Care Trajectories of Veterans in the 12 Months After Hospitalization for Acute Ischemic Stroke

Trajectory Analysis for Identifying Classes of Attention Deficit Hyperactivity Disorder (ADHD) in Children of the United States

Background

Attention Deficit Hyperactivity Disorder (ADHD) is a mental health disorder that affects attention and behavior. People with ADHD frequently encounter challenges in social interactions, facing issues, like social rejection and difficulties in interpersonal relationships, due to their inattention, impulsivity, and hyperactivity.

Methods

A National Longitudinal Survey of Youth (NLSY) database was employed to identify patterns of ADHD symptoms. The children who were born to women in the NLSY study between 1986 and 2014 were included. A total of 1,847 children in the NLSY 1979 cohort whose hyperactivity/inattention score was calculated when they were four years old were eligible for this study. A trajectory modeling method was used to evaluate the trajectory classes. Sex, baseline antisocial score, baseline anxiety score, and baseline depression score were adjusted to build the trajectory model. We used stepwise multivariate logistic regression models to select the risk factors for the identified trajectories.

Results

The trajectory analysis identified six classes for ADHD, including (1) no sign class, (2) few signs since preschool being persistent class, (3) few signs in preschool but no signs later class, (4) few signs in preschool that magnified in elementary school class, (5) few signs in preschool that diminished later class, and (6) many signs since preschool being persistent class. The sensitivity analysis resulted in a similar trajectory pattern, except for the few signs since preschool that magnified later class. Children's race, breastfeeding status, headstrong score, immature dependent score, peer conflict score, educational level of the mother, baseline antisocial score, baseline anxious/depressed score, and smoking status 12 months prior to the birth of the child were found to be risk factors in the ADHD trajectory classes.

Conclusion

The trajectory classes findings obtained in the current study can (a) assist a researcher in evaluating an intervention (or combination of interventions) that best decreases the long-term impact of ADHD symptoms and (b) allow clinicians to better assess as to which class a child with ADHD belongs so that appropriate intervention can be employed.

Functional and Cognitive Impairments Increased Risks of Outcomes of Healthcare Utilization in Patients With Stroke Receiving Home and Community-Based Care in Taiwan

Aim: Stroke is a leading cause of disability; however, little is known about the outcomes of the utilization of long-term care (LTC) recipients in Taiwan. This study aimed to quantify the burdens of disease of stroke survivors receiving LTC by evaluating the outcomes of their utilization including mortality, readmissions, and re-emergency within 1 year after diagnoses of strokes. Methods: By interlinkages among the national mortality registry, LTC dataset (LTC-CM), and the National Health Insurance Research Dataset (NHIRD), the outcomes and the factors associated with receiving LTC up to 1 year were explored. Patients were aged 50 years and over with an inpatient claim of the first diagnosis of stroke of intracerebral hemorrhage (ICH) and ischemic stroke during 2011-2016. Outcomes of the healthcare utilization include rehospitalization and re-emergency. Results: There were 15,662 patients with stroke who utilized the LTC services in the dataset among the stroke population in NHIRD. Stroke survivors receiving LTC showed no difference in clinical characteristics and their expected years of life loss (EYLL = 7.4 years) among those encountered in NHIRD. The LTC recipients showed high possibilities to be rehospitalized and resent to emergency service within 1 year after diagnosis. Apart from the comorbidity and stroke severity, both the physical and mental functional disabilities and caregiving resources predicted the outcomes of the utilization. Conclusions: For stroke survivors, both severe functional impairments and cognitive impairments were found as important factors for healthcare utilizations. These results regarding reserving functional abilities deserve our consideration in making the decision on the ongoing LTC policy reform in the aged society of Taiwan.

End-of-Life Cost Trajectories in Cancer Patients Treated by Medicare versus the Veterans Health Administration

BACKGROUND/OBJECTIVES

To evaluate differences in end-of-life cost trajectories for cancer patients treated through Medicare versus by the Veterans Health Administration (VA).

DESIGN

A retrospective analysis of VA and Medicare administrative data from FY 2010 to 2014. We employed three-level generalized estimating equations to evaluate monthly cost trajectories experienced by patients in their last year of life, with patients nested within hospital referral region.

SETTING

Care received at VA facilities or by Medicare-reimbursed providers nationwide.

PARTICIPANTS

A total of 36,401 patients dying from cancer and dually enrolled in VA and Medicare.

