers and direction of effect. Results We included 124 publications/reports (30 from the UK). Integrated care and quality improvement programmes providing additional support to care homes (e.g. the English Care Homes Vanguard initiatives and hospital-based services in Australia) appeared to reduce unplanned admissions relative to usual care. Simpler training and staff development initiatives showed mixed results, as did interventions aimed at tackling specific problems (e.g. medication review). Advance care planning was key to the success of most quality improvement programmes but do-not-hospitalise orders were problematic. Qualitative research identified tensions affecting decision-making involving paramedics, care home staff and residents/family carers. The best way to reduce end-of-life admissions through access to palliative care was unclear in the face of inconsistent and generally low-quality evidence. Conclusions Effective implementation of interventions at various stages of residents' care pathways may reduce unplanned admissions. Most interventions are complex and require adaptation to local contexts. Work at the interface between health and social care is key to successful implementation. Limitations Much of the evidence identified was of low quality because of factors such as uncontrolled study designs and small sample size. Meta-analysis was not possible. Future work We identified a need for improved economic evidence and the evaluation of integrated care models of the type delivered by hospital-based teams. Researchers should carefully consider what is realistic in terms of study design and data collection given the current context of extreme pressure on care homes. Study registration This study is registered as PROSPERO database CRD42021289418. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (award number NIHR133884) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 18. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Duncan Chambers
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anna Cantrell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Louise Preston
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Carl Marincowitz
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Simon Conroy
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | - Adam Lee Gordon
- Academic Unit of Injury, Recovery and Inflammation Sciences (IRIS), School of Medicine, University of Nottingham, Nottingham, UK
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Needham C, Wheaton N, Wong Shee A, McNamara K, Malakellis M, Murray M, Alston L, Peeters A, Ugalde A, Huggins C, Yoong S, Allender S. Enhancing healthcare at home for older people in rural and regional Australia: A protocol for co-creation to design and implement system change. PLoS One 2023; 18:e0290386. [PMID: 37682945 PMCID: PMC10490867 DOI: 10.1371/journal.pone.0290386] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 08/07/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND World-wide, health service providers are moving towards innovative models of clinical home-based care services as a key strategy to improve equity of access and quality of care. To optimise existing and new clinical home-based care programs, evidence informed approaches are needed that consider the complexity of the health care system across different contexts. METHODS We present a protocol for working with health services and their partners to perform rapid identification, prioritisation, and co-design of content-appropriate strategies to optimise the delivery of healthcare at home for older people in rural and regional areas. The protocol combines Systems Thinking and Implementation Science using a Consensus Mapping and Co-design (CMC) process delivered over five workshops. DISCUSSION The protocol will be implemented with rural and regional healthcare providers to identify digital and non-digital solutions that have the potential to inform models of service delivery, improve patient experience, and optimise health outcomes. The combination of system and implementation science is a unique approach for optimising healthcare at home for older populations, especially in the rural context where need is high. This is the first protocol to integrate the use of systems and implementation science into one process and articulating these methods will help with replicating this in future practice. Results of the design phase will translate into practice through standard health service planning methods to enhance implementation and sustainability. The delivery of the protocol will include building capacity of health service workers to embed the design, implementation, and evaluation approach into normal practice. This protocol forms part of the DELIVER (Delivering Enhanced heaLthcare at home through optImising Virtual tools for oldEr people in Rural and regional Australia) Project. Funded by Australia's Medical Research Future Fund, DELIVER involves a collaboration with public health services of Western Victoria, Australia.
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Affiliation(s)
- Cindy Needham
- Institute for Health Transformation, Global Centre for Preventative Health and Nutrition, School of Health and Social Development Faculty of Health, Deakin University, Geelong, Australia
| | - Nikita Wheaton
- Institute for Health Transformation, Global Centre for Preventative Health and Nutrition, School of Health and Social Development Faculty of Health, Deakin University, Geelong, Australia
| | - Anna Wong Shee
- Deakin Rural Health, School of Medicine, Faculty of Health, Deakin University, Geelong, Australia
- Community and Aged Care, Grampians Health, Ballarat, Victoria, Australia
| | - Kevin McNamara
- Deakin Rural Health, School of Medicine, Faculty of Health, Deakin University, Geelong, Australia
| | - Mary Malakellis
- Deakin Rural Health, School of Medicine, Faculty of Health, Deakin University, Geelong, Australia
| | - Margaret Murray
- Deakin Rural Health, School of Medicine, Faculty of Health, Deakin University, Geelong, Australia
| | - Laura Alston
- Deakin Rural Health, School of Medicine, Faculty of Health, Deakin University, Geelong, Australia
- Research Unit, Colac Area Health, Colac, Victoria, Australia
| | - Anna Peeters
- Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, Australia
| | - Anna Ugalde
- Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, Australia
| | - Catherine Huggins
- Institute for Health Transformation, Global Centre for Preventative Health and Nutrition, School of Health and Social Development Faculty of Health, Deakin University, Geelong, Australia
| | - Serene Yoong
- Institute for Health Transformation, Global Centre for Preventative Health and Nutrition, School of Health and Social Development Faculty of Health, Deakin University, Geelong, Australia
| | - Steven Allender
- Institute for Health Transformation, Global Centre for Preventative Health and Nutrition, School of Health and Social Development Faculty of Health, Deakin University, Geelong, Australia
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11
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Greene L, Lane R, Crotty M, Whitehead C, Potter E, Bierer P, Laver K. Evaluating a new emergency department avoidance service for older people: patient and relative experiences. Emerg Med J 2023; 40:641-645. [PMID: 37400224 PMCID: PMC10447360 DOI: 10.1136/emermed-2022-212949] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 06/21/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND High emergency department (ED) usage by older individuals for non-emergencies is a global concern. ED avoidance initiatives have proven effective in addressing this issue. To specifically cater to individuals aged 65 and above, the Southern Adelaide Local Health Network introduced an innovative ED avoidance service. This study assessed the acceptability of the service among its users. METHOD The Complex And RestorativE (CARE) Centre is a six-bed unit staffed by a multidisciplinary geriatric team. Patients are transported directly to CARE after calling for an ambulance and being triaged by a paramedic. The evaluation took place between September 2021 and September 2022. Semi-structured interviews were conducted with patients and relatives who had accessed the service. Data analysis was performed using a six-step thematic analysis. RESULTS Seventeen patients and 15 relatives were interviewed, who described the experience of 32 attendances to the urgent CARE centre between them. Patients accessed the service for several reasons but over half were associated with falls. There was a hesitation to call emergency services for several reasons, the primary being long wait times in ED and/or the prospect of an overnight stay in hospital. Some individuals attempted to contact their General Practitioner (GP) for the presenting problem but were unable to get a timely appointment. Most participants had previously attended a local ED and had a negative experience. All individuals reported favouring the CARE centre over the traditional ED for numerous reasons including a quieter and safer environment and specially trained geriatric staff who were less rushed than ED staff. Several participants would have appreciated a standardised follow-up process after discharge. CONCLUSION Our findings suggest that ED admission avoidance programmes may be an acceptable alternative treatment for older people requiring urgent care, potentially benefiting both public health systems and user experience.
