Gender differences in home care clients and admission to long-term care in Ontario, Canada: a population-based retrospective cohort study

Using Exploratory Structural Equation Modeling to Examine Caregiver Distress and Its Contributors

OBJECTIVES

To develop and test the direct and indirect associations between caregiver distress and its many contributing factors and covariates.

DESIGN

Analysis using data from a national, cross-sectional survey of Canadian caregivers.

SETTING AND PARTICIPANTS

A total of 6502 respondents of the 2012 General Social Survey-Caregiving and Care-receiving who self-identified as a caregiver.

METHODS

We used exploratory structural equation modeling to achieve our aims. Based on literature review, we hypothesized a structural model of 5 caregiving factors that contribute to distress: caregiving burden, caregiving network and support, disruptions of family and social life, positive emotional experiences, and caregiving history. Survey items hypothesized to measure each latent factor were modeled using exploratory factor analysis (EFA). After establishing a well-fit EFA model, structural equation modeling was performed to examine the relationships between caregiving factors and caregiver distress while controlling for covariates such as caregiver's and care-recipient's sociodemographic characteristics and kinship.

RESULTS

EFA established a well-fit model that represented caregiver distress and its 5 contributing factors as hypothesized. Although all 5 had significant effects on caregiver distress, disruptions of family and social life contributed the most (β = 0.462), almost 3 times that of caregiving burden (β = 0.162). Positive emotional experiences also substantially reduced distress (β = -0.310).

CONCLUSIONS AND IMPLICATIONS

Understanding the multifaceted nature of caregiver distress is crucial for developing effective strategies to support caregivers. In addition to reducing caregiving burden, having flexible resources and policies to minimize disruptions to caregivers' families (eg, flexible work policies; family-oriented education, training, and counseling) and enhance the positive aspects of caregiving may more effectively reduce distress.

Sex-based trajectories of health system use in lonely and not lonely older people: A population-based cohort study

BACKGROUND

There is growing interest in understanding the care needs of lonely people but studies are limited and examine healthcare settings separately. We estimated and compared healthcare trajectories in lonely and not lonely older female and male respondents to a national health survey.

METHODS

We conducted a retrospective cohort study of community-dwelling, Ontario respondents (65+ years) to the 2008/2009 Canadian Community Health Survey-Healthy Aging. Respondents were classified at baseline as not lonely, moderately lonely, or severely lonely using the Three-Item Loneliness Scale and then linked with health administrative data to assess healthcare transitions over a 12 -year observation period. Annual risks of moving from the community to inpatient, long-stay home care, long-term care settings-and death-were estimated across loneliness levels using sex-stratified multistate models.

RESULTS

Of 2684 respondents (58.8% female sex; mean age 77 years [standard deviation: 8]), 635 (23.7%) experienced moderate loneliness and 420 (15.6%) severe loneliness. Fewer lonely respondents remained in the community with no transitions (not lonely, 20.3%; moderately lonely, 17.5%; and severely lonely, 12.6%). Annual transition risks from the community to home care and long-term care were higher in female respondents and increased with loneliness severity for both sexes (e.g., 2-year home care risk: 6.1% [95% CI 5.5-6.6], 8.4% [95% CI 7.4-9.5] and 9.4% [95% CI 8.2-10.9] in female respondents, and 3.5% [95% CI 3.1-3.9], 5.0% [95% CI 4.0-6.0], and 5.4% [95% CI 4.0-6.8] in male respondents; 5-year long-term care risk: 9.2% [95% CI 8.0-10.8], 11.1% [95% CI 9.3-13.6] and 12.2% [95% CI 9.9-15.3] [female], and 5.3% [95% CI 4.2-6.7], 9.1% [95% CI 6.8-12.5], and 10.9% [95% CI 7.9-16.3] [male]).

CONCLUSIONS

Lonely older female and male respondents were more likely to need home care and long-term care, with severely lonely female respondents having the highest probability of moving to these settings.

Sex Differences in Healthcare Utilization in Persons Living with Dementia Between 2000 and 2017: A Population-Based Study in Quebec, Canada

Objectives: Describe sex differences in healthcare utilization and mortality in persons with new dementia in Quebec, Canada. Methods: We conducted a repeated cohort study from 2000 to 2017 using health administrative databases. Community-dwelling persons aged 65+ with a new diagnosis of dementia were included. We measured 23 indicators of healthcare use across five care settings: ambulatory care, pharmacological care, acute hospital care, long-term care, and mortality. Clinically meaningful sex differences in age-standardized rates were determined graphically through expert consultations. Results: Women with dementia had higher rates of ambulatory care and pharmacological care, while men with dementia had higher acute hospital care, admission to long-term care, and mortality. There was no meaningful difference in visits to cognition specialists, antipsychotic prescriptions, and hospital death. Discussion: Men and women with dementia demonstrate differences in healthcare utilization and mortality. Addressing these differences will inform decision-makers, care providers and researchers and guide more equitable policy and interventions in dementia care.

The Relationship Between Residential Mobility and Mortality Following Acute Myocardial Infarction

BACKGROUND

The extent to which residential mobility is associated with declining health among disease-specific populations, such as survivors of acute myocardial infarction (AMI), remains unknown.

METHODS

This prospective cohort study consisted of 3377 patients followed from index AMI (December 1, 1999 to March 30, 2003) to death or the last available follow-up date (March 30, 2020) in Ontario, Canada. Each residential postal code move from a patient's sentinel AMI event was tracked. Time-varying Cox proportional hazards examined the associated impact of each residential postal code move on mortality after adjusting for age, sex, baseline socioeconomic, psychosocial factors, changes in neighbourhood income level from each residential move, preexisting cardiovascular and noncardiovascular illnesses, and rural residence. All models evaluated death and long-term care institutionalisation as competing risks to distinguish mortality from other end-of-life destination outcomes among community-dwelling populations.

RESULTS

The study sample included 3369 patients with 1828 (54.3%) having at least 1 residential move throughout the study; 86.5% of patients either died in the community or moved from a community dwelling into a long-term care facility as an end-of-life destination. When adjusted for baseline factors and changing neighbourhood socioeconomic status over time, each residential move was associated with a 12% higher rate of death (adjusted hazard ratio [HR] 1.12, 95% confidence interval [CI] 1.05-1.19; P < 0.001) and a 26% higher rate of long-term care end-of-life institutionalisation (adjusted HR 1.26, 95% CI 1.14-1.58; P < 0.001).

CONCLUSIONS

Residential mobility was associated with higher mortality after AMI. Further research is needed to better evaluate intermediary causal pathways that may explain why residential mobility is associated with end-of-life outcomes.

Inter-provincial variation in older home care clients and their pathways: a population-based retrospective cohort study in Canada

BACKGROUND

In Canada, publicly-funded home care programs enable older adults to remain and be cared for in their home for as long as possible but they often differ in types of services offered, and the way services are delivered. This paper examines whether these differing approaches to care shape the pathway that home care clients will take. Older adult client pathways refer to trajectories within, and out of, the home care system (e.g., improvement, long term care (LTC) placement, death).

METHODS

A retrospective analysis of home care assessment data (RAI-HC was linked with health administrative data, long-term care admissions and vital statistics in Nova Scotia Health (NSH) and Winnipeg Regional Health Authority (WRHA). The study cohort consists of clients age 60 + years, admitted to home care between January 1, 2011 to December 31, 2013 and up to four years from baseline. Differences in home care service use, client characteristics and their pathways were tested across the two jurisdictions overall, and among the four discharge streams within jurisdictions using t-tests and chi-square tests of significance.

RESULTS

NS and WHRA clients were similar in age, sex, and marital status. NS clients had higher levels of need (ADL, cognitive impairment, CHESS) at base line and were more likely discharged to LTC (43% compared to 38% in WRHA). Caregiver distress was a factor correlated with being discharged to LTC. While a third remained as home care clients after 4 years; more than half were no longer in the community - either discharged to LTC placement or death. Such discharges occurred on average at around two years, a relatively short time period.