MEASUREMENTS

We evaluated trajectories for total, inpatient, outpatient, and drug costs, using the last 12 months of life. Cost trajectories were prioritized as costs are not directly comparable across Medicare and VA. Patients were assigned to be VA-reliant, Medicare-reliant or Mixed-reliant based on their healthcare utilization in the last year of life.

RESULTS

All three groups experienced significantly different cost trajectories for total costs in the last year of life. Inpatient cost trajectories were significantly different between Medicare-reliant and VA-reliant patients, but did not differ between VA-reliant and Mixed-reliant patients. Outpatient and drug cost trajectories exhibited the inverse pattern: they were significantly different between VA-reliant and Mixed-reliant patients, but not between VA-reliant and Medicare-reliant patients. However, visual examination of cost trajectories revealed similar cost patterns in the last year of life among all three groups; there was a sharp rise in costs as patients approach death, largely due to inpatient care.

CONCLUSION

Despite substantially different financial incentives and organization, VA- and Medicare-treated patients exhibit similar patterns of increasing end-of-life costs, largely driven by inpatient costs. Both systems require improvement to ensure quality of end-of-life care is aligned with recommended practice.

Veteran stroke survivors' lived experiences after being discharged home: a phenomenological study

BACKGROUND

Stroke is a leading cause of disability in adults and second cause of death in the United States. Survivors face challenges postdischarge, including risks in self-management (SM) following prescribed regimens. Although SM education can help develop skills to control risk factors for stroke recurrence, little is known about lived experiences of patients adopting SM.

AIMS

To examine Veterans' lived poststroke experiences after discharge and their experiences in SM goal setting/attainment.

METHODS

Patients within one year of discharge from a Veterans Administration Medical Center in the United States with two risk factors for stroke recurrence were enrolled and received an SM workbook. Eight patients were interviewed (six males, two females; mean age 62: range 45-80). Part I concerned lived experience. Part II described experiences with goal setting and attainment. Data were analyzed inductively, identifying common experiences. Deductive analysis described goal setting and attainment. Transcript reviews identified SM themes and strategies.

RESULTS

Lived experiences included 1) uncertainty about life, 2) anger and frustration, and 3) healthcare system challenges. Coping skills and setting goals to manage risks were critical for physical and emotional functioning.

CONCLUSIONS

SM coping and goal setting aided recovery and improved life quality among Veterans after stroke. SM interventions assisted in regaining physical and emotional function. Findings may help in design of interventions for survivors, using SM and goal setting and attainment.IMPLICATIONS FOR REHABILITATIONSeveral implications for clinical practice were identified:Providers should acknowledge Veterans' challenges and struggles after their stroke and help Veterans to re-establish social identity, enhance self-esteem and improve mood.More emphasis should be given to the Veterans' caregivers' availability and willingness to help with their loved one's recovery, work reinstatement status and financial struggles.Recognition of the importance of the social context of recovery after a stroke is important, as nonmedical social interaction is often overlooked.Improvements are needed in the area of providers working with social workers and physical, occupational and mental health therapists to arrange more inpatient and outpatient treatments, including more frequent home visits.Veterans should be strongly encouraged to attend self-management diabetes education classes and smoking cessation and weight-loss programs offered for free within the Veterans Health Administration system.Self-management strategies using goal-setting and attainment concepts may assist individuals with stroke to regain physical and emotional functions, subsequently preventing another stroke.

Trajectory Modelling Techniques Useful to Epidemiological Research: A Comparative Narrative Review of Approaches

Trajectory modelling techniques have been developed to determine subgroups within a given population and are increasingly used to better understand intra- and inter-individual variability in health outcome patterns over time. The objectives of this narrative review are to explore various trajectory modelling approaches useful to epidemiological research and give an overview of their applications and differences. Guidance for reporting on the results of trajectory modelling is also covered. Trajectory modelling techniques reviewed include latent class modelling approaches, ie, growth mixture modelling (GMM), group-based trajectory modelling (GBTM), latent class analysis (LCA), and latent transition analysis (LTA). A parallel is drawn to other individual-centered statistical approaches such as cluster analysis (CA) and sequence analysis (SA). Depending on the research question and type of data, a number of approaches can be used for trajectory modelling of health outcomes measured in longitudinal studies. However, the various terms to designate latent class modelling approaches (GMM, GBTM, LTA, LCA) are used inconsistently and often interchangeably in the available scientific literature. Improved consistency in the terminology and reporting guidelines have the potential to increase researchers' efficiency when it comes to choosing the most appropriate technique that best suits their research questions.