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Affiliation(s)
- Leanne Greene
- Rehabilitation, Aged and Extended Care, Flinders University, Adelaide, South Australia, Australia
| | - Rachel Lane
- Rehabilitation, Aged and Extended Care, Flinders University, Adelaide, South Australia, Australia
| | - Maria Crotty
- Rehabilitation, Aged and Extended Care, Flinders University, Adelaide, South Australia, Australia
| | - Craig Whitehead
- Rehabilitation, Aged and Extended Care, Flinders University, Adelaide, South Australia, Australia
| | - Elizabeth Potter
- Rehabilitation, Aged and Extended Care, Flinders University, Adelaide, South Australia, Australia
| | - Petra Bierer
- Rehabilitation, Aged and Extended Care, Southern Adelaide Local Health Network, Bedford Park, South Australia, Australia
| | - Kate Laver
- Rehabilitation, Aged and Extended Care, Flinders University, Adelaide, South Australia, Australia
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12
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Kakad M, Utley M, Dahl FA. Using stochastic simulation modelling to study occupancy levels of decentralised admission avoidance units in Norway. Health Syst (Basingstoke) 2023; 12:317-331. [PMID: 37860598 PMCID: PMC10583632 DOI: 10.1080/20476965.2023.2174453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 01/26/2023] [Indexed: 02/17/2023] Open
Abstract
Identifying alternatives to acute hospital admission is a priority for many countries. Over 200 decentralised municipal acute units (MAUs) were established in Norway to divert low-acuity patients away from hospitals. MAUs have faced criticism for low mean occupancy and not relieving pressures on hospitals. We developed a discrete time simulation model of admissions and discharges to MAUs to test scenarios for increasing absolute mean occupancy. We also used the model to estimate the number of patients turned away as historical data was unavailable. Our experiments suggest that mergers alone are unlikely to substantially increase MAU absolute mean occupancy as unmet demand is generally low. However, merging MAUs offers scope for up to 20% reduction in bed capacity, without affecting service provision. Our work has relevance for other admissions avoidance units and provides a method for estimating unconstrained demand for beds in the absence of historical data.
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Affiliation(s)
- Meetali Kakad
- Health Services Research Unit, Akershus University Hospital Trust, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Martin Utley
- Clinical Operational Research Unit, Department of Mathematics, University College London, London, UK
| | - Fredrik A. Dahl
- Health Services Research Unit, Akershus University Hospital Trust, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Image Analysis and Earth Observation, Norwegian Computing Centre, Oslo, Norway
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13
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Kontunen PJ, Holstein RM, Torkki PM, Lang ES, Castrén MK. Acute outreach service to nursing homes: A systematic review with GRADE and triple aim approach. Scand J Caring Sci 2023; 37:582-594. [PMID: 36718539 DOI: 10.1111/scs.13148] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/23/2022] [Accepted: 01/05/2023] [Indexed: 02/01/2023]
Abstract
BACKGROUND People living in nursing homes face the risk of visiting the emergency department (ED). Outreach services are developing to prevent unnecessary transfers to ED. AIMS We aim to assess the performance of acute care services provided to people living in nursing homes or long-term homecare, focusing on ED transfer prevention, safety, cost-effectiveness and experiences. MATERIALS & METHODS This review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Studies were eligible for inclusion if they were peer-reviewed and examined acute outreach services dedicated to delivering care to people in nursing homes or long-term homecare. The service models could also have preventive components. The databases searched were Scopus and CINAHL. In addition, Robins-I and SIGN checklists were used. The primary outcomes of prevented ED transfers or hospitalisations and the composite outcome of adverse events (mortality/Emergency Medical Service or ED visit after outreach service contact related to the same clinical condition) were graded with GRADE. RESULTS Fifteen relevant original studies were found-all were observational and focused on nursing homes. The certainty of evidence for acute outreach services with preventive components to prevent ED transfers or hospitalisations was low. Stakeholders were satisfied with these services. The certainty of evidence for solely acute outreach services to prevent ED transfers or hospitalisations was very low and inconclusive. Reporting of adverse events was inconsistent, certainty of evidence for adverse events was low. CONCLUSION Published data might support adopting acute outreach services with preventive components for people living in nursing homes to reduce ED transfers, hospitalisations and possibly costs. If an outreach service is started, it is recommended that a cluster-randomised or quasi-experimental research design be incorporated to assess the effectiveness and safety of the service. More evidence is also needed on cost-effectiveness and stakeholders' satisfaction. Systematic review registration number: PROSPERO CRD42020211048, date of registration: 25.09.2020.
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Affiliation(s)
- Perttu J Kontunen
- Department of Emergency Medicine and Services, Helsinki University and Helsinki University Hospital, Helsinki, Finland.,Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Ria M Holstein
- Department of Emergency Medicine and Services, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - Paulus M Torkki
- Department of Public Health, University of Helsinki, Helsinki, Finland.,Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
| | - Eddy S Lang
- Department of Emergency Medicine, Cumming School of Medicin, University of Calgary, Calgary, Canada.,Alberta Health Service, Edmonton, Canada
| | - Maaret K Castrén
- Department of Emergency Medicine and Services, Helsinki University and Helsinki University Hospital, Helsinki, Finland
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14
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Barreira LF, Paiva A, Araújo B, Campos MJ. Challenges to Systems of Long-Term Care: Mapping of the Central Concepts from an Umbrella Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1698. [PMID: 36767064 PMCID: PMC9914432 DOI: 10.3390/ijerph20031698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 01/12/2023] [Accepted: 01/16/2023] [Indexed: 06/18/2023]
Abstract
The ageing of the population poses urgent challenges to the health and social protection sectors, including the need for greater adequacy and integration of health care services provided to older people. It is considered necessary and urgent to understand the state-of-the-art of community-based models of care for older people in institutional care and at home. This study aims to map the concepts that politicians and providers need to address through an umbrella review as a review method. Articles describing the structuring aspects of care models appropriate to the needs in long-term care and systematic reviews or meta-analyses targeting people aged 65 years or more were considered. A total of 350 studies met the inclusion criteria and were included in the review. The results identified the need to contribute to effective and more efficient integration and articulation of all the stakeholders, based essentially on professional care at the patient's homes, focused on their needs using the available technologies, empowering patients and families. Eight categories emerged that addressed factors and variables involved in care models for the long-term care needs of institutionalised and home-based older people as a guarantee of accessibility to healthcare and to enhance the well-being and quality of life of patients and family caregivers.
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Affiliation(s)
- Luís Filipe Barreira
- Center for Interdisciplinary Research in Health, Instituto Ciências da Saúde, Universidade Católica Portuguesa, Rua de Diogo Botelho 1327, 4169-005 Porto, Portugal
- Instituto de Ciências da Saúde do Porto, Universidade Católica Portuguesa, R. de Diogo Botelho 1327, 4169-005 Porto, Portugal
| | - Abel Paiva
- Porto School of Nursing, Escola Superior de Enfermagem do Porto, 4200-072 Porto, Portugal
| | - Beatriz Araújo
- Center for Interdisciplinary Research in Health, Instituto Ciências da Saúde, Universidade Católica Portuguesa, Rua de Diogo Botelho 1327, 4169-005 Porto, Portugal
- Instituto de Ciências da Saúde do Porto, Universidade Católica Portuguesa, R. de Diogo Botelho 1327, 4169-005 Porto, Portugal
| | - Maria Joana Campos
- Porto School of Nursing, Escola Superior de Enfermagem do Porto, 4200-072 Porto, Portugal
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15
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Norman G, Bennett P, Vardy ERLC. Virtual wards: a rapid evidence synthesis and implications for the care of older people. Age Ageing 2023; 52:afac319. [PMID: 36633298 PMCID: PMC9835137 DOI: 10.1093/ageing/afac319] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 11/11/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Virtual wards are being rapidly developed within the National Health Service in the UK, and frailty is one of the first clinical pathways. Virtual wards for older people and existing hospital at home services are closely related. METHODS In March 2022, we searched Medline, CINAHL, the Cochrane Database of Systematic Reviews and medRxiv for evidence syntheses which addressed clinical-effectiveness, cost-effectiveness, barriers and facilitators, or staff, patient or carer experience for virtual wards, hospital at home or remote monitoring alternatives to inpatient care. RESULTS We included 28 evidence syntheses mostly relating to hospital at home. There is low to moderate certainty evidence that clinical outcomes including mortality (example pooled RR 0.77, 95% CI 0.60-0.99) were probably equivalent or better for hospital at home. Subsequent residential care admissions are probably reduced (example pooled RR 0.35, 95% CI 0.22-0.57). Cost-effectiveness evidence demonstrated methodological issues which mean the results are uncertain. Evidence is lacking on cost implications for patients and carers. Barriers and facilitators operate at multiple levels (organisational, clinical and patient). Patient satisfaction may be improved by hospital at home relative to inpatient care. Evidence for carer experience is limited. CONCLUSIONS There is substantial evidence for the clinical effectiveness of hospital at home but less evidence for virtual wards. Guidance for virtual wards is lacking on key aspects including team characteristics, outcome selection and data protection. We recommend that research and evaluation is integrated into development of virtual ward models. The issue of carer strain is particularly relevant.
