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Nasu K, Miyashita M, Hirooka K, Endo T, Fukahori H. Ambulance use and emergency department visits among people with dementia: A cross-sectional survey. Nurs Health Sci 2023; 25:712-720. [PMID: 37987542 DOI: 10.1111/nhs.13066] [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: 04/07/2023] [Revised: 09/29/2023] [Accepted: 10/26/2023] [Indexed: 11/22/2023]
Abstract
This study aimed to explore factors associated with ambulance use and emergency department (ED) visits among people with dementia in the month before death. A web-based survey of bereaved family caregivers of people with dementia was conducted in March 2020. Multivariate logistic regression analyses were conducted with ambulance use and ED visits in the month before death as dependent variables. Age and gender of people with dementia and their family caregivers, home care use, decision-makers, comorbidities, degree of independence in daily living, and caregivers' preparedness for death were independent variables. Data were collected from 817 caregivers of people with dementia who had died at hospitals (52.4%), long-term care facilities (25.0%), or own homes (22.4%). Caregivers' lack of preparedness for death was significantly associated with ambulance use in the month before death. Comorbidites and males with dementia were significantly associated with ED visits in the month before death. Better death preparedness of family caregivers may reduce ambulance use for symptoms that can be more effectively addressed by palliative care than acute care for people with dementia.
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Affiliation(s)
- Katsumi Nasu
- Keio Research Institute at SFC, Fujisawa, Japan
- School of Nursing, Yasuda Women's University, Hiroshima, Japan
| | | | - Kayo Hirooka
- Graduate School of Health Care Science, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takuro Endo
- International University of Health and Welfare Narita Hospital, Narita, Japan
| | - Hiroki Fukahori
- Faculty of Nursing and Medical Care, Keio University, Fujisawa, Japan
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Kinsky S, Liang Q, Bellon J, Helwig A, McCracken P, Minnier T, Thirumala PD, Hanmer J. Predicting Unplanned Health Care Utilization and Cost: Comparing Patient-reported Outcomes Measurement Information System and Claims. Med Care 2021; 59:921-928. [PMID: 34183621 DOI: 10.1097/mlr.0000000000001601] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES There is little literature describing if and how payers are utilizing patient-reported outcomes to predict future costs. This study assessed if Patient-reported Outcomes Measurement Information System (PROMIS) domain scores, collected in routine practice at neurology clinics, improved payer predictive models for unplanned care utilization and cost. STUDY DESIGN Retrospective cohort analysis of private Health Plan-insured patients with visits at 18 Health Plan-affiliated neurology clinics. METHODS PROMIS domains (Anxiety v1.0, Cognitive Function Abilities v2.0, Depression v1.0, Fatigue v1.0, Pain Interference v1.0, Physical Function v2.0, Sleep Disturbance v1.0, and Ability to Participate in Social Roles and Activities v2.0) are collected as part of routine care. Data from patients' first PROMIS measures between June 27, 2018 and April 16, 2019 were extracted and combined with claims data. Using (1) claims data alone and (2) PROMIS and claims data, we examined the association of covariates to utilization (using a logit model) and cost (using a generalized linear model). We evaluated model fit using area under the receiver operating characteristic curve (for unplanned care utilization), akaike information criterion (for unplanned care costs), and sensitivity and specificity in predicting top 15% of unplanned care costs. RESULTS Area under the receiver operating curve values were slightly higher, and akaike information criterion values were similar, for PROMIS plus claims covariates compared with claims alone. The PROMIS plus claims model had slightly higher sensitivity and equivalent specificity compared with claims-only models. CONCLUSION One-time PROMIS measure data combined with claims data slightly improved predictive model performance compared with claims alone, but likely not to an extent that indicates improved practical utility for payers.