CONCLUSIONS

By following older clients over 4 years, we provide enhanced evidence of client pathways, the characteristics that influence these paths, as well as the length of time to the outcomes. This evidence is central to identification of clients at risk in the community and aids in planning for future home care servicing needs that will allow more older adults to remain living in the community.

Profiles of socially isolated community-dwelling older adults during the COVID-19 pandemic: A latent class analysis

OBJECTIVE

To identify different profiles of socially isolated older adults during the first wave of COVID-19 in Quebec, Canada.

STUDY DESIGN

Cross-sectional data were obtained through a telehealth socio-geriatric risk assessment tool, ESOGER, administered to adults aged 70 years or more between April and July 2020 in Montreal, Canada.

MEASURES

Those living alone with no social contacts in the last few days were considered socially isolated. Latent class analysis was performed to identify profiles of socially isolated older adults based on: age, sex, polypharmacy, use of home care, use of a walking aid, recall of current year/month, anxiety level (scale 0-10), and need for follow-up from a healthcare provider.

RESULTS

Three-hundred and eighty (380) older adults identified as socially isolated were analyzed, of whom 75.5 % were female and 56.6 % were over 85. Three classes were identified: Class 1 ("physically frail older females") had the highest proportion of polypharmacy, walking aid, and home care use. Class 2 ("anxious, relatively younger males") were predominantly males who used the least home care but had the highest anxiety levels. Class 3 ("seemingly well older females") had the highest proportion of females, lowest proportion of polypharmacy, lowest anxiety level, and none used a walking aid. Recall of current year/month was similar across the three classes.

CONCLUSIONS

This study found heterogeneity among socially isolated older adults during the first wave of the COVID-19 pandemic with varying levels of physical and mental health. Our findings may contribute to the development of targeted interventions to support this vulnerable population during and after the pandemic.

Long-Term Exercise Assistance: Group and One-on-One Interactions between a Social Robot and Seniors

For older adults, regular exercises can provide both physical and mental benefits, increase their independence, and reduce the risks of diseases associated with aging. However, only a small portion of older adults regularly engage in physical activity. Therefore, it is important to promote exercise among older adults to help maintain overall health. In this paper, we present the first exploratory long-term human–robot interaction (HRI) study conducted at a local long-term care facility to investigate the benefits of one-on-one and group exercise interactions with an autonomous socially assistive robot and older adults. To provide targeted facilitation, our robot utilizes a unique emotion model that can adapt its assistive behaviors to users’ affect and track their progress towards exercise goals through repeated sessions using the Goal Attainment Scale (GAS), while also monitoring heart rate to prevent overexertion. Results of the study show that users had positive valence and high engagement towards the robot and were able to maintain their exercise performance throughout the study. Questionnaire results showed high robot acceptance for both types of interactions. However, users in the one-on-one sessions perceived the robot as more sociable and intelligent, and had more positive perception of the robot’s appearance and movements.

Caring for older men and women: whose caregivers are more distressed? A population-based retrospective cohort study

BACKGROUND

To our knowledge, no population-based studies have examined whether family or friend caregivers of men and women differ in their experience of distress over time. Thus, we aimed to describe, on a population-level and longitudinally, how older men and women care-receivers differed in their health and care needs, compare their caregivers' distress trajectories, and identify factors that contribute to the observed differences.

METHODS

This is a population-based, retrospective cohort study using routinely collected data. We examined longitudinally 485,407 community-dwelling Ontario residents, aged over 50 years, who have received at least one Residential Assessment Instrument-Home Care (RAI-HC) assessment between April 2008 and June 2015. Descriptive analyses were performed on the demographic characteristics, health profiles, and care needs of men and women. We also compared their caregivers' baseline and one-year change in distress status. Logistic regressions were performed to examine if the effect of gender on caregiver distress is reduced after controlling for care-receiver's health and functional status as well as their caregiver's kinship and co-residence status.

RESULTS

Men (39.5% of our cohort) were frailer, required more care, were mostly cared for by their spouses (52%), and mostly lived with their caregiver (66%). In contrast, women (60.5%) were more likely cared for by their child/child-in-law (60%), less likely to live with caregivers (47%), and received less care. Caregivers of men were more likely to be distressed at baseline (27.7% versus 20.4% of women caregivers) and remain distressed (74.6% versus 69.5%) or become distressed (19.3% versus 14.3%) throughout the year. In logistic regression modelling, the effect of care-receiver's gender on caregiver distress is reduced from an unadjusted odds ratio of 1.49 (95% CI: 1.47-1.51) to 1.17 (95% CI: 1.15-1.19) when care-receiver's health and caregiving factors are controlled for.

CONCLUSION

Older men and women differed in health and care needs. Caregivers, especially those caring for men, were often distressed and remained so through time. These results highlight the need for policies that account for the differential care needs and caregiver profiles of men and women in order to offer targetted and appropriate support.

Caregiving Needs Are Unmet for Many Older Homeless Adults: Findings from the HOPE HOME Study

BACKGROUND

The homeless population is aging, with early onset of cognitive and functional impairments. It is unclear whether older homeless adults receive caregiving assistance that could prevent long-term disability.

OBJECTIVE

We describe characteristics of older homeless-experienced adults with caregiving need and determine factors associated with having unmet need.

DESIGN AND PARTICIPANTS

Cross-sectional analysis of a longitudinal study, Health Outcomes in People Experiencing Homelessness in Older Middle Age (HOPE HOME), examining health, life course events, and functional status among older homeless-experienced (i.e., currently and recently homeless) adults. We recruited 350 homeless adults (July 2013-June 2014) and an additional 100 (August 2017 to July 2018) in Oakland, California; this study includes 303 participants who completed caregiving interviews.

MEASUREMENTS

We defined caregiving need as difficulty with activities of daily living (ADLs), instrumental activities of daily living (IADLs), falls, Short Physical Performance Battery (SPPB) score < 10, or Modified Mini-Mental State (3MS) exam impairment. We defined unmet need as having caregiving need and reporting not receiving caregiving assistance in the last 6 months. Using logistic regression, we analyzed associations between respondent characteristics and unmet caregiving need.

RESULTS

Among 303 participants, the mean age was 61.3 ± 5.0 years; 73% were men and 82% were Black. Eighty-one percent had caregiving needs, and in 82% of those, their caregiving needs were unmet. Better self-rated health (AOR 2.13, CI [1.02-4.46], p = 0.04) and being a man (AOR 2.30, CI [1.12-4.69], p = 0.02) were associated with higher odds of unmet need. Moderate or high-risk substance use (AOR 0.47, CI [0.23, 0.94], p = 0.03) was associated with lower odds of unmet need.

CONCLUSIONS

Older homeless-experienced adults have high prevalence of unmet caregiving need. Interventions that increase caregiving access for homeless-experienced individuals may help avoid poor health outcomes and costly long-term-care needs due to untreated disabilities.

People Living with a Dementia Diagnosis with No Eldercare at all: Who Are They?

Dementia is a non-curable disease that progressively affects people's ability to handle their everyday life. Still, previous Swedish research found that many people living with dementia (PlwD) do not use any eldercare. In this study, we investigated the association between not using eldercare services and key social background factors: years with dementia, hospital care, and country of birth for PlwD. We identified all people aged 65+ diagnosed with dementia between January 2006 and March 2015 (n = 43,372) using secondary data analysis of information taken from multiple Swedish nationwide registers. Results showed that not using eldercare was more common among younger age groups and men. The likelihood of having no eldercare was three times higher for those cohabiting; notably, almost a fifth of the PlwD who had the diagnosis for four years or more did not have eldercare at all. Finally, people born outside Europe used eldercare less than persons born in Sweden. Since the public dementia policy in Sweden is basically geared toward PlwD in a later stage and primarily in residential care, there has been almost no policy development around the needs and rights of PlwD in their homes. This study provides a ground for reconsidering dementia policy regardless of the ethnic and cultural backgrounds of PlwD.