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Affiliation(s)
- Gill Norman
- Division of Nursing, Midwifery & Social Work; School of Health Sciences; Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
- NIHR Applied Research Collaboration Greater Manchester, University of Manchester, Oxford Road, Manchester, UK
| | - Paula Bennett
- Health Innovation Manchester, City Labs, Nelson Street, Manchester, UK
| | - Emma R L C Vardy
- Salford Care Organisation, Northern Care Alliance NHS Foundation Trust, Stott Lane, Salford, UK
- Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Oxford Road, Manchester, UK
- NIHR Applied Research Collaboration Greater Manchester, University of Manchester, Oxford Road, Manchester, UK
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16
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Belmin J, Villani P, Gay M, Fabries S, Havreng-Théry C, Malvoisin S, Denis F, Veyron JH. Real-world implementation of an eHealth system based on an artificial intelligence designed to predict and reduce emergency department visits by older adults: pragmatic trial. J Med Internet Res 2022; 24:e40387. [PMID: 35921685 PMCID: PMC9501682 DOI: 10.2196/40387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 07/28/2022] [Accepted: 07/30/2022] [Indexed: 11/25/2022] Open
Abstract
Background Frail older people use emergency services extensively, and digital systems that monitor health remotely could be useful in reducing these visits by earlier detection of worsening health conditions. Objective We aimed to implement a system that produces alerts when the machine learning algorithm identifies a short-term risk for an emergency department (ED) visit and examine health interventions delivered after these alerts and users’ experience. This study highlights the feasibility of the general system and its performance in reducing ED visits. It also evaluates the accuracy of alerts’ prediction. Methods An uncontrolled multicenter trial was conducted in community-dwelling older adults receiving assistance from home aides (HAs). We implemented an eHealth system that produces an alert for a high risk of ED visits. After each home visit, the HAs completed a questionnaire on participants’ functional status, using a smartphone app, and the information was processed in real time by a previously developed machine learning algorithm that identifies patients at risk of an ED visit within 14 days. In case of risk, the eHealth system alerted a coordinating nurse who could then inform the family carer and the patient’s nurses or general practitioner. The primary outcomes were the rate of ED visits and the number of deaths after alert-triggered health interventions (ATHIs) and users’ experience with the eHealth system; the secondary outcome was the accuracy of the eHealth system in predicting ED visits. Results We included 206 patients (mean age 85, SD 8 years; 161/206, 78% women) who received aid from 109 HAs, and the mean follow-up period was 10 months. The HAs monitored 2656 visits, which resulted in 405 alerts. Two ED visits were recorded following 131 alerts with an ATHI (2/131, 1.5%), whereas 36 ED visits were recorded following 274 alerts that did not result in an ATHI (36/274, 13.4%), corresponding to an odds ratio of 0.10 (95% IC 0.02-0.43; P<.001). Five patients died during the study. All had alerts, 4 did not have an ATHI and were hospitalized, and 1 had an ATHI (P=.04). In terms of overall usability, the digital system was easy to use for 90% (98/109) of HAs, and response time was acceptable for 89% (98/109) of them. Conclusions The eHealth system has been successfully implemented, was appreciated by users, and produced relevant alerts. ATHIs were associated with a lower rate of ED visits, suggesting that the eHealth system might be effective in lowering the number of ED visits in this population. Trial Registration clinicaltrials.gov NCT05221697; https://clinicaltrials.gov/ct2/show/NCT05221697.
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Affiliation(s)
- Joël Belmin
- Hôpital Charles Foix, Assistance Publique-Hôpitaux de Paris, Ivry-sur-Seine, FR.,Laboratoire Informatique Médicale et Ingénierie des Connaissances en eSanté (UMRS 1142), Institut National de la Santé et de la Recherche Médicale and Sorbonne Université, Paris, France, Paris, FR
| | - Patrick Villani
- Unité de médecine interne, gériatrie et thérapeutique, Assistance Publique-Hôpitaux de Marseille, Marseille, FR.,Université Aix-Marseille, Centre National de la Recherche Scientifique, Etablissement Français du Sang, Anthropologie bio-culturelle, Droit, Ethique et Santé, Marseille, FR
| | - Mathias Gay
- Communauté professionnelle de santé Itinéraire Santé, Marseille, FR
| | - Stéphane Fabries
- Intervenants Libéraux et Hospitaliers Unis pour le Patient, Marseille, FR
| | - Charlotte Havreng-Théry
- Laboratoire Informatique Médicale et Ingénierie des Connaissances en eSanté (UMRS 1142), Institut National de la Santé et de la Recherche Médicale and Sorbonne Université, Paris, France, Paris, FR.,PRESAGE, 72 boulevard de Sébastopol, Paris, FR
| | | | - Fabrice Denis
- Institut Inter-Régional de Cancérologie Jean Bernard, Le Mans, FR
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van der Kluit MJ, Dijkstra GJ. Outcomes as experienced by older patients after hospitalisation: satisfaction, acceptance, frustration and hope-a grounded theory study. Age Ageing 2022; 51:6649129. [PMID: 35871418 PMCID: PMC9308987 DOI: 10.1093/ageing/afac166] [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: 12/15/2021] [Indexed: 11/18/2022] Open
Abstract
Background outcomes of hospitalisation are often described in quantitative terms. It is unknown how older frail patients describe their own outcomes. Objective to discover how older frail persons describe their own hospitalisation outcomes and the meaning of these outcomes for their daily lives. Design Constructivist Grounded Theory approach. Participants frail older people discharged from hospital. Methods Open interviews in the participant’s home. Transcripts were coded inductively according to the Constructivist Grounded Theory approach. Results Twenty-four interviews were conducted involving 20 unique participants. Although for some participants hospitalisation was just a ripple, for others, it was a turning point. It could have positive or negative impacts on outcomes, including remaining alive, disease, fatigue/condition, complaints, daily functioning, social activities and intimate relationships, hobbies, living situation and mental well-being. Few participants were completely satisfied, but for many, a discrepancy between expectation and reality existed. Some participants could accept this, others remained hopeful and some were frustrated. Factors associated with these categories were research and treatment options, (un)clarity about the situation, setting the bar too high or pushing boundaries, confidence in physicians, character traits and social factors. Conclusions of the persons whose outcomes did not meet their expectations, some were frustrated, others hopeful and others accepted the situation. The following interventions can help patients to accept: clear communication about options and expectations before, during and after hospitalisation; giving room for emotions; help finding social support, encouragement to engage in pleasant activities and find meaning in small things. For some patients, psychological treatment may be needed.