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Affiliation(s)
| | | | | | | | - Polly McCracken
- School of General Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | | | - Janel Hanmer
- School of General Medicine, University of Pittsburgh, Pittsburgh, PA
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Godard-Sebillotte C, Strumpf E, Sourial N, Rochette L, Pelletier E, Vedel I. Primary care continuity and potentially avoidable hospitalization in persons with dementia. J Am Geriatr Soc 2021; 69:1208-1220. [PMID: 33635538 DOI: 10.1111/jgs.17049] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 01/10/2021] [Accepted: 01/14/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND/OBJECTIVE To measure the association between high primary care continuity and potentially avoidable hospitalization in community-dwelling persons with dementia. Our hypothesis was that high primary care continuity is associated with fewer potentially avoidable hospitalizations. DESIGN Population-based retrospective cohort (2012-2016), with inverse probability of treatment weighting using the propensity score. SETTING Quebec (Canada) health administrative database, recording most primary, secondary and tertiary care services provided via the public universal health insurance system. PARTICIPANTS Population-based sample of 22,060 community-dwelling 65 + persons with dementia on March 31st, 2015, with at least two primary care visits in the preceding year (mean age 81 years, 60% female). Participants were followed for 1 year, or until death or long-term care admission. EXPOSURE High primary care continuity on March 31st, 2015, i.e., having had every primary care visit with the same primary care physician, during the preceding year. MAIN OUTCOME MEASURES Primary: Potentially avoidable hospitalization in the follow-up period as defined by ambulatory care sensitive conditions (ACSC) hospitalization (general and older population definitions), 30-day hospital readmission; Secondary: Hospitalization and emergency department visit. RESULTS Among the 22,060 persons, compared with the persons with low primary care continuity, the 14,515 (65.8%) persons with high primary care continuity had a lower risk of ACSC hospitalization (general population definition) (relative risk reduction 0.82, 95% CI 0.72-0.94), ACSC hospitalization (older population definition) (0.87, 0.79-0.95), 30-day hospital readmission (0.81, 0.72-0.92), hospitalization (0.90, 0.86-0.94), and emergency department visit (0.92, 0.90-0.95). The number needed to treat to prevent one event were, respectively, 118 (69-356), 87 (52-252), 97 (60-247), 23 (17-34), and 29 (21-47). CONCLUSION Increasing continuity with a primary care physician might be an avenue to reduce potentially avoidable hospitalizations in community-dwelling persons with dementia on a population-wide level.
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Affiliation(s)
| | - Erin Strumpf
- Department of Epidemiology, Biostatics, and Occupational Health, McGill University, Montreal, Quebec, Canada.,Department of Economics, McGill University, Montreal, Quebec, Canada
| | - Nadia Sourial
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Louis Rochette
- Institut national de santé publique du Québec (INSPQ), Montreal, Quebec, Canada
| | - Eric Pelletier
- Institut national de santé publique du Québec (INSPQ), Montreal, Quebec, Canada
| | - Isabelle Vedel
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
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Dooley J, Booker M, Barnes R, Xanthopoulou P. Urgent care for patients with dementia: a scoping review of associated factors and stakeholder experiences. BMJ Open 2020; 10:e037673. [PMID: 32938596 PMCID: PMC7497532 DOI: 10.1136/bmjopen-2020-037673] [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: 02/11/2020] [Revised: 06/22/2020] [Accepted: 07/08/2020] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES People with dementia are more vulnerable to complications in urgent health situations due to older age, increased comorbidity, higher dependency on others and cognitive impairment. This review explored the factors associated with urgent care use in dementia and the experiences of people with dementia, informal carers and professionals. DESIGN Scoping review. The search strategy and data synthesis were informed by people with dementia and carers. DATA SOURCES Searches of CINAHL, Embase, Medline, PsycINFO, PubMed were conducted alongside handsearches of relevant journals and the grey literature through 15 January 2019. ELIGIBILITY CRITERIA Empirical studies including all research designs, and other published literature exploring factors associated with urgent care use in prehospital and emergency room settings for people with dementia were included. Two authors independently screened studies for inclusion. DATA EXTRACTION AND SYNTHESIS Data were extracted using charting techniques and findings were synthesised according to content and themes. RESULTS Of 2967 records identified, 54 studies were included in the review. Specific factors that influenced use of urgent care included: (1) common age-related conditions occurring alongside dementia, (2) dementia as a diagnosis increasing or decreasing urgent care use, (3) informal and professional carers, (4) patient characteristics such as older age or behavioural symptoms and (5) the presence or absence of community support services. Included studies reported three crucial components of urgent care situations: (1) knowledge of the patient and dementia as a condition, (2) inadequate non-emergency health and social care support and (3) informal carer education and stress. CONCLUSIONS The scoping review highlighted a wider variety of sometimes competing factors that were associated with urgent care situations. Improved and increased community support for non-urgent situations, such as integrated care, caregiver education and dementia specialists, will both mitigate avoidable urgent care use and improve the experience of those in crisis.