Developing an evidence-informed model of long-term life care at home for older adults with medical, functional and/or social care needs in Ontario, Canada: a mixed methods study protocol

INTRODUCTION

The COVID-19 pandemic exacerbated existing challenges within the Canadian healthcare system and reinforced the need for long-term care (LTC) reform to prioritise building an integrated continuum of services to meet the needs of older adults. Almost all Canadians want to live, age and receive care at home, yet funding for home and community-based care and support services is limited and integration with primary care and specialised geriatric services is sparse. Optimisation of existing home and community care services would equip the healthcare system to proactively meet the needs of older Canadians and enhance capacity within the hospital and residential care sectors to facilitate access and reduce wait times for those whose needs are best served in these settings. The aim of this study is to design a model of long-term 'life care' at home (LTlifeC model) to sustainably meet the needs of a greater number of community-dwelling older adults.

METHODS AND ANALYSIS

An explanatory sequential mixed methods design will be applied across three phases. In the quantitative phase, secondary data analysis will be applied to historical Ontario Home Care data to develop unique groupings of patient needs according to known predictors of residential LTC home admission, and to define unique patient vignettes using dominant care needs. In the qualitative phase, a modified eDelphi process and focus groups will engage community-based clinicians, older adults and family caregivers in the development of needs-based home care packages. The third phase involves triangulation to determine initial model feasibility.

ETHICS AND DISSEMINATION

This study has received ethics clearance from the University of Waterloo Research Ethics Board (ORE #42182). Results of this study will be disseminated through peer-reviewed publications and local, national and international conferences. Other forms of knowledge mobilisation will include webinars, policy briefs and lay summaries to elicit support for implementation and pilot testing phases.

Approaching person-centered long-term care: The trajectories of intrinsic capacity and functional decline in Taiwan

AIM

To examine the longitudinal trajectory of intrinsic capacity over a 3-year period among long-term care recipients in Taiwan, its association with functional decline and the onset of severe dependency.

METHODS

A total of 9448 individuals aged ≥50 years utilizing home and community-based long-term care services with complete data from three separate evaluations in Taiwan were included in the study. We carried out a latent class linear mixed model to identify heterogeneous patterns of intrinsic capacity over time, a mixed-effects model to investigate their impact on activities of daily living and a Kaplan-Meier analysis to examine the onset year of severe dependency among different intrinsic capacity classes.

RESULTS

The results identified four classes sharing similar longitudinal the intrinsic capacity trajectories: "high-stable" (20.13%), "normal-stable" (40.58%), "sensory-dysfunction" (29.53%) and "all-dysfunction" (9.76%). Individuals with predisposing characteristics were associated with lower activities of daily living, with the exception of age and education level. In addition, the poor intrinsic capacity class (b from -16.94 to -6.61, P < 0.001) had a worse evolution in terms of activity of daily living scores, and was associated with an earlier onset of severe dependency in 2.5 years in the all-dysfunction class.

CONCLUSIONS

Heterogeneous patterns of intrinsic capacity that delay further functional decline are promising markers of function trajectories for a person-centered care approach in long-term care services. Targeting the needs of intrinsic capacity groups to prevent functional decline offer insights into: (i) strengthening function-centered care modalities to delay severe dependency as individuals get older; and (ii) validating regular monitoring intrinsic capacity as an early warning system to achieve healthy aging. Geriatr Gerontol Int 2022; ••: ••-••.

Eldercare services for people with and without a dementia diagnosis: an analysis of Swedish registry data

Background

The growing number of people living with dementia (PlwD) implies an increase in the demand for eldercare services in Sweden like in many other countries. Few studies have analyzed the use of eldercare services for PlwD. The aim of the present study is to investigate the association between demographic factors (age, sex, cohabiting status) and the use of municipal eldercare services (including both home care and residential care) for older adults with dementia compared to older adults without dementia in Sweden.

Methods

This study used several nationwide Swedish registers targeting all individuals aged 65 and above living in Sweden in 2014 and still alive 31st of March 2015 (n = 2,004,409). The primary outcomes variables were different types of eldercare service, and all participants were clustered based on age, sex, cohabiting status, and dementia diagnosis. In addition to descriptive statistics, we performed multivariate logistic regression models for binary outcomes and linear regression models for continuous outcomes.

Results

Results showed that (1) older age is a significantly strong predictor for the use of eldercare services, although PlwD start using eldercare at an earlier age compared with people without dementia; (2) women tend to receive more eldercare services than men, especially in older age, although men with dementia who live alone are more likely than women living alone to receive eldercare; (3) having a dementia diagnosis is a strong predictor for receiving eldercare. However, it was also found that a substantial proportion of men and women with dementia did not receive any eldercare services.

Conclusions

We found that people with a dementia diagnosis use more as well as start to use eldercare services at an earlier age than people without dementia. However, further research is needed to investigate why a substantial part of people with a dementia diagnosis does not have any eldercare at all and what the policy implications of this might be.

Gender disparity in the individual attitude toward longevity among Japanese population: Findings from a national survey

The unprecedented population aging brings profound influences to the social values of longevity. The individual attitudes toward the expended life time deserves scrutiny, as it reflects the impacts of social networks and social welfare on people’s life and wellbeing. This study aims to examine whether and how gender disparity is affecting the individual anticipation to longevity among Japanese citizen. We used the dataset of National Survey on Social Security and Peoples Life implemented in 2017 to calculate the odds ratios (OR) of the individual anticipation to longevity. Besides gender, other demographic characteristics, physical and mental health, the experience of nursing care for the elderly, financial conditions and social networks are examined by performing the multilevel mixed-effects logistic regression analysis. The results indicate the robust effects of gender disparity on the individual aspiration for longevity. The proportion of those who inclined the positive statement on longevity was estimated to be 69.7% (95% CI: 68.6% - 70.9%) in the whole population, and 70.9% (95% CI: 69.4% - 72.5%) and 68.7% (95% CI: 67.1% - 70.2%) in male and female, respectively. Besides gender, independent factors significantly affecting the individual valuation of longevity include age, annual household income, the experience of nursing care, household saving, having a conversation with others and the availability of reliable partner(s) for relevant supports; while the common factors affecting the outcome variable were self-perceived health status and mental distress measured by K6. The interaction of gender and these significant factors were determined as well. In conclusion, with relevant representativeness and quality of data source, this analysis adds knowledge on gender disparity in the individual anticipation on longevity. The findings are suggestive to reform the social security system in the super aged society.

Impact of Dementia on Patterns of Home Care After Inpatient Rehabilitation Discharge for Older Adults After Hip Fractures

OBJECTIVE

To describe differences in home care use in the 30 days after discharge from inpatient rehabilitation after a hip fracture among older adults with dementia compared with those without dementia.

DESIGN

Retrospective cohort study of individually linked health administrative data.

SETTING

Community-dwelling older adults after discharge from inpatient rehabilitation facilities in Ontario, Canada.

PARTICIPANTS

A total of 17,263 older adults (N=17,263), of whom 2489 had dementia (14.4%), who were treated for hip fracture in acute care and then admitted to inpatient rehabilitation facilities between January 1, 2011 and March 31, 2017.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The proportion receiving home care services and number of visits (physiotherapy, occupational therapy, nursing, personal/homemaking) in the 30 days after discharge were compared by dementia status with multivariate models, stratified by sex.