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Affiliation(s)
- Maria Johanna van der Kluit
- University of Groningen, University Medical Center Groningen, University Center for Geriatric Medicine, Hanzeplein 1, 9700 RB Groningen, The Netherlands
| | - Geke J Dijkstra
- University of Groningen, University Medical Center Groningen, Department of Health Sciences, Applied Health Research, Groningen, The Netherlands.,NHL Stenden University of Applied Sciences, Research Group Living, Wellbeing and Care for Older People, Leeuwarden, The Netherlands
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18
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Knight T, Lasserson D. Hospital at home for acute medical illness: The 21st century acute medical unit for a changing population. J Intern Med 2022; 291:438-457. [PMID: 34816527 DOI: 10.1111/joim.13394] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Recent trends across Europe show a year-on-year increase in the number of patients with acute medical illnesses presenting to hospitals, yet there are no plans for a substantial expansion in acute hospital infrastructure or staffing to address demand. Strategies to meet increasing demand need to consider the fact that there is limited capacity in acute hospitals and focus on new care models in both hospital and community settings. Increasing the efficiency of acute hospital provision by reducing the length of stay entails supporting acute ambulatory care, where patients receive daily acute care interventions but do not stay overnight in the hospitals. This approach may entail daily transfer between home and an acute setting for ongoing treatment, which is unsuitable for some patients living with frailty. Acute hospital at home (HaH) is a care model which, thanks to advances in point of care diagnostic capability, can provide a credible model of acute medical assessment and treatment without the need for hospital transfer. Investment and training to support scaling up of HaH are key strategic aims for integrated healthcare systems.
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Affiliation(s)
- Thomas Knight
- Department of Acute Medicine, Sandwell and West Birmingham Hospitals NHS Foundation Trust, Birmingham, UK
| | - Daniel Lasserson
- Acute Hospital at Home, Department of Geratology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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Ford J, Knight J, Brittain J, Bentley C, Sowden S, Castro A, Doran T, Cookson R. Reducing inequality in avoidable emergency admissions: Case studies of local health care systems in England using a realist approach. J Health Serv Res Policy 2021; 27:31-40. [PMID: 34289742 DOI: 10.1177/13558196211021618] [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: 11/16/2022]
Abstract
OBJECTIVE People in disadvantaged areas are more likely to have an avoidable emergency hospital admission. Socio-economic inequality in avoidable emergency hospital admissions is monitored in England. Our aim was to inform local health care purchasing and planning by identifying recent health care system changes (or other factors), as reported by local health system leaders, that might explain narrowing or widening trends. METHODS Case studies were undertaken in one pilot and at five geographically distinct local health care systems (Clinical Commissioning Groups, CCGs), identified as having consistently increasing or decreasing inequality. Local settings were explored through discussions with CCG officials and stakeholders to identify potential local determinants. Data were analysed using a realist evaluation approach to generate context-mechanism-outcome (CMO) configurations. RESULTS Of the five geographically distinct CCGs, two had narrowing inequality, two widening, and one narrowing inequality, which widened during the project. None of the CCGs had designed a large-scale package of service changes with the explicit aim of reducing socio-economic inequality in avoidable emergency admissions, and local decision makers were unfamiliar with their own trends. Potential primary and community care determinants included: workforce, case finding and exclusion, proactive care co-ordination for patients with complex needs, and access and quality. Potential commissioning determinants included: data use and incentives, and targeting of services. Other potential determinants included changes in care home services, national A&E targets, and wider issues - such as public services financial constraints, residential gentrification, and health care expectations. CONCLUSIONS We did not find any bespoke initiatives that explained the inequality trends. The trends were more likely due to an interplay of multiple health care and wider system factors. Local decision makers need greater awareness, understanding and support to interpret, use and act upon inequality indicators. They are unlikely to find simple, cheap interventions to reduce inequalities in avoidable emergency admissions. Rather, long-term multifaceted interventions are required that embed inequality considerations into mainstream decision making.
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Affiliation(s)
- John Ford
- Clinical Lecturer, Department of Public Health and Primary Care, University of Cambridge
| | - Julia Knight
- Public Health Registrar, Leicestershire County Council, UK
| | - John Brittain
- Principal Operational Researcher, NHS England and NHS Improvement, UK
| | | | - Sarah Sowden
- Clinical Lecturer and Honorary Public Health Consultant, Population Health Sciences Institute, University of Newcastle, UK
| | - Ana Castro
- Research Fellow, Health Sciences, University of York, UK
| | - Tim Doran
- Professor, Health Sciences, University of York, UK
| | - Richard Cookson
- Professor, Centre for Health Economics, University of York, UK
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Elias TCN, Bowen J, Hassanzadeh R, Lasserson DS, Pendlebury ST. Factors associated with admission to bed-based care: observational prospective cohort study in a multidisciplinary same day emergency care unit (SDEC). BMC Geriatr 2021; 21:8. [PMID: 33407210 PMCID: PMC7788859 DOI: 10.1186/s12877-020-01942-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 12/01/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The development of ambulatory emergency care services, now called 'Same Day Emergency Care' (SDEC) has been advocated to provide sustainable high quality healthcare in an ageing population. However, there are few data on SDEC and the factors associated with successful ambulatory care in frail older people. We therefore undertook a prospective observational study to determine i) the clinical characteristics and frailty burden of a cohort in an SDEC designed around the needs of older patients and ii) the factors associated with hospital admission within 30-days after initial assessment. METHODS The study setting was the multidisciplinary Abingdon Emergency Medical Unit (EMU) located in a community hospital and led by a senior interface physician (geriatrician or general practitioner). Consecutive patients from August-December 2015 were assessed using a structured paper proforma including cognitive/delirium screen, comorbidities, functional, social, and nutritional status. Physiologic parameters were recorded. Illness severity was quantified using the Systemic Inflammatory Response Syndrome (SIRS> 1). Factors associated with hospitalization within 30-days were determined using multivariable logistic regression. RESULTS Among 533 patients (median (IQR) age = 81 (68-87), 315 (59%) female), 453 (86%) were living at home but 283 (54%) required some form of care and 299 (56%) had Barthel< 20. Falls, urinary incontinence and dementia affected 81/189 (43%), 50 (26%) and 40 (21%) of those aged > 85 years." Severe illness was present in 148 (28%) with broadly similar rates across age groups. Overall, 210 (39%) patients had a hospital admission within 30-days with higher rates in older patients: 96 (87%) of < 65 years remained on an ambulatory pathway versus only 91 (48%) of ≥ 85 years (p < 0.0001). Factors independently associated with hospital admission were severe illness (SIRS/point, OR = 1.46,95% CI = 1.15-1.87, p = 0.002) and markers of frailty: delirium (OR = 11.28,3.07-41.44, p < 0.0001), increased care needs (OR = 3.08,1.55-6.12, p = 0.001), transport requirement (OR = 1.92,1.13-3.27), and poor nutrition (OR = 1.13-3.79, p = 0.02). CONCLUSIONS Even in an SDEC with a multidisciplinary approach, rates of hospital admission in those with severe illness and frailty were high. Further studies are required to understand the key components of hospital bed-based care that need to be replicated by models delivering acute frailty care closer to home, and the feasibility, cost-effectiveness and patient/carer acceptability of such models.
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Affiliation(s)
- Tania C N Elias
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, and the University of Oxford, Wolfson Building, Oxford, OX3 9DU, England.,Departments of Acute Internal Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, England
| | - Jordan Bowen
- Departments of Acute Internal Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, England
| | - Royah Hassanzadeh
- Departments of Acute Internal Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, England
| | - Daniel S Lasserson
- PIONEER Health Data Research Hub, Institute for Applied Health Research, University of Birmingham, Birmingham, B15 2TT, England.,Department of Acute Medicine, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, B18 7QH, England
| | - Sarah T Pendlebury
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, and the University of Oxford, Wolfson Building, Oxford, OX3 9DU, England. .,Departments of Acute Internal Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, England. .,NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, OX3 9DU, England.