Comparison of the Measurement of Long-Term Care Costs between China and Other Countries: A Systematic Review of the Last Decade

BACKGROUND

The rapid aging of populations in some countries has led to a growing number of the disabled elderly, creating a huge need for Long-Term Care (LTC) and meeting its costs, which is a heavy economic burden on the families of the disabled elderly and governments. Therefore, the measurement of Long-Term Care (LTC) costs has become an important basis for the government to formulate Long-Term Care (LTC) policies, and academic research on Long-Term Care (LTC) costs is also in the process of continuous development and deepening.

METHODS

This is a systematic review that aims to examine the evidence published in the last decade (2010-2019) regarding the comparison of the measurement of Long-Term Care (LTC) costs between China and other countries.

RESULTS

Eighteen Chinese studies and 17 other countries' studies were included in this review. Most Chinese scholars estimated long-term care costs based on the degree of disability among the disabled elderly. However, the studies of European and American countries are more and more in-depth and comprehensive, and more detailed regarding the post-care cost of specific diseases, such as Parkinson's disease, Alzheimer's disease, and epilepsy.

CONCLUSION

In future academic research, we should fully consider the human value of long-term care providers and further study the differences in the long-term care costs of different chronic diseases. In China's future policymaking, according to the experience of Germany, Sweden, and other countries, it may be an effective way to develop private long-term care insurance and realize the effective complementarity between private long-term care insurance and public long-term care insurance (LTCI).

Healthcare utilization after a first hospitalization for COPD: a new approach of State Sequence Analysis based on the '6W' multidimensional model of care trajectories

Background

Published methods to describe and visualize Care Trajectories (CTs) as patterns of healthcare use are very sparse, often incomplete, and not intuitive for non-experts.

Our objectives are to propose a typology of CTs one year after a first hospitalization for Chronic Obstructive Pulmonary Disease (COPD), and describe CT types and compare patients’ characteristics for each CT type.

Methods

This is an observational cohort study extracted from Quebec’s medico-administrative data of patients aged 40 to 84 years hospitalized for COPD in 2013 (index date). The cohort included patients hospitalized for the first time over a 3-year period before the index date and who survived over the follow-up period. The CTs consisted of sequences of healthcare use (e.g. ED-hospital-home-GP-respiratory therapists, etc.) over a one-year period. The main variable was a CT typology, which was generated by a ‘tailored’ multidimensional State Sequence Analysis, based on the “6W” model of Care Trajectories. Three dimensions were considered: the care setting (“where”), the reason for consultation (“why”), and the speciality of care providers (“which”). Patients were grouped into specific CT types, which were compared in terms of care use attributes and patients’ characteristics using the usual descriptive statistics.

Results

The 2581 patients were grouped into five distinct and homogeneous CT types: Type 1 (n = 1351, 52.3%) and Type 2 (n = 748, 29.0%) with low healthcare and moderate healthcare use respectively; Type 3 (n = 216, 8.4%) with high healthcare use, mainly for respiratory reasons, with the highest number of urgent in-hospital days, seen by pulmonologists and respiratory therapists at primary care settings; Type 4 (n = 100, 3.9%) with high healthcare use, mainly cardiovascular, high ED visits, and mostly seen by nurses in community-based primary care; Type 5 (n = 166, 6.4%) with high healthcare use, high ED visits and non-urgent hospitalisations, and with consultations at outpatient clinics and primary care settings, mainly for other reasons than respiratory or cardiovascular. Patients in the 3 highest utilization CT types were older, and had more comorbidities and more severe condition at index hospitalization.

Conclusions

The proposed method allows for a better representation of the sequences of healthcare use in the real world, supporting data-driven decision making.

Healthcare utilization and cost trajectories post-stroke: role of caregiver and stroke factors

BACKGROUND

It is essential to study post-stroke healthcare utilization trajectories from a stroke patient caregiver dyadic perspective to improve healthcare delivery, practices and eventually improve long-term outcomes for stroke patients. However, literature addressing this area is currently limited. Addressing this gap, our study described the trajectory of healthcare service utilization by stroke patients and associated costs over 1-year post-stroke and examined the association with caregiver identity and clinical stroke factors.