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Affiliation(s)
- Jemima Dooley
- Centre for Academic Primary Care, School for Social and Community Medicine, Bristol University, Bristol, UK
| | - Matthew Booker
- Centre for Academic Primary Care, School for Social and Community Medicine, Bristol University, Bristol, UK
| | - Rebecca Barnes
- Centre for Academic Primary Care, School for Social and Community Medicine, Bristol University, Bristol, UK
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Thoits T, Sadasivan J, Parker JL, Andersen NJ. Acute Healthcare Utilization of a Multidisciplinary Neurocognitive Dementia Patient Cohort. J Clin Neurol 2020; 16:433-437. [PMID: 32657064 PMCID: PMC7354981 DOI: 10.3988/jcn.2020.16.3.433] [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: 10/15/2019] [Revised: 03/23/2020] [Accepted: 03/23/2020] [Indexed: 11/30/2022] Open
Abstract
Background and Purpose Upon referral from the primary care provider (PCP), dementia is diagnosed either by a neuropsychological evaluation (NPE) or at a multidisciplinary neurocognitive clinic (MNC). Following the NPE, patients continue receiving care from their PCP. In contrast, patients at the MNC are followed by a multidisciplinary care team that provides expertise across specialties in dementia care and education for the patient, family members, and care providers. The purpose of the study was to determine the utilization of acute healthcare services during the 2 years following a diagnosis of dementia in patients from the MNC and NPE. Methods A retrospective review was performed of 581 electronic medical records from January 2010 through December 2014 for 2 cohorts of patients diagnosed with dementia 1) by a neuropsychologist or 2) in a MNC. Acute-care hospital admissions, emergency room (ER) visits, and nonroutine PCP visits were identified. Categorical demographics and utilization variables were summarized by frequency. Chi-square analysis was used to analyze demographic characteristics and overall utilization between MNCs and NPE. Utilization in comparison with various demographic characteristics was analyzed using Spearman correlation coefficients and negative binomial regressions. Results Patients evaluated in the MNC were older, more severely impaired, and lived alone more often compared with NPE patients, but there was no increase in hospital admissions and ER visits. Patients who underwent NPE were 1.58 times more likely to have a nonroutine PCP office visit than patients evaluated in the MNC (p=0.0093). Conclusions Performing follow-up in multidisciplinary clinics provides patients with more education and may help to reduce the utilization of healthcare services.
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Affiliation(s)
- Timothy Thoits
- Division of Clinical Neurosciences, Spectrum Health, Grand Rapids, MI, USA.
| | - Janani Sadasivan
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
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Guterman EL, Allen IE, Josephson SA, Merrilees JJ, Dulaney S, Chiong W, Lee K, Bonasera SJ, Miller BL, Possin KL. Association Between Caregiver Depression and Emergency Department Use Among Patients With Dementia. JAMA Neurol 2019; 76:1166-1173. [PMID: 31282955 DOI: 10.1001/jamaneurol.2019.1820] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Current attempts to gauge the acute care needs of patients with dementia have not effectively addressed the role of caregivers, despite their extensive involvement in decisions about acute care management. Objective To determine whether caregiver depression is associated with increased use of the emergency department (ED) among patients with dementia. Design, Setting, and Participants This longitudinal cohort study used data from the Care Ecosystem study, a randomized clinical trial examining telephone-based supportive care for patients with dementia and their caregivers. Patients were 45 years or older with any type of dementia. A total of 780 caregiver-patient dyads were enrolled from March 20, 2015, until February 28, 2017, and 663 dyads contributed baseline and 6-month data and were included in the analysis. Exposures Caregiver depression (9-item Patient Health Questionnaire score of ≥10). Secondary analyses examined caregiver burden and self-efficacy. Main Outcomes and Measures The primary outcome was the number of ED visits in a 6-month period. Results Among the 663 caregivers (467 women and 196 men; mean [SD] age, 64.9 [11.8] years), 84 caregivers (12.7%) had depression at baseline. The mean incidence rate of ED visits was 0.9 per person-year. Rates of ED presentation were higher among dyads whose caregiver did vs did not have depression (1.5 vs 0.8 ED visits per person-year). In a Poisson regression model adjusting for patient age, sex, severity of dementia, number of comorbidities, and baseline ED use, as well as caregiver age and sex, caregiver depression continued to be associated with ED use, with a 73% increase in rates of ED use among dyads with caregivers with depression (adjusted incident rate ratio, 1.73; 95% CI, 1.30-2.30). Caregiver burden was associated with higher ED use in the unadjusted model, but this association did not reach statistical significance after adjustment (incident rate ratio, 1.19; 95% CI, 0.93-1.52). Caregiver self-efficacy was inversely proportional to the number of ED visits in the unadjusted and adjusted models (adjusted incident rate ratio, 0.96; 95% CI, 0.92-0.99). Conclusions and Relevance Among patients with dementia, caregiver depression appears to be significantly associated with increased ED use, revealing a key caregiver vulnerability, which, if addressed with patient- and caregiver-centered dementia care, could improve health outcomes and lower costs for this high-risk population.