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21
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Varg S, Vicente V, Castren M, Lindgren P, Rehnberg C. Healthcare pathways and resource use: mapping consequences of ambulance assessment for direct care with alternative healthcare providers. BMC Emerg Med 2020; 20:85. [PMID: 33126854 PMCID: PMC7602326 DOI: 10.1186/s12873-020-00380-5] [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: 06/10/2020] [Accepted: 10/16/2020] [Indexed: 11/10/2022] Open
Abstract
Background A decision system in the ambulance allowing alternative pathways to alternate healthcare providers has been developed for older patients in Stockholm, Sweden. However, subsequent healthcare resource use resulting from these pathways has not yet been addressed. The aim of this study was therefore to describe patient pathways, healthcare utilisation and costs following ambulance transportation to alternative healthcare providers. Methods The design of this study was descriptive and observational. Data from a previous RCT, where a decision system in the ambulance enabled alternative healthcare pathways to alternate healthcare providers were linked to register data. The receiving providers were: primary acute care centre or secondary geriatric ward, both located at the same community hospital, or the conventional pathway to the emergency department at an acute hospital. Resource use over 10 days, subsequent to assessment with the decision system, was mapped in terms of healthcare pathways, utilisation and costs for the 98 included cases. Results Almost 90% were transported to the acute care centre or geriatric ward. The vast majority arriving to the geriatric ward stayed there until the end of follow-up or until discharged, whereas patients conveyed to the acute care centre to a large extent were admitted to hospital. The median patient had 6 hospital days, 2 outpatient visits and costed roughly 4000 euros over the 10-day period. Arrival destination geriatric ward indicated the longest hospital stay and the emergency department the shortest. However, the cost for the 10-day period was lower for cases arriving to the geriatric ward than for those arriving to the emergency department. Conclusions The findings support the appropriateness of admittance directly to secondary geriatric care for older adults. However, patients conveyed to the acute care centre ought to be studied in more detail with regards to appropriate level of care.
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Affiliation(s)
- Sofi Varg
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden. .,Centre for Health Economics, Informatics and Health Services Research, Stockholm Health Care Services, Stockholm, Sweden.
| | - Veronica Vicente
- Ambulance Medical Service in Stockholm [Ambulanssjukvården i Storstockholm AB], Stockholm, Sweden.,Academic Emergency Medical Services, Stockholm, Sweden.,Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
| | - Maaret Castren
- Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden.,Emergency Medicine, Helsinki University and Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | - Peter Lindgren
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden.,The Swedish Institute for Health Economics, Lund, Sweden
| | - Clas Rehnberg
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden.,Centre for Health Economics, Informatics and Health Services Research, Stockholm Health Care Services, Stockholm, Sweden
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22
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Casteli CPM, Mbemba GIC, Dumont S, Dallaire C, Juneau L, Martin E, Laferrière MC, Gagnon MP. Indicators of home-based hospitalization model and strategies for its implementation: a systematic review of reviews. Syst Rev 2020; 9:172. [PMID: 32771062 PMCID: PMC7415182 DOI: 10.1186/s13643-020-01423-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 07/10/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Home-based hospitalization (HBH) offers an alternative delivery model to hospital care. There has been a remarkable increase in pilot initiatives and deployment of this model to optimize services offered to a population with a variety of progressive and chronic diseases. Our objectives were to systematically summarize the indicators of HBH as well as the factors associated with the successful implementation and use of this model. METHODS We used a two-stage process. First, five databases were consulted, with no date delimitation. We included systematic reviews of quantitative, qualitative, and mixed studies published in English, French, Spanish, or Portuguese. We followed guidance from PRISMA and the Cochrane Collaboration. Second, we used the Nursing Care Performance Framework to categorize the indicators, a comprehensive grid of barriers and facilitators to map the factors affecting HBH implementation, and a thematic synthesis of the qualitative and quantitative findings. RESULTS Fifteen reviews were selected. We identified 26 indicators related to nursing care that are impacted by the use of HBH models and 13 factors related to their implementation. The most frequently documented indicators of HBH were cost of resources, problem and symptom management, comfort and quality of life, cognitive and psychosocial functional capacity, patient and caregiver satisfaction, hospital mortality, readmissions, and length of stay. Our review also highlighted new indicators, namely use of hospital beds, new emergency consultations, and use of healthcare services as indicators of resources of cost, and bowel complications, caregiver satisfaction, and survival time as indicators of change in the patient's condition. The main facilitators for HBH implementation were related to internal organizational factors (multidisciplinary collaboration and skill mix of professionals) whereas barriers were linked to the characteristics of the HBH, specifically eligibility criteria (complexity and social situation of the patient). CONCLUSION To the best of our knowledge, this is the first review that synthesizes both the types of indicators associated with HBH and the factors that influence its implementation. Considering both the processes and outcomes of HBH will help to identify strategies that could facilitate the implementation and evaluation of this innovative model of care delivery. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018103380.
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Affiliation(s)
- Christiane Pereira Martins Casteli
- Faculty of Nursing Sciences, Université Laval, Québec City, QC Canada
- University Health and Social Services Centre (IUHSSC) of Capitale-Nationale (CN), Québec City, QC Canada
| | | | - Serge Dumont
- School of Social Work, Université Laval, Québec City, QC Canada
- Primary Care and Services Research Center, Université Laval - Primary Health Care and Social Services University Institute, IUHSSC-CN, Québec City, QC Canada
| | - Clémence Dallaire
- Faculty of Nursing Sciences, Université Laval, Québec City, QC Canada
- Research Center of the CHU de Québec-Université Laval, 1050 Avenue de la Médecine. Pavillon Ferdinand-Vandry, Québec City, QC G1V0A6 Canada
| | - Lucille Juneau
- University Health and Social Services Centre (IUHSSC) of Capitale-Nationale (CN), Québec City, QC Canada
- Center of Excellence on Aging Quebec (CEVQ), IUHSSC-CN, Québec City, QC Canada
| | - Elisabeth Martin
- Faculty of Nursing Sciences, Université Laval, Québec City, QC Canada
- Primary Care and Services Research Center, Université Laval - Primary Health Care and Social Services University Institute, IUHSSC-CN, Québec City, QC Canada
| | | | - Marie-Pierre Gagnon
- Faculty of Nursing Sciences, Université Laval, Québec City, QC Canada
- Research Center of the CHU de Québec-Université Laval, 1050 Avenue de la Médecine. Pavillon Ferdinand-Vandry, Québec City, QC G1V0A6 Canada
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Dawson S, Kunonga P, Beyer F, Spiers G, Booker M, McDonald R, Cameron A, Craig D, Hanratty B, Salisbury C, Huntley A. Does health and social care provision for the community dwelling older population help to reduce unplanned secondary care, support timely discharge and improve patient well-being? A mixed method meta-review of systematic reviews. F1000Res 2020; 9:857. [PMID: 34621521 PMCID: PMC8482050 DOI: 10.12688/f1000research.25277.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/23/2020] [Indexed: 11/20/2022] Open
Abstract
Background: This study aimed to identify and examine systematic review evidence of health and social care interventions for the community-dwelling older population regarding unplanned hospital admissions, timely hospital discharge and patient well-being. Methods: A meta-review was conducted using Joanna Briggs and PRISMA guidance. A search strategy was developed: eight bibliographic medical and social science databases were searched, and references of included studies checked. Searches were restricted to OECD countries and to systematic reviews published between January 2013-March 2018. Data extraction and quality appraisal was undertaken by one reviewer with a random sample screened independently by two others. Results: Searches retrieved 21,233 records; using data mining techniques, we identified 8,720 reviews. Following title and abstract and full-paper screening, 71 systematic reviews were included: 62 quantitative, seven qualitative and two mixed methods reviews. There were 52 reviews concerned with healthcare interventions and 19 reviews concerned with social care interventions. This meta-review summarises the evidence and evidence gaps of nine broad types of health and social care interventions. It scrutinises the presence of research in combined health and social care provision, finding it lacking in both definition and detail given. This meta-review debates the overlap of some of the person-centred support provided by community health and social care provision. Research recommendations have been generated by this process for both primary and secondary research. Finally, it proposes that research recommendations can be delivered on an ongoing basis if meta-reviews are conducted as living systematic reviews. Conclusions: This meta-review provides evidence of the effect of health and social care interventions for the community-dwelling older population and identification of evidence gaps. It highlights the lack of evidence for combined health and social care interventions and for the impact of social care interventions on health care outcomes. Registration: PROSPERO ID CRD42018087534; registered on 15 March 2018.