RESULTS

Compared with those without dementia, adults with dementia were older, had lower functional scores, and were more likely to receive home care services in the 30 days after discharge from inpatient rehabilitation (87.0% vs 79.0%, P<.001), including personal/homemaking services (66.1% vs 46.4%, P<.001) and occupational therapy (45.3% vs 37.4, P<.001) but not physiotherapy (55.8% vs 56.2%, P=.677) or nursing (19.6% vs 18.7%, P=.268). After adjustment, older adults with dementia were more likely to receive home care in both men (odds ratio [OR] =2.01; 95% confidence interval [CI], 1.57-2.57) and women (OR=1.50; 95% CI, 1.30-1.74) as well as more services (rate ratio men=1.60; 95% CI, 1.44-1.79; rate ratio women=1.50; 95% CI, 1.41-1.60).

CONCLUSIONS

Among older adults discharged from inpatient rehabilitation, older adults with dementia received home care services more often than older adults without dementia. However, irrespective of sex and dementia status, almost half of this population (44%) did not receive physiotherapy. We recommend that, resources permitting, all older adults receive physiotherapy to facilitate recovery.

Sex-based differences in clinical outcomes and resource utilization of type 2 myocardial infarction

BACKGROUND

Sex-based differences in clinical outcomes have been previously well described in type 1 myocardial infarction (T1MI). However, type 2 myocardial infarction (T2MI) is more common in contemporary practice, with scarce data regarding sex-based differences of outcomes.

METHODS

The Nationwide Readmission Database 2018 was queried for hospitalizations with T2MI as a primary or secondary diagnosis. Complex samples multivariable logistic and linear regression models were used to determine the association between T2MI and outcomes (in-hospital mortality, index length of stay [LOS], hospital costs, discharge to nursing facility, and 30-day all-cause readmissions) in females compared to males with T2MI.

RESULTS

A total of 252,641 hospitalizations [119,783 (47.4%) females and 132,858 (52.6%) males] were included in this analysis. Females with T2MI was associated with lower in-hospital mortality (adjusted odds ratio [aOR] 0.92; 95% confidence interval [CI] 0.88-0.96; P < 0.001), shorter LOS (adjusted parameter estimate [aPE] -0.28; 95% CI -0.38-0.17; P < 0.001), less hospital costs (aPE -1510.70; 95% CI -1916.04-1105.37; P < 0.001), and increased nursing home discharges (aOR 1.08; 95% CI 1.05-1.12; P < 0.001) compared to males with T2MI. Females and males with T2MI had similar rates of 30-day all-cause readmission (aOR 1.00; 95% CI 0.97-1.04; P = 0.841).

CONCLUSION

Among T2MI hospitalizations, females have lower in-hospital mortality, hospitalization costs, shorter LOS, and increased rates of nursing home discharge compared to males. Although statistically significant, the clinical significance of these small differences are unknown and require future studies.

Medical care needs for patients receiving home healthcare in Taiwan: Do gender and income matter?

Studies about medical care needs for home healthcare (HHC) previously focused on disease patterns but not gender and income differences. We used the Taiwan National Health Research Insurance Database from 1997 to 2013 to examine trends in medical care needs for patients who received HHC, and the gender and income gaps in medical care needs, which were represented by resource utilization groups (RUG). We aimed to clarify three questions: 1. Are women at a higher level of medical care needs for HHC than men, 2. Does income relate to medical care needs? 3. Is the interaction term (gender and income) related to the likelihood of medical care needs? Results showed that the highest level of medical care need in HHC was reducing whereas the basic levels of medical care need for HHC are climbing over time in Taiwan during 1998 and 2013. The percentages of women with income-dependent status in RUG1 to RUG4 are 26.43%, 26.24%, 30.68%, and 32.07%, respectively. Women were more likely to have higher medical care needs than men (RUG 3: odds ratio, OR = 1.17, 95% confidence interval, CI = 1.10-1.25; RUG4: OR = 1.13, 95% CI = 1.06-1.22) in multivariates regression test. Compared to the patients with the high-income status, patients with the income-dependent status were more likely to receive RUG3 (OR = 2.34, 95% CI = 1.77-3.09) and RUG4 (OR = 1.98, 95% CI = 1.44-2.71). The results are consistent with the perspectives of fundamental causes of disease and feminization of poverty theory, implying gender and income inequalities in medical care needs. Policymakers should increase public spending for delivering home-based integrated care resources, especially for women with lower income, to reduce the double burden of female poverty at the higher levels of medical care needs for HHC.

Making the Decision to Move to a Nursing Home: Longitudinal Evidence From the Health and Retirement Study

This study applied the theory of planned behavior to examine predictors of U.S. older adults' (65+ years) intention and behavior of moving to a nursing home. Two waves of Health and Retirement Study data were used (N = 9,969). Moving intention was measured by respondents' self-reported probability to move in the next 5 years in Wave 1. Moving behavior was measured by whether they actually moved in Wave 2. Structural equation modeling was used to examine the relationships of demographic and health predictors with moving intention and behavior. For both genders, advanced age, poorer health, having fewer children, and long-term care insurance were associated with higher levels of moving intention and behavior. Men's intention was a significant predictor of subsequent moving behavior. However, women's intention was not associated with moving behavior, probably due to inadequate resources to support their preference. The findings provide meaningful personhood-centered insights into nursing home entry decisions.

Long-term care use after a stroke or femoral fracture and the role of family caregivers

Background

There has been a shift from institutional care towards home care, and from formal to informal care to contain long-term care (LTC) costs in many countries. However, substitution to home care or informal care might be harder to achieve for some conditions than for others. Therefore, insight is needed in differences in LTC use, and the role of potential informal care givers, across specific conditions. We analyze differences in LTC use of previously independent older patients after a fracture of femur and stroke, and in particular examine to what extent having a partner and children affects LTC use for these conditions.

Methods

Using administrative data on Dutch previously independent older people (55+) with a fracture of femur or stroke in 2013, we investigate their LTC use in the year after the condition takes place. We use administrative treatment data to select individuals who were treated by a medical specialist for a stroke or femoral fracture in 2013. Subsequent LTC use is measured as using no formal care, home care, institutional care or being deceased at 13 consecutive four-weekly periods after initial treatment. We relate long-term care use to having a partner, having children, other personal characteristics and the living environment.

Results

The probability to use no formal care 1 year after the initial treatment is equally high for both conditions, but patients with a fracture are more likely to use home care, while patients with a stroke are more likely to use institutional care or have died. Having a spouse has a negative effect on home care and institutional care use, but the timing of the effect, especially for institutional care, differs strongly between the two conditions. Having children also has a negative effect on formal care use, and this effect is consistently larger for patients with a fracture than patients with a stroke.

Conclusion

As the condition and the effect of potential informal care givers matter for subsequent long-term care use, policy makers should take the expected prevalence of specific conditions within the older people population into account when designing long-term care policies.

Profile of Long-Term Care Recipients Receiving Home and Community-Based Services and the Factors That Influence Utilization in Taiwan

In response to the irreversible aging trend, the Taiwan government has promoted the Long-Term Care (LTC) policy 1.0 launched in 2007 and the LTC policy 2.0 reform since 2016. This study aimed to explore the utilization of formal home and community-based care under LTC policy 1.0 to add scientific support for the on-going LTC policy 2.0 reform. Methods: By using Andersen and Aday’s behavioral model of healthcare utilization, the long-term care dataset was analyzed from 2013 to 2016. A total of 101,457 care recipients were identified after data cleaning. Results: The results revealed that about 40.7% of the care recipients stayed in the care system for more than two years. A common factor influencing the length of home and community-based services (HCBS) utilization period included need factors, where more dependent recipients leave the LTC system regardless of their socio-economic status. However, the utilization period of non-low-income households is significantly affected by the level of service resources. Conclusion: For long-term care needs, the phenomenon of a short utilization period was concerning. This study adds information which suggests policy should reconsider care capacity and quality, especially for moderate to severely dependent recipients. This will allow for better understanding to help maintain care recipients in their own communities to achieve the goal of having an aging in place policy.