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Affiliation(s)
- Elan L Guterman
- Department of Neurology, University of California, San Francisco.,Weill Institute for Neurosciences, University of California, San Francisco
| | - I Elaine Allen
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - S Andrew Josephson
- Department of Neurology, University of California, San Francisco.,Weill Institute for Neurosciences, University of California, San Francisco.,Editor, JAMA Neurology
| | - Jennifer J Merrilees
- Department of Neurology, University of California, San Francisco.,Weill Institute for Neurosciences, University of California, San Francisco
| | - Sarah Dulaney
- Department of Neurology, University of California, San Francisco.,Weill Institute for Neurosciences, University of California, San Francisco
| | - Winston Chiong
- Department of Neurology, University of California, San Francisco.,Weill Institute for Neurosciences, University of California, San Francisco
| | - Kirby Lee
- Department of Clinical Pharmacy, University of California, San Francisco
| | - Stephen J Bonasera
- Department of Geriatrics, Gerontology, and Palliative Medicine, University of Nebraska Medical Center, Omaha.,Department of Internal Medicine, University of Nebraska Medical Center, Omaha
| | - Bruce L Miller
- Department of Neurology, University of California, San Francisco.,Weill Institute for Neurosciences, University of California, San Francisco
| | - Katherine L Possin
- Department of Neurology, University of California, San Francisco.,Weill Institute for Neurosciences, University of California, San Francisco
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Hunt LJ, Coombs LA, Stephens CE. Emergency Department Use by Community-Dwelling Individuals With Dementia in the United States: An Integrative Review. J Gerontol Nurs 2018; 44:23-30. [PMID: 29355877 DOI: 10.3928/00989134-20171206-01] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 08/29/2017] [Indexed: 11/20/2022]
Abstract
As part of the National Plan to Address Alzheimer's Disease, reducing potentially avoidable emergency department (ED) use by individuals with dementia has been identified as a component of enhancing the quality and efficiency of care for this population. To help inform the development of interventions to achieve this goal, an integrative review was conducted to: (a) compare rates and reasons for ED visits by community-dwelling individuals with and without dementia, considering also the effect of dementia subtype and severity; and (b) identify other risk factors for increased ED use among community-dwelling individuals with dementia. Nineteen articles met inclusion criteria. Individuals with dementia had higher rates of ED visits compared to those without dementia, although differences were attenuated in the last year of life. Increased symptoms and disability were associated with increased rates of ED visits, whereas resources that enabled effective management of increased need decreased rates. Gerontological nurses across settings are on the frontlines of preventing potentially avoidable ED visits by community-dwelling individuals with dementia through patient and family education and leadership in the development of new models of care. [Journal of Gerontological Nursing, 44(3), 23-30.].
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Sleeman KE, Perera G, Stewart R, Higginson IJ. Predictors of emergency department attendance by people with dementia in their last year of life: Retrospective cohort study using linked clinical and administrative data. Alzheimers Dement 2017; 14:20-27. [DOI: 10.1016/j.jalz.2017.06.2267] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 04/18/2017] [Accepted: 06/08/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Katherine E. Sleeman
- Cicely Saunders Institute, Policy and Rehabilitation King's College London London United Kingdom
| | - Gayan Perera
- Institute of Psychiatry, Psychology and Neuroscience King's College London London United Kingdom
| | - Robert Stewart
- Institute of Psychiatry, Psychology and Neuroscience King's College London London United Kingdom
- South London and Maudsley NHS Foundation Trust London United Kingdom
| | - Irene J. Higginson
- Cicely Saunders Institute, Policy and Rehabilitation King's College London London United Kingdom
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