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Affiliation(s)
- Shoba Dawson
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Patience Kunonga
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, UK, Newcastle, UK
| | - Fiona Beyer
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, UK, Newcastle, UK
| | - Gemma Spiers
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, UK, Newcastle, UK
| | - Matthew Booker
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Ruth McDonald
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Ailsa Cameron
- School for Policy Studies, University of Bristol, Bristol, UK
| | - Dawn Craig
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, UK, Newcastle, UK
| | - Barbara Hanratty
- Population Health Sciences Institute, Biomedical Research Building, Campus for Ageing and Vitality, Newcastle University, UK, Newcastle, UK
| | - Chris Salisbury
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Alyson Huntley
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
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Goossens LMA, Vemer P, Rutten-van Mölken MPMH. The risk of overestimating cost savings from hospital-at-home schemes: A literature review. Int J Nurs Stud 2020; 109:103652. [PMID: 32569827 DOI: 10.1016/j.ijnurstu.2020.103652] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 05/08/2020] [Accepted: 05/12/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND The concept of hospital-at-home means that home treatment is provided to patients who would otherwise have been treated in the hospital. This may lead to lower costs, but estimates of savings may be overstated if inpatient hospital costs are priced incorrectly. OBJECTIVE The objective of this study was to evaluate the quality of cost analyses of hospital-at-home studies for acute conditions published from 1996 through 2019 and to present an overview of evidence. DESIGN Literature review DATA SOURCES: The PubMed and NHS EED databases were searched. REVIEW METHODS The overall quality of studies was evaluated based on Quality of Health Economic Studies (QHES) score, design, sample size, alignment of cost calculation with study perspective, time horizon, use of tariffs or real resource use and clarity of calculations. Furthermore, we systematically assessed whether cost savings were likely to be overestimated, based on criteria about the costing of inpatient hospital days, informal care costs and bias. RESULTS We identified 48 studies. The average QHES score was 60 out of a maximum of 100 points. Almost all studies violated one or more criteria for the risk of overestimation of cost savings. The most frequent problems were the use of average unit prices per inpatient day (not taking into account the decreasing intensity of care) and biased designs. Most studies found cost differences in favour of hospital-at-home; the range varied from savings of €8773 to a cost increase of €2316 per patient. CONCLUSION Overall quality of studies was not good, with some exceptions. Many cost savings were probably overestimated.
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Affiliation(s)
- Lucas M A Goossens
- Erasmus School for Health Policy & Management, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR Rotterdam 3000, the Netherlands.
| | - Pepijn Vemer
- Erasmus School for Health Policy & Management, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR Rotterdam 3000, the Netherlands; Department of Pharmacotherapy, Epidemiology & Economics, University of Groningen, P.O. Box 196, 9700 AD, Groningen, the Netherlands
| | - Maureen P M H Rutten-van Mölken
- Erasmus School for Health Policy & Management, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR Rotterdam 3000, the Netherlands
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Young J, Hulme C, Smith A, Buckell J, Godfrey M, Holditch C, Grantham J, Tucker H, Enderby P, Gladman J, Teale E, Thiebaud JC. Measuring and optimising the efficiency of community hospital inpatient care for older people: the MoCHA mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background
Community hospitals are small hospitals providing local inpatient and outpatient services. National surveys report that inpatient rehabilitation for older people is a core function but there are large differences in key performance measures. We have investigated these variations in community hospital ward performance.
Objectives
(1) To measure the relative performance of community hospital wards (studies 1 and 2); (2) to identify characteristics of community hospital wards that optimise performance (studies 1 and 3); (3) to develop a web-based interactive toolkit that supports operational changes to optimise ward performance (study 4); (4) to investigate the impact of community hospital wards on secondary care use (study 5); and (5) to investigate associations between short-term community (intermediate care) services and secondary care utilisation (study 5).
Methods
Study 1 – we used national data to conduct econometric estimations using stochastic frontier analysis in which a cost function was modelled using significant predictors of community hospital ward costs. Study 2 – a national postal survey was developed to collect data from a larger sample of community hospitals. Study 3 – three ethnographic case studies were performed to provide insight into less tangible aspects of community hospital ward care. Study 4 – a web-based interactive toolkit was developed by integrating the econometrics (study 1) and case study (study 3) findings. Study 5 – regression analyses were conducted using data from the Atlas of Variation Map 61 (rate of emergency admissions to hospital for people aged ≥ 75 years with a length of stay of < 24 hours) and the National Audit of Intermediate Care.
Results
Community hospital ward efficiency is comparable with the NHS acute hospital sector (mean cost efficiency 0.83, range 0.72–0.92). The rank order of community hospital ward efficiencies was distinguished to facilitate learning across the sector. On average, if all community hospital wards were operating in line with the highest cost efficiency, savings of 17% (or £47M per year) could be achieved (price year 2013/14) for our sample of 101 wards. Significant economies of scale were found: a 1% rise in output was associated with an average 0.85% increase in costs. We were unable to obtain a larger community hospital sample because of the low response rate to our national survey. The case studies identified how rehabilitation was delivered through collaborative, interdisciplinary working; interprofessional communication; and meaningful patient and family engagement. We also developed insight into patients’ recovery trajectories and care transitions. The web-based interactive toolkit was established [http://mocha.nhsbenchmarking.nhs.uk/ (accessed 9 September 2019)]. The crisis response team type of intermediate care, but not community hospitals, had a statistically significant negative association with emergency admissions.
Limitations
The econometric analyses were based on cross-sectional data and were also limited by missing data. The low response rate to our national survey means that we cannot extrapolate reliably from our community hospital sample.
Conclusions
The results suggest that significant community hospital ward savings may be realised by improving modifiable performance factors that might be augmented further by economies of scale.