Evaluating quality of overall care among older adults with diabetes with comorbidities in Ontario, Canada: a retrospective cohort study

OBJECTIVES

This study aimed to: (1) explore whether the quality of overall care for older people with diabetes is differentially affected by types and number of comorbid conditions and (2) examine the association between process of care measures and the likelihood of all-cause hospitalisations.

DESIGN

A population-based, retrospective cohort study.

SETTING

The province of Ontario, Canada.

PARTICIPANTS

We identified 673 197 Ontarians aged 65 years and older who had diabetes comorbid with hypertension, chronic ischaemic heart disease, osteoarthritis or depression on 1 April 2010.

MAIN OUTCOME MEASURES

The study outcome was the likelihood of having at least one hospital admission in each year, during the study period, from 1 April 2010 to 3 March 2014. Process of care measures specific to older adults with diabetes and these comorbidities, developed by means of a Delphi panel, were used to assess the quality of care. A generalised estimating equations approach was used to examine associations between the process of care measures and the likelihood of hospitalisations.

RESULTS

The study findings suggest that patients are at risk of suboptimal care with each additional comorbid condition, while the incidence of hospitalisations and number of prescribed drugs markedly increased in patients with 2 versus 1 selected comorbid condition, especially in those with discordant comorbidities. The median continuity of care score was higher among patients with diabetes-concordant conditions compared with those with diabetes-discordant conditions, and it declined with additional comorbid conditions in both groups. Greater continuity of care was associated with lower hospital utilisation for older diabetes patients with both concordant and discordant conditions.

CONCLUSIONS

There is a need for focusing on improving continuity of care and prioritising treatment in older adults with diabetes with any multiple conditions but especially in those with diabetes-discordant conditions (eg, depression).

Gender differences regarding opinions on long-term care arrangements: A study of community-dwelling older adults

BACKGROUND

Numerous studies have attempted to identify predictors of institutionalization in the general population. Gender studies have led to inconsistent results. Some authors argued that older women were more likely than older men to use long-term care services, while others failed to highlight a specific gender effect on the use of long-term care services. The aim of this study was to assess the effects of gender on the preferences of older citizens for long-term care using a panel of disability situations.

METHODS

We used a set of ten vignettes displaying disability situations with or without an able-bodied spouse present and used a population-based survey to inquire about appropriate long-term care. Participants were 3102 community-dwelling persons aged 68-83 years included in the representative Lausanne cohort 65+ study in January 2017. Multinomial logistic regression analyses were used to explore the effect of gender on long-term care choices by older men and women, controlling for the respondent's age and living arrangement.

RESULTS

The respondents' choices shifted toward institutionalization when the disorder severity increased in vignettes and when there was no spouse able to help. Men were more likely to choose a home setting with caregiving only by spouse even when the level of disability increased. Women chose help from professionals, sheltered homes, or institutionalization more quickly than men.

CONCLUSIONS

Exploring gender preferences for long-term care arrangements is critical for improving and planning long-term care services.

Improving Prediction of Risk of Admission to Long-Term Care or Mortality Among Home Care Users With IDD

Background

Frailty is an established predictor of admission into long-term care (LTC) and mortality in the elderly population. Assessment of frailty among adults with intellectual and developmental disabilities (IDD) using a generic frailty marker may not be as predictive, as some lifelong disabilities associated with IDD may be interpreted as a sign of frailty. This study set out to determine if adding the Home Care-Intellectual and Developmental Disabilities Frailty Index (HC-IDD Frailty Index), developed for use in home care users with IDD, to a basic list of predictors (age, sex, rural status, and the Johns Hopkins Frailty Marker) increases the ability to predict admission to long-term care or death within one year.

Methods

A retrospective cohort study was conducted using Residential Assessment Instrument for Home Care (RAI-HC) data for adult home care users with IDD who had a home care assessment between January 1, 2010 and December 31, 2013 (N = 6,169).

Results

The HC-IDD Frailty Index was found to significantly improve prediction of transitions into LTC or death by explaining an additional 5.95% of the variance in such transitions among home care users with IDD (p value < .0001).

Conclusions

We recommend the use of the HC-IDD Frailty Index in care planning and in further research related to the effectiveness of interventions to reduce or delay adverse age-related outcomes among adults with IDD.

Lower Prescription Rates in Centenarians with Heart Failure and Heart Failure and Kidney Disease Combined: Findings from a Longitudinal Cohort Study of Very Old Patients

BACKGROUND

Centenarians are considered as models of successful aging and represent a special group of patients. The aim of this study was to analyze heart failure epidemiology and treatment trajectories in centenarians compared to nonagenarians (90-99 years of age) and octogenarians (80-89 years of age) with heart failure and with heart failure and kidney disease combined.

METHODS

This cohort study used quarterly structured routine data from 1398 German insurants over 6 years prior to death (398 centenarians were compared with 500 nonagenarians and 500 octogenarians). Of those, 525 individuals were diagnosed with heart failure before death; 164 had heart failure and kidney disease combined. Generalized estimation equations were used to assess the association of diagnoses of heart failure and other diseases with medication prescriptions.

RESULTS

Across age groups, heart failure was significantly more prevalent in centenarians compared with octogenarians and nonagenarians. Prevalence of heart failure increased over time. Female sex [odds ratio (men) = 0.70, p = 0.024], kidney disease (odds ratio = 1.31, p < 0.001), and hypertension (odds ratio = 1.52, p < 0.001) were all associated with heart failure. Overall, heart failure treatment changed significantly over time with an increased prescription rate of loop diuretics and a decreased rate of renin-angiotensin-system inhibitors. Centenarians were significantly less likely to receive treatment with renin-angiotensin-system inhibitors, loop diuretics, or beta-blockers compared with nonagenarians and octogenarians. Furthermore, aldosterone inhibitors were seldom prescribed; If-channel and neprilysin inhibitors were not routinely used in our sample. For those with heart failure and kidney disease combined, our data revealed that the prevalence of kidney disease was lower in centenarians than in younger patients before death. However, differences in prescription rates across age groups were non-significant, although numerically large. Finally, half of the patients in all three age groups with heart failure and kidney disease received treatment with renin-angiotensin-system inhibitors; about two out of five patients received beta-blockers, while prescription rates of aldosterone inhibitors were low.

CONCLUSIONS

While heart failure prevalence shows a continuous increase with age, prescription rates are lower in centenarians, emphasizing the need for further studies considering the quality of care and outcomes in this patient population. Disease management programs and trials are needed to develop guidelines that address the medically challenging treatment for very old patients with comorbid heart failure and kidney disease.

The Effectiveness of Home Services in Taiwan: A People-Centered Approach

Among available home and community-based services in Taiwan, there should be a focus on providing people with people-centered, value-based services. This study aims to follow up the people-centered health outcomes of care recipients and to examine the factors associated with to feedback for policy and practice in long-term care. A total of 9889 persons from the long-term care dataset were followed up for two years (T0–T4). The Cox Proportional Hazard Regression analyses to analyze mortality and the mixed effect models for health outcomes were used. Three classes among the care recipients were identified. Health profiles (HR = 1.46 and 2.56 for FI and FD compared with RI, p < 0.001), subsidy gap (HR = 1.01), and living status (HR = 0.88 for those living with spouse only) had a significant impact on mortality. The overall dropout rate was 52.3% at two years, and the health profiles at baseline significantly influenced the health outcome’s change. The health heterogeneity matters and influences subsequent outcomes. To reach the goal of the HCBS, regular and exact monitoring of care recipients is crucial, while feedback regarding health outcomes and a greater focus on providing person-centered and responsive services in the community are also required.