METHODS

Patient and caregiver variables were obtained from a prospective cohort, while healthcare data was obtained from the national claims database. Generalized estimating equation approach was used to get the population average estimates of healthcare utilization and cost trend across 4 quarters post-stroke.

RESULTS

Five hundred ninety-two stroke patient and caregiver dyads were available for current analysis. The highest utilization occurred in the first quarter post-stroke across all service types and decreased with time. The incidence rate ratio (IRR) of hospitalization decreased by 51, 40, 11 and 1% for patients having spouse, sibling, child and others as caregivers respectively when compared with not having a caregiver (p = 0.017). Disability level modified the specialist outpatient clinic usage trajectory with increasing difference between mildly and severely disabled sub-groups across quarters. Stroke type and severity modified the primary care cost trajectory with expected cost estimates differing across second to fourth quarters for moderately-severe ischemic (IRR: 1.67, 1.74, 1.64; p = 0.003), moderately-severe non-ischemic (IRR: 1.61, 3.15, 2.44; p = 0.001) and severe non-ischemic (IRR: 2.18, 4.92, 4.77; p = 0.032) subgroups respectively, compared to first quarter.

CONCLUSION

Highlighting the quarterly variations, we reported distinct utilization trajectories across subgroups based on clinical characteristics. Caregiver availability reducing hospitalization supports revisiting caregiver's role as potential hidden workforce, incentivizing their efforts by designing socially inclusive bundled payment models for post-acute stroke care and adopting family-centered clinical care practices.

Trajectory Modelling to Assess Trends in Long-Term Readmission Rate among Abdominal Aortic Aneurysm Patients

Introduction

The aim of the study was to use trajectory analysis to categorise high-impact users based on their long-term readmission rate and identify their predictors following AAA (abdominal aortic aneurysm) repair. Methods. In this retrospective cohort study, group-based trajectory modelling (GBTM) was performed on the patient cohort (2006-2009) identified through national administrative data from all NHS English hospitals. Proc Traj software was used in SAS program to conduct GBTM, which classified patient population into groups based on their annual readmission rates during a 5-year period following primary AAA repair. Based on the trends of readmission rates, patients were classified into low- and high-impact users. The high-impact group had a higher annual readmission rate throughout 5-year follow-up. Short-term high-impact users had initial high readmission rate followed by rapid decline, whereas chronic high-impact users continued to have high readmission rate.

Results

Based on the trends in readmission rates, GBTM classified elective AAA repair (n=16,973) patients into 2 groups: low impact (82.0%) and high impact (18.0%). High-impact users were significantly associated with female sex (P=0.001) undergoing other vascular procedures (P=0.003), poor socioeconomic status index (P < 0.001), older age (P < 0.001), and higher comorbidity score (P < 0.001). The AUC for c-statistics was 0.84. Patients with ruptured AAA repair (n=4144) had 3 groups: low impact (82.7%), short-term high impact (7.2%), and chronic high impact (10.1%). Chronic high impact users were significantly associated with renal failure (P < 0.001), heart failure (P = 0.01), peripheral vascular disease (P < 0.001), female sex (P = 0.02), open repair (P < 0.001), and undergoing other related procedures (P=0.05). The AUC for c-statistics was 0.71.

Conclusion

Patients with persistent high readmission rates exist among AAA population; however, their readmissions and mortality are not related to AAA repair. They may benefit from optimization of their medical management of comorbidities perioperatively and during their follow-up.

The '6W' multidimensional model of care trajectories for patients with chronic ambulatory care sensitive conditions and hospital readmissions

OBJECTIVES

To synthesize concepts and approaches related to the analysis of patterns or processes of care and patient's outcomes into a comprehensive model of care trajectories, focusing on hospital readmissions for patients with chronic ambulatory care sensitive conditions (ACSCs).

STUDY DESIGN

Narrative literature review.

METHODS

Published studies between January 2000 and November 2017, using the concepts of 'continuity', 'pathway', 'episode', and 'trajectory', and focused on readmissions and chronic ACSCs, were collected in electronic databases. Qualitative content analysis was performed with emphasis on key constituents to build a comprehensive model.

RESULTS

Specific common constituents are shared by the concepts reviewed: they focus on the patient, aim to measure and improve outcomes, follow specific periods of time and consider other factors related to care providers, care units, care settings, and treatments. Using these common denominators, the comprehensive '6W' multidimensional model of care trajectories was created. Considering patients' attributes and their chronic ACSCs illness course ('who' and 'why' dimensions), this model reflects their patterns of health care use across care providers ('which'), care units ('where'), and treatments ('what'), at specific periods of time ('when').