Future work
How less efficient hospitals might reduce costs and sustain quality requires further research.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 1. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- John Young
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Leeds, UK
| | - Claire Hulme
- Academic Unit of Health Economics, University of Leeds, Leeds, UK
| | - Andrew Smith
- Institute for Transport Studies, University of Leeds, Leeds, UK
| | - John Buckell
- Academic Unit of Health Economics, University of Leeds, Leeds, UK
| | - Mary Godfrey
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Leeds, UK
| | | | | | - Helen Tucker
- Community Hospitals Association, Crowborough, UK
| | - Pam Enderby
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - John Gladman
- University of Nottingham Medical School, University of Nottingham, Nottingham, UK
| | - Elizabeth Teale
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Leeds, UK
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26
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Huntley AL, Davies B, Jones N, Rooney J, Goyder P, Purdy S, Baxter H. Determining when a hospital admission of an older person can be avoided in a subacute setting: a systematic review and concept analysis. J Health Serv Res Policy 2019; 25:252-264. [PMID: 31805793 DOI: 10.1177/1355819619886885] [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: 11/16/2022]
Abstract
OBJECTIVE To conduct a systematic review of the evidence for when a hospital admission for an older person can be avoided in subacute settings. We examined the definition of admission avoidance and the evidence for the factors that are required to avoid admission to hospital in this setting. METHODS Using defined PICOD criteria, we conducted searches in three databases (Medline, Embase and Cinahl) from January 2006 to February 2018. References were screened by title and abstract followed by full paper screening by two reviewers. Additional studies were searched from the grey literature, experts in the field and forward and backward referencing. Data were narratively described, and concept analysis was used to investigate the definition of admission avoidance. RESULTS A total of 17 studies were considered eligible for review; eight provided a definition of admission avoidance and 10 described admission avoidance criteria. We identified three factors which play a key role in admission avoidance in the subacute setting: (1) ambulatory care sensitive conditions and common medical scenarios for the older person, which included respiratory infections or pneumonia, urinary tract infections and catheter care, dehydration and associated symptoms, falls and behavioural management, and managing ongoing chronic conditions; (2) criteria/tools, referring to interventions that have used clinical expertise in conjunction with a range of general and geriatric triage tools; in condition-specific interventions, the decision whether to admit or not was based on level of risk determined by defined clinical tools; and (3) personnel and resources, referring to the need for experts to make the initial decision to avoid an admission. Supervision by nurses or physicians was still needed at subacute level, requiring resources such as short-stay beds, intravenous antibiotic treatment or fluids for rehydration and rapid access to laboratory tests. CONCLUSION The review identified a set of criteria for ambulatory care sensitive conditions and common medical scenarios for the older person that can be treated in the subacute setting with appropriate tools and resources. This information can help commissioners and care providers to take on these important elements and deliver them in a locally designed way.
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Affiliation(s)
- Alyson L Huntley
- Senior Research Fellow, Centre of Academic Primary Care, School of Population Science, University of Bristol, UK
| | - Ben Davies
- Honorary Senior Research Associate, Centre of Academic Primary Care, School of Population Science, University of Bristol, UK
| | - Nigel Jones
- Consultant Physician, North Bristol Trust, UK
| | - James Rooney
- Senior Project Manager, Transformation & Consultancy, NHS Bristol, North Somerset & South Gloucestershire CCG, UK
| | - Peter Goyder
- General Practitioner Commissioner, NHS Bristol, North Somerset & South Gloucestershire CCG, UK
| | - Sarah Purdy
- Pro Vice-Chancellor, Centre of Academic Primary Care, School of Population Science, University of Bristol, UK
| | - Helen Baxter
- Senior Research Associate, Centre of Academic Primary Care, School of Population Science, University of Bristol, UK
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Sempé L, Billings J, Lloyd-Sherlock P. Multidisciplinary interventions for reducing the avoidable displacement from home of frail older people: a systematic review. BMJ Open 2019; 9:e030687. [PMID: 31678943 PMCID: PMC6830674 DOI: 10.1136/bmjopen-2019-030687] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 07/04/2019] [Accepted: 09/03/2019] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES To synthesise existing literature on interventions addressing a new concept of avoidable displacement from home for older people with multimorbidity or frailty. The review focused on home-based interventions by any type of multidisciplinary team aimed at reducing avoidable displacement from home to hospital settings. A second objective was to characterise these interventions to inform policy. DESIGN A systematic search of the main bibliographic databases was conducted to identify studies relating to interventions addressing avoidable displacement from home for older people. Studies focusing on one specific condition or interventions without multidisciplinary teams were excluded. A narrative synthesis of data was conducted, and themes were identified by using an adapted thematic framework analysis approach. RESULTS The search strategy was performed using the following electronic databases: the American National Library of Medicine and the National Institutes of Health (PubMed), Scopus, Cochrane Library (Central and CDRS), CINAHL, Social Care Online, Web of Science as well as the database of the Latin American and Caribbean Health Sciences Literature. The database search was done in September 2018 and completed in October 2018. Overall 3927 articles were identified and 364 were retained for full text screening. Fifteen studies were included in the narrative review. Four themes were identified and discussed: (1) types of interventions, (2) composition of teams, (3) intervention effectiveness and (4) types of outcomes. Within intervention types, three categories of care types were identified; transitional care, case-management services and hospital at home. Each individual article was assessed in terms of risk of bias following Cochrane Collaboration guidelines. CONCLUSIONS The review identified some potential interventions and relevant topics to be addressed in order to develop effective and sustainable interventions to reduce the avoidable displacement from home of older people. However the review was not able to identify robust impact evidence, either in terms of quantity or quality from the studies presented. As such, the available evidence is not sufficiently robust to inform policy or interventions for reducing avoidable displacement from home. This finding reflects the complexity of these interventions and a lack of systematic data collection. PROSPERO REGISTRATION NUMBER CRD42018108116.
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Affiliation(s)
- Lucas Sempé
- School of International Development, University of East Anglia, Norwich, UK
| | - Jenny Billings
- Centre for Integrated Care Research, University of Kent, Canterbury, UK
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de Sousa Vale J, Franco AI, Oliveira CV, Araújo I, Sousa D. Hospital at Home: An Overview of Literature. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2019. [DOI: 10.1177/1084822319880930] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The development of new management solutions is needed to generate great changes in the health sector, especially in addressing the current collision course between growing health care demands, rising costs, and limited resources. One of these solutions is the hospital at home (HAH). This article aims to explore the existing literature, regarding possible health gains and economical outcomes in HAH programs versus traditional inpatient hospitalization. A search of literature was conducted to identify papers regarding HAH programs and their respective health and economical outcomes. The concept of HAH encompasses different levels or care schemes. Several examinations and treatments can be carried out at home. Hospital at home may optimize patient flow and relieve pressure on hospital bed availability. However, questions are raised regarding the uncertainty of the efficacy of HAH and the limited evidence on which model setting is most appropriate.
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Leniz J, Higginson IJ, Stewart R, Sleeman KE. Understanding which people with dementia are at risk of inappropriate care and avoidable transitions to hospital near the end-of-life: a retrospective cohort study. Age Ageing 2019; 48:672-679. [PMID: 31135024 DOI: 10.1093/ageing/afz052] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 03/20/2019] [Accepted: 04/25/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND transitions between care settings near the end-of-life for people with dementia can be distressing, lead to physical and cognitive deterioration, and may be avoidable. OBJECTIVE to investigate determinants of end-of-life hospital transitions, and association with healthcare use, among people with dementia. DESIGN retrospective cohort study. SETTING electronic records from a mental health provider in London, linked to national mortality and hospital data. SUBJECTS people with dementia who died in 2007-2016. METHODS end-of-life hospital transitions were defined as: multiple admissions in the last 90 days (early), or any admission in the last three days of life (late). Determinants were assessed using logistic regression. RESULTS of 8,880 people, 1,421 (16.0%) had at least one end-of-life transition: 505 (5.7%) had early, 788 (8.9%) late, and 128 (1.5%) both types. Early transitions were associated with male gender (OR 1.33, 95% CI 1.11-1.59), age (>90 vs <75 years OR 0.69, 95% CI 0.49-0.97), physical illness (OR 1.52, 95% CI 1.20-1.94), depressed mood (OR 1.49, 95% CI 1.17-1.90), and deprivation (most vs least affluent quintile OR 0.58, 95% CI 0.37-0.90). Care home residence was associated with fewer early (OR 0.63, 95% CI 0.53 to 0.76) and late (OR 0.80, 95% CI 0.65 to 0.97) transitions. Early transitions were associated with more hospital admissions throughout the last year of life compared to those with late and no transitions (mean 4.56, 1.89, 1.60; P < 0.001). CONCLUSIONS in contrast to late transitions, early transitions are associated with higher healthcare use and characteristics that are predictable, indicating potential for prevention.