Home Care in Ontario: Perspectives on Equity

Home care is an integral aspect of the Canadian health care system. Services provided to individuals allow them to live with independence and dignity within the comfort of their own residences. This article examines the historical evolution of Ontario’s home care reform and the current challenges faced by staff members, patients, and their caregivers in reference to health equity. Political economy and feminist lenses are used to highlight the impact of market-based health care reforms on gendered experiences and access to home care services. Research and reports are used to critique the development of the home care system to date. Findings suggest that the current home care system is underfunded, understaffed, and inequitable in access to care. At this time, policies strategically remain blinded to the harsh realities of the home care sector in order to justify cost cutting, deregulation, and privatization of services.

Dementia-specific drug treatment in home care settings: A German multicentre study

AIMS AND OBJECTIVES

The aim of this study was to identify and analyse factors influencing the use of drugs for dementia treatment in home care settings.

BACKGROUND

While the number of care-dependent people with dementia is growing, it is not clear whether their medication follows the state of the art, especially in home care settings where over two-thirds of them are cared for in Germany. Although dementia is not curable, it is possible to reduce cognitive, behavioural and psychological symptoms of dementia with the appropriate use of medication. However, there is a lack of information concerning the drug treatment in home care settings.

METHODS

The study was conducted as a multicentre cross-sectional survey, including 923 participants from 102 home care institutions throughout Germany. Medical diagnosis, medication, consultations with a specialist within the previous 12 weeks of the initial assessment and additional general information were assessed following a standardised study protocol. Data were analysed using univariate and multivariate statistical methods. The manuscript was developed utilising the STROBE checklist for cross-sectional studies.

RESULTS

In home care, one in seven clients (14.8%) is diagnosed with some form of dementia. 52.6% (n = 72) of them were treated with dementia medication: AchEIs 16.1% (n = 22), memantine 9.5% (n = 13), antidepressants 23.4% (n = 32), antipsychotic medication 9.5% (n = 13), tranquilisers 16.8% (n = 23) and anticonvulsant drugs 6.6% (n = 9). Drug treatment for dementia was significantly associated with the consultation of a neurologist/psychiatrist in the previous 12 weeks.

CONCLUSIONS

It has been demonstrated that the use of drugs as a component of home care treatment for dementia depends on many factors and therefore varies.

RELEVANCE TO CLINICAL PRACTICE

It can be assumed that people living with dementia in home care settings are not sufficiently supplied with medication. Their medical care can be improved by establishing interdisciplinary care involving a neurologist/psychiatrist.

Variation in the health outcomes associated with frailty among home care clients: relevance of caregiver distress and client sex

Background

The identification of contextual factors that modify associations between client frailty and their health and service use outcomes is essential for informed home health care and policy planning. Our objective was to examine variation in the associations between frailty and select 1-year health outcomes by caregiver distress and client sex among community-residing older care recipients.

Methods

We conducted a retrospective cohort study using linked population-based clinical and health administrative databases for all long-stay home care clients (n = 234,552) aged 66+ years assessed during April 2010–2013 in Ontario, Canada. Frailty was assessed using a previously validated 72-item frailty index (FI). Presence of caregiver distress was derived from clinical assessment items administered by trained home care assessors. Multivariable log-binomial regression models were used to examine variations in the associations between frailty and outcomes of interest (mortality, nursing home [NH] placement, all-cause and prolonged hospitalization) by caregiver distress, with further model stratification by client sex.

Results

Frailty prevalence varied little by sex (19.3% women, 19.9% men) despite significant sex-differences in clients’ sociodemographic and health characteristics. In both sexes, frailty was significantly associated with all outcomes, particularly NH placement (RR = 3.84, 95%CI 3.75–3.93) and death (RR = 2.32, 95%CI 2.27–2.37), though risk ratios were greater for women. Caregiver distress was more common with increasing frailty and for male clients, and a significant independent predictor of NH placement and prolonged hospitalization in both sexes. The association between frailty and NH placement (but not other outcomes) varied by caregiver distress for both men and women (p < 0.001 interaction terms), showing a greater magnitude of association among clients without (vs. with) a distressed caregiver.

Conclusions

As caregiver distress varies by client sex, represents a key driver of NH placement (even among relatively robust clients), and modifies the impact of other risk factors such as frailty, it should be routinely assessed. Further, sex-differences should be considered when developing and evaluating community-based services for older adults and their caregivers.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0899-8) contains supplementary material, which is available to authorized users.

Determinants for utilization and transitions of long-term care in adults 65+ in Germany: results from the longitudinal KORA-Age study

BACKGROUND

Societies around the world face the burden of an aging population with a high prevalence of chronic conditions. Thus, the demand for different types of long-term care will increase and change over time. The purpose of this exploratory study was to identify determinants for utilization and transitions of long-term care in adults older than 65 years by using Andersen's Behavioral Model of Health Services Use.

METHODS

The study examined individuals older than 65 years between 2011/2012 (t₁) and 2016 (t₂) from the population-based Cooperative Health Research in the Region of Augsburg (KORA)-Age study from Southern Germany. Analyzed determinants consisted of predisposing (age, sex, education), enabling (living arrangement, income) and need (multimorbidity, disability) factors. Generalized estimating equation logistic models were used to identify determinants for utilization and types of long-term care. A logistic regression model examined determinants for transitions to long-term care over four years through a longitudinal analysis.

RESULTS

We analyzed 810 individuals with a mean age of 78.4 years and 24.4% receiving long-term care at t₁. The predisposing factors higher age and female sex, as well as the need factors higher multimorbidity and higher disability score, were determinants for both utilization and transitions of long-term care. Living alone, higher income and a higher disability score had a significant influence on the utilization of formal versus informal long-term care.

CONCLUSION

Our results emphasize that both utilization and transitions of long-term care are influenced by a complex construct of predisposing, enabling and need factors. This knowledge is important to identify at-risk populations and helps policy-makers to anticipate future needs for long-term care.

TRIAL REGISTRATION

Not applicable.

Where You Age Matters: Individual- and County-Level Predictors of Formal and Informal Care in Rural Appalachia

OBJECTIVE

Despite overall improvements in the U.S. health care, older adults living in rural counties, such as Appalachian Virginia, continue to be underserved.

METHOD

Multinomial regression models, including both individual and county data from 503 older adults aged 65+, were used to examine factors associated with informal and formal care use.

RESULTS

Older adults with stronger filial beliefs and less positive attitudes toward community services preferred informal help. If the county had more formal care services, however, older adults were more likely to use them, regardless of their filial beliefs. Disparities based on gender were observed, in that women who lived in counties with a higher percentage of older adults below the poverty line were more likely to receive no help than men.

DISCUSSION

Developing effective service promotion tactics, destigmatizing community services, and targeting services and support, especially to women, could decrease health disparities in rural Appalachia and similar geographic areas.

A large cluster randomized trial of outcome-based pathways to improve home-based wound care

BACKGROUND

Although not always recognized as a pressing health care problem, wounds are a common, complex and costly condition. The burden of treating wounds is growing rapidly due to increasing health care costs, an aging population and a sharp rise in the incidence of diabetes and obesity worldwide. The Integrated Client Care (ICC) Project was a multi-year initiative to develop and test a new, integrated model of wound care within the home care sector in Ontario, Canada to improve health outcomes for patients and decrease system costs.

METHODS

Cluster randomized trial, with allocation of intervention randomized at the cluster level (14 home care centers) and analysis of outcomes based on individual-level data (patients). Primary analysis was an intention-to-treat (ITT) analysis. Two wound types, diabetic foot ulcers and pilonidal sinus, were selected as tracer conditions to assess the impact of the intervention on two different patient populations. Time to successful discharge from home care was analyzed using multivariable Cox proportional hazards regression. Hazard ratios (HRs) and 95% confidence intervals (CIs) are presented.