CONCLUSIONS

The '6W' model of care trajectories could provide valuable information on 'missed opportunities' to reduce readmission rates and improve quality of both ambulatory and inpatient care.

Functional Impairment: An Unmeasured Marker of Medicare Costs for Postacute Care of Older Adults

OBJECTIVES

To assess the effects of preadmission functional impairment on Medicare costs of postacute care up to 365 days after hospital discharge.

DESIGN

Longitudinal cohort study.

SETTING

Health and Retirement Study (HRS).

PARTICIPANTS

Nationally representative sample of 16,673 Medicare hospitalizations of 8,559 community-dwelling older adults from 2000 to 2012.

MEASUREMENTS

The main outcome was total Medicare costs in the year after hospital discharge, assessed according to Medicare claims data. The main predictor was functional impairment (level of difficulty or dependence in activities of daily living (ADLs)), determined from HRS interview preceding hospitalization. Multivariable linear regression was performed, adjusted for age, race, sex, income, net worth, and comorbidities, with clustering at the individual level to characterize the association between functional impairment and costs of postacute care.

RESULTS

Unadjusted mean Medicare costs for 1 year after discharge increased with severity of impairment in a dose-response fashion (P < .001 for trend); 68% had no functional impairment ($25,931), 17% had difficulty with one ADL ($32,501), 7% had dependency in one ADL ($39,928), and 8% had dependency in two or more ADLs ($45,895). The most severely impaired participants cost 77% more than those with no impairment; adjusted analyses showed attenuated effect size (33% more) but no change in trend. Considering costs attributable to comorbidities, only three conditions were more expensive than severe functional impairment (lymphoma, metastatic cancer, paralysis).

CONCLUSION

Functional impairment is associated with greater Medicare costs for postacute care and may be an unmeasured but important marker of long-term costs that cuts across conditions.

A retrospective cohort study of high-impact users among patients with cerebrovascular conditions

OBJECTIVE

To apply group-based trajectory modelling (GBTM) to the hospital administrative data to evaluate, model and visualise trends and changes in the frequency of long-term hospital care use of the subgroups of patients with cerebrovascular conditions.

DESIGN

A retrospective cohort study of patients with cerebrovascular conditions.

SETTINGS

Secondary care of all patients with cerebrovascular conditions admitted to English National Hospital Service hospitals.

PARTICIPANTS

All patients with cerebrovascular conditions identified through national administrative data (Hospital Episode Statistics) and subsequent emergency hospital admissions followed up for 4 years.

MAIN OUTCOME MEASURE

Annual number of emergency hospital readmissions.

RESULTS

GBTM model classified patients with intracranial haemorrhage (n=2605) into five subgroups, whereas ischaemic stroke (n=34 208) and transient ischaemic attack (TIA) (n=20 549) patients were shown to have two conventional groups, low and high impact. The covariates with significant association with high-impact users (17.1%) among ischaemic stroke were epilepsy (OR 2.29), previous stroke (OR 2.18), anxiety/depression (OR 1.63), procedural complication (OR 1.43), admission to intensive therapy unit (ITU) or high dependency unit (HDU) (OR 1.42), comorbidity score (OR 1.36), urinary tract infections (OR 1.32), vision loss (OR 1.32), chest infections (OR 1.25), living alone (OR 1.25), diabetes (OR 1.23), socioeconomic index (OR 1.20), older age (OR 1.03) and prolonged length of stay (OR 1.00). The covariates associated with high-impact users among TIA (20.0%) were thromboembolic event (OR 3.67), previous stroke (OR 2.51), epilepsy (OR 2.25), hypotension (OR 1.86), anxiety/depression (OR 1.63), amnesia (OR 1.62), diabetes (OR 1.58), anaemia (OR 1.55), comorbidity score (OR 1.39), atrial fibrillation (OR 1.27), living alone (OR 1.25), socioeconomic index (OR 1.13), older age (OR 1.04) and prolonged length of stay (OR 1.02). The high-impact users (0.5%) among intracranial haemorrhage were strongly associated with thromboembolic event (OR 20.3) and inversely related to older age (OR 0.58).

CONCLUSION

GBTM effectively assessed trends in the use of hospital care by the subgroups of patients with cerebrovascular conditions. High-impact users persistently had higher annual readmission during the follow-up period.