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Affiliation(s)
- Javiera Leniz
- King's College London, Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, UK
| | - Irene J Higginson
- King's College London, Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, UK
| | - Robert Stewart
- King's College London, Institute of Psychiatry, Psychology and Neuroscience; South London and Maudsley NHS Foundation Trust, Biomedical Research Centre, UK
| | - Katherine E Sleeman
- King's College London, Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, UK
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The impact of an ageing population on the required hospital capacity: results from forecast analysis on administrative data. Eur Geriatr Med 2019; 10:697-705. [DOI: 10.1007/s41999-019-00219-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 07/10/2019] [Indexed: 10/26/2022]
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Oliver D. David Oliver: Avoiding hospital admission-are we really falling short? BMJ 2019; 364:l747. [PMID: 30808616 DOI: 10.1136/bmj.l747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Southerland LT, Pearson S, Hullick C, Carpenter CR, Arendts G. Safe to send home? Discharge risk assessment in the emergency department. Emerg Med Australas 2019; 31:266-270. [DOI: 10.1111/1742-6723.13250] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 01/20/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Lauren T Southerland
- Department of Emergency MedicineThe Ohio State University Wexner Medical Center Columbus Ohio USA
| | - Scott Pearson
- Department of Emergency MedicineChristchurch Hospital Christchurch New Zealand
| | - Carolyn Hullick
- Faculty of HealthThe University of Newcastle Newcastle New South Wales Australia
- Hunter Medical Research Institute Newcastle New South Wales Australia
| | | | - Glenn Arendts
- School of MedicineThe University of Western Australia Perth Western Australia Australia
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[Rapid increase of patients with dementia in emergency medical facilities]. Nihon Ronen Igakkai Zasshi 2019; 56:6-14. [PMID: 30760685 DOI: 10.3143/geriatrics.56.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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Lynch B, Fitzgerald AP, Corcoran P, Buckley C, Healy O, Browne J. Drivers of potentially avoidable emergency admissions in Ireland: an ecological analysis. BMJ Qual Saf 2018; 28:438-448. [PMID: 30314977 DOI: 10.1136/bmjqs-2018-008002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 09/07/2018] [Accepted: 09/10/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND Many emergency admissions are deemed to be potentially avoidable in a well-performing health system. OBJECTIVE To measure the impact of population and health system factors on county-level variation in potentially avoidable emergency admissions in Ireland over the period 2014-2016. METHODS Admissions data were used to calculate 2014-2016 age-adjusted emergency admission rates for selected conditions by county of residence. Negative binomial regression was used to identify which a priori factors were significantly associated with emergency admissions for these conditions and whether these factors were also associated with total/other emergency admissions. Standardised incidence rate ratios (IRRs) associated with a 1 SD change in risk factors were reported. RESULTS Nationally, potentially avoidable emergency admissions for the period 2014-2016 (266 395) accounted for 22% of all emergency admissions. Of the population factors, a 1 SD change in the county-level unemployment rate was associated with a 24% higher rate of potentially avoidable emergency admissions (IRR: 1.24; 95% CI 1.04 to 1.41). Significant health system factors included emergency admissions with length of stay equal to 1 day (IRR: 1.20; 95% CI 1.11 to 1.30) and private health insurance coverage (IRR: 0.92; 95% CI 0.89 to 0.96). The full model accounted for 50% of unexplained variation in potentially avoidable emergency admissions in each county. Similar results were found across total/other emergency admissions. CONCLUSION The results suggest potentially avoidable emergency admissions and total/other emergency admissions are primarily driven by socioeconomic conditions, hospital admission policy and private health insurance coverage. The distinction between potentially avoidable and all other emergency admissions may not be as useful as previously believed when attempting to identify the causes of regional variation in emergency admission rates.
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Affiliation(s)
- Brenda Lynch
- School of Public Health, University College Cork, Cork, Ireland
| | | | - Paul Corcoran
- School of Public Health, University College Cork, Cork, Ireland
| | - Claire Buckley
- School of Public Health, University College Cork, Cork, Ireland
| | - Orla Healy
- Public Health, Health Service Executive South, Cork, Ireland
| | - John Browne
- School of Public Health, University College Cork, Cork, Ireland
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Corbella X, Barreto V, Bassetti S, Bivol M, Castellino P, de Kruijf EJ, Dentali F, Durusu-Tanriöver M, Fierbinţeanu-Braticevici C, Hanslik T, Hojs R, Kiňová S, Lazebnik L, Livčāne E, Raspe M, Campos L. Hospital ambulatory medicine: A leading strategy for Internal Medicine in Europe. Eur J Intern Med 2018; 54:17-20. [PMID: 29661692 DOI: 10.1016/j.ejim.2018.04.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 04/08/2018] [Indexed: 10/17/2022]
Abstract
Addressing the current collision course between growing healthcare demands, rising costs and limited resources is an extremely complex challenge for most healthcare systems worldwide. Given the consensus that this critical reality is unsustainable from staff, consumer, and financial perspectives, our aim was to describe the official position and approach of the Working Group on Professional Issues and Quality of Care of the European Federation of Internal Medicine (EFIM), for encouraging internists to lead a thorough reengineering of hospital operational procedures by the implementation of innovative hospital ambulatory care strategies. Among these, we include outpatient and ambulatory care strategies, quick diagnostic units, hospital-at-home, observation units and daycare hospitals. Moving from traditional 'bed-based' inpatient care to hospital ambulatory medicine may optimize patient flow, relieve pressure on hospital bed availability by avoiding hospital admissions and shortening unnecessary hospital stays, reduce hospital-acquired complications, increase the capacity of hospitals with minor structural investments, increase efficiency, and offer patients a broader, more appropriate and more satisfactory spectrum of delivery options.
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Affiliation(s)
- Xavier Corbella
- Department of Internal Medicine, Bellvitge University Hospital-IDIBELL, Faculty of Medicine and Health Sciences, Universitat Internacional de Catalunya, Barcelona, Spain.
| | - Vasco Barreto
- Medicine Department/Internal Medicine Service, Hospital Pedro Hispano, Matosinhos Local Health Unit, Matosinhos, Portugal
| | - Stefano Bassetti
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Monica Bivol
- Medical Division, Akershus University Hospital, Lorenskog, Norway
| | | | - Evert-Jan de Kruijf
- Department of Internal Medicine, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Francesco Dentali
- Dipartimento Medicina Clinica e Sperimentale, Università dell'Insubria, Varese, Italy
| | - Mine Durusu-Tanriöver
- Department of General Internal Medicine, Hacettepe University Hospital, Ankara, Turkey
| | - Carmen Fierbinţeanu-Braticevici
- Department of Gastroenterology, University Hospital Bucharest, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Thomas Hanslik
- Service de Médecine Interne, Hôpital Ambroise Paré, Paris, France
| | - Radovan Hojs
- Clinic for Internal Medicine, University Medical Centre Maribor, University of Maribor, Faculty of Medicine, Maribor, Slovenia
| | - Soňa Kiňová
- Department of Internal Medicine, University Hospital, Comenius University, Bratislava, Slovakia
| | - Leonid Lazebnik
- The Moscow State University of Medicine and Dentistry, Moscow, Russian Federation
| | - Evija Livčāne
- Centre of TB and Lung Diseases, Riga East Clinical University Hospital, Riga, Latvia
| | - Matthias Raspe
- Department of Internal Medicine, Infectious Diseases and Respiratory Medicine, Charité - Universitaetsmedizin Berlin, Berlin, Germany
| | - Luis Campos
- Internal Medicine Department, Hospital São Francisco Xavier, Lisboa, Portugal
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