RESULTS

A total of 12,063 diabetic foot ulcer patients and 1954 pilonidal sinus patient records were available for analysis. No appreciable differences were observed between patients in the control and intervention arms for either of the primary or secondary analyses in either condition group. In the diabetic foot ulcer group, 72.7% patients in the control arm and 73.6% patients in the intervention arm were discharged in the follow-up period (HR 1.05; 95% CI 0.94 to 1.17). In the pilonidal sinus group, 91.0% patients in the control arm and 89.0% patients in the intervention arm were discharged in the follow-up period (HR 0.96; 95% CI 0.82 to 1.12).

CONCLUSION

As implemented, the ICC intervention was not effective, most likely due to failure of implementation, and is, therefore, not ready for widespread implementation in Ontario. Significant work remains to be done to correct the implementation process so that the concept of outcome-based health care can be properly evaluated.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT01573832 . Registered on 12 January 2012.

Diabetes and the hospitalized patient : A cluster analytic framework for characterizing the role of sex, race and comorbidity from 2006 to 2011

In the US, one in four adults has two or more chronic conditions; this population accounts for two thirds of healthcare spending. Comorbidity, the presence of multiple simultaneous health conditions in an individual, is increasing in prevalence and has been shown to impact patient outcomes negatively. Comorbidities associated with diabetes are correlated with increased incidence of preventable hospitalizations, longer lengths of stay (LOS), and higher costs. This study focuses on sex and race disparities in outcomes for hospitalized adult patients with and without diabetes. The objective is to characterize the impact of comorbidity burden, measured as the Charlson Weighted Index of Comorbidities (WIC), on outcomes including LOS, total charges, and disposition (specifically, probability of routine discharge home). Data from the National Inpatient Sample (2006-2011) were used to build a cluster-analytic framework which integrates cluster analysis with multivariate and logistic regression methods, for several goals: (i) to evaluate impact of these covariates on outcomes; (ii) to identify the most important comorbidities in the hospitalized population; and (iii) to create a simplified WIC score. Results showed that, although hospitalized women had better outcomes than men, the impact of diabetes was worse for women. Also, non-White patients had longer lengths of stay and higher total charges. Furthermore, the simplified WIC performed equivalently in the generalized linear models predicting standardized total charges and LOS, suggesting that this new score can sufficiently capture the important variability in the data. Our findings underscore the need to evaluate the differential impact of diabetes on physiology and treatment in women and in minorities.

Age and sex differences in hospitalisation of nursing home residents: a systematic review

OBJECTIVES

Nursing home residents (NHRs) are frequently suffering from multimorbidity, functional and cognitive impairment, often leading to hospital admissions. Studies have found that male NHRs are more often hospitalised. The influence of age is inconclusive. We aimed to investigate the epidemiology of hospitalisations in NHRs, particularly focusing on age-specific and sex-specific differences.

DESIGN

A systematic review was performed in PubMed, CINAHL and Scopus. Quality of studies was assessed.

SETTING

Studies conducted in nursing homes were included.

PARTICIPANTS

Nursing home residents.

PRIMARY AND SECONDARY OUTCOMES

Outcome measures were the prevalence, incidence or duration of all-cause hospitalisation by age or sex.

RESULTS

We identified 21 studies, 13 were conducted in the USA. The proportion of residents being hospitalised ranged across studies from 6.8% to 45.7% for various time periods of follow-up. A total of 20 studies assessed the influence of sex and found that hospitalisations are more often in male NHRs. A total of 16 studies conducted multivariate analyses and the OR of hospitalisation for males was between 1.22 and 1.67. Overall, 18 studies assessed the influence of age. Some studies showed an increasing proportion of admissions with increasing age, but several studies also found decreasing hospitalisations above the age of about 80-85 years. 8 of 13 studies conducting multivariate analyses included age as a continuous variable. Only 1 study reported stratified analyses by age and sex. 2 studies investigating primary causes of hospitalisation stratified by sex found some differences in main diagnoses.

DISCUSSION

Male NHRs are more often hospitalised than females, but reasons for that are not well investigated. The influence of age is less clear, but there seems to be no clear linear relationship between age and the proportion being hospitalised. Further studies should investigate age and sex differences in frequencies and reasons for hospitalisation in NHRs.

The prevalence and health consequences of frailty in a population-based older home care cohort: a comparison of different measures

Background

Evaluating different approaches to identifying frail home care clients at heightened risk for adverse health outcomes is an important but understudied area. Our objectives were to determine the prevalence and correlates of frailty (as operationally defined by three measures) in a home care cohort, the agreement between these measures, and their predictive validity for several outcomes assessed over one year.

Methods

We conducted a retrospective cohort study with linked population-based administrative and clinical (Resident Assessment Instrument [RAI]) data for all long-stay home care clients (aged 66+) assessed between April 2010–2013 in Ontario, Canada (n = 234,552). We examined two versions of a frailty index (FI), a full and modified FI, and the CHESS scale, compared their baseline characteristics and their predictive accuracy (by calculating the area under the ROC curve [AUC]) for death, long-term care (LTC) admission, and hospitalization endpoints in models adjusted for age, sex and comorbidity.

Results

Frailty prevalence varied by measure (19.5, 24.4 and 44.1 %, for full FI, modified FI and CHESS, respectively) and was similar among female and male clients. All three measures were associated with a significantly increased risk of death, LTC admission and hospitalization endpoints in adjusted analyses but their addition to base models resulted in modest improvement for most AUC estimates. There were significant differences between measures in predictive accuracy, with the full FI demonstrating a higher AUC for LTC admission and CHESS a higher AUC for hospitalization - although none of the measures performed well for the hospitalization endpoints.

Conclusions

The different approaches to detecting vulnerability resulted in different estimates of frailty prevalence among home care clients in Ontario. Although all three measures were significant predictors of the health outcomes examined, the gains in predictive accuracy were often modest with the exception of the full FI in predicting LTC admission. Our findings provide some support for the clinical utility of a comprehensive FI measure and also illustrate that it is feasible to derive such a measure at the population level using routinely collected data. This may facilitate further research on frailty in this setting, including the development and evaluation of interventions for frailty.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-016-0309-z) contains supplementary material, which is available to authorized users.

The association between multimorbidity and hospitalization is modified by individual demographics and physician continuity of care: a retrospective cohort study

Background

Multimorbidity poses a significant clinical challenge and has been linked to greater health services use, including hospitalization; however, we have little knowledge about the influence of contextual factors on outcomes in this population. Objectives: To describe the extent to which the association between multimorbidity and hospitalization is modified by age, gender, primary care practice model, or continuity of care (COC) among adults with at least one chronic condition.

Methods

A retrospective cohort study with linked population-based administrative data.

Setting: Ontario, Canada. Cohort: All individuals 18 and older with at least one of 16 priority chronic conditions as of April 1, 2009 (baseline). Main Outcome Measures: Any hospitalization, 3 or more hospitalizations, non-medical discharge delay, and 30-day readmission within the 1 year following baseline.

Results

Of 5,958,514 individuals, 484,872 (8.1 %) experienced 646,347 hospitalizations. There was a monotonic increase in the likelihood of hospitalization and related outcomes with increasing multimorbidity which was modified by age, gender, and COC but not primary care practice model. The effect of increasing multimorbidity was greater in younger adults than older adults and in those with lower COC than with higher COC. The effect of increasing multimorbidity on hospitalization was greater in men than women but reversed for the other outcomes.

Conclusions

The effect of multimorbidity on hospitalization is influenced by age and gender, important considerations in the development of person-centred care models. Greater continuity of physician care lessened the effect of multimorbidity on hospitalization, further demonstrating the need for care continuity across providers for people with chronic conditions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1415-5) contains supplementary material, which is available to authorized users.

Frailty as a Predictor of Institutionalization Among Adults With Intellectual and Developmental Disabilities

Adults with intellectual and developmental disabilities (IDD) frequently become frail earlier than the general population, resulting in higher care needs. This population is at risk for institutionalization, or re-institutionalization, into long-term care (LTC). Using a retrospective cohort design to follow 3,034 individuals (18-99 years) living in Ontario, Canada, and assessed with the Resident Assessment Instrument-Home Care, individuals were characterized with a frailty index (FI) for persons with IDD. Survival analyses determined differences in rates of admission to LTC and survival in the community. Frail individuals had greater rates of admission than non-frail individuals, adjusted HR = 2.19, 95% CI [1.81, 2.64]. The FI predicts institutionalization.

Home support workers perceptions of family members of their older clients: a qualitative study

Background

Health care discourse is replete with references to building partnerships between formal and informal care systems of support, particularly in community and home based health care. Little work has been done to examine the relationship between home health care workers and family caregivers of older clients. The purpose of this study is to examine home support workers’ (HSWs) perceptions of their interactions with their clients’ family members. The goal of this research is to improve client care and better connect formal and informal care systems.

Methods

A qualitative study, using in-depth interviews was conducted with 118 home support workers in British Columbia, Canada. Framework analysis was used and a number of strategies were employed to ensure rigor including: memo writing and analysis meetings. Interviews were transcribed verbatim and sent to a professional transcription agency. Nvivo 10 software was used to manage the data.

Results

Interactions between HSWs and family members are characterized in terms both of complementary labour (family members providing informational and instrumental support to HSWs), and disrupted labour (family members creating emotion work and additional instrumental work for HSWs). Two factors, the care plan and empathic awareness, further impact the relationship between HSWs and family caregivers.

Conclusions

HSWs and family members work to support one another instrumentally and emotionally through interdependent interactions and empathic awareness. Organizational Care Plans that are too rigid or limited in their scope are key factors constraining interactions.

Association between age, gender and multimorbidity level and receiving home health care: a population-based Swedish study

Background

Home health care is an important part of primary health care. How delivery of home health care is organised is probably important for sustainability of the healthcare system as a whole. More than 50 % of individuals over 65 years old have multimorbidity, which increases with higher age, also influencing the needs of home health care. Our aim was to study the proportion of the population above 65 years receiving home health care according to age, gender and multimorbidity level.

Methods

The study population comprised 32,130 people aged 65 or more, living in Blekinge County in southern Sweden. We analysed data from patient electronic medical records for patients receiving home health care delivered in patients’ own homes by nurses, physiotherapists and occupational therapists. We used the Adjusted Clinical Groups Case-Mix System in order to group individuals according to diagnoses into six levels of multimorbidity. In order to analyse the differences between individuals receiving home health care and those who did not, we used Chi squared test. Logistic regression analysis was conducted in order to study how the dependent variable was influenced by the independent variables.

Results

A total of 7860 (28 %) of the studied population received home health care in 2011. Logistic regression analysis showed that men had 26 % lower odds of receiving home care compared to women (OR = 0.74, 95 % CI 0.69–0.78). There was also a substantial group (22 %) with low multimorbidity level among people receiving home health care. Adjusting for gender and age showed no differences in odds of receiving home health care for patients with lower levels of multimorbidity. However, for patients with higher levels of morbidity the odds increased dramatically for both genders.

Conclusion

The question of to whom and to what extent home health care should be provided is an important challenge for policy makers. Our results show that there are differences in the use of home health care dependent on gender, age and multimorbidity level, but also that home health care is provided to individuals with low morbidity. Further studies could explain the factors influencing home health care use.

Gender disparities in German home-care arrangements

An ageing population correlates with rising needs for long-term care (LTC). Support programmes should consider the specific needs of the various subgroups of care dependents and family caregivers. The objective of this study was to analyse the gender-specific disparities in home-care arrangements in Germany, and for this purpose, survey and insurance claims data were used. A survey of 2545 insured care recipients with high-level care needs was conducted in 2012 with the Barmer GEK, a major German statutory healthcare insurance. Insurance claims data were provided for a follow-up, focussing on the group aged 60 years and older. For statistical comparison, chi-squared test and t-tests were used, and a p-value < 0.05 was considered statistically significant. Most care recipients are female, and they are on average 2 years older than males. Men receive family care mostly from their wives, whereas widows frequently live alone and receive care from daughters, sons, other relatives, neighbours and friends, as well as from professional nursing services. Furthermore, women more often anticipate the need for (further) professional assistance and move in with a relative or to an assisted living facility or a nursing home in good time. The desired rate for relocation to a nursing home was higher than the anticipated, and during the 6-month follow-up, the actual rate of relocations was in between both. In summary, the caring situation of men and women is different. Care-receiving men are most often cared for by their wives. Widowed women need a social network and their children in order to remain in their own home. To provide better home-care arrangements for women in this situation, the family and social networks need a stronger focus in politics and research. To stabilise the home-care situation of men with high-level care needs, their wives need more support.

Gender-differences in disease distribution and outcome in hospitalized elderly: data from the REPOSI study

BACKGROUND AND PURPOSE

Women live longer and outnumber men. On the other hand, older women develop more chronic diseases and conditions such as arthritis, osteoporosis and depression, leading to a greater number of years of living with disabilities. The aim of this study was to describe whether or not there are gender differences in the demographic profile, disease distribution and outcome in a population of hospitalized elderly people.

METHODS

Retrospective observational study including all patients recruited for the REPOSI study in the year 2010. Analyses are referred to the whole group and gender categorization was applied.

RESULTS

A total of 1380 hospitalized elderly subjects, 50.5% women and 49.5% men, were considered. Women were older than men, more often widow and living alone or in nursing homes. Disease distribution showed that malignancy, diabetes, coronary artery disease, chronic kidney disease and chronic obstructive pulmonary disease were more frequent in men, but hypertension, osteoarthritis, anemia and depression were more frequent in women. Severity and comorbidity indexes according to the Cumulative Illness Rating Scale (CIRS-s and CIRS-c) were higher in men, while cognitive impairment evaluated by the Short Blessed Test (SBT), mood disorders by the Geriatric Depression Scale (GDS) and disability in daily life measured by Barthel Index (BI) were worse in women. In-hospital and 3-month mortality rates were higher in men.

CONCLUSIONS

Our study showed a gender dimorphism in the demographic and morbidity profiles of hospitalized elderly people, emphasizing once more the need for a personalized process of healthcare.

Effects of impairment in activities of daily living on predicting mortality following hip fracture surgery in studies using administrative healthcare databases

BACKGROUND

Impairment in activities of daily living (ADL) is an important predictor of outcomes although many administrative databases lack information on ADL function. We evaluated the impact of ADL function on predicting postoperative mortality among older adults with hip fractures in Ontario, Canada.

METHODS

Sociodemographic and medical correlates of ADL impairment were first identified in a population of older adults with hip fractures who had ADL information available prior to hip fracture. A logistic regression model was developed to predict 360-day postoperative mortality and the predictive ability of this model were compared when ADL impairment was included or omitted from the model.

RESULTS

The study sample (N = 1,329) had a mean age of 85.2 years, were 72.8% female and the majority resided in long-term care (78.5%). Overall, 36.4% of individuals died within 360 days of surgery. After controlling for age, sex, medical comorbidity and medical conditions correlated with ADL impairment, addition of ADL measures improved the logistic regression model for predicting 360 day mortality (AIC = 1706.9 vs. 1695.0; c -statistic = 0.65 vs 0.67; difference in - 2 log likelihood ratios: χ(2) = 16.9, p = 0.002).

CONCLUSIONS

Direct measures of ADL impairment provides additional prognostic information on mortality for older adults with hip fractures even after controlling for medical comorbidity. Observational studies using administrative databases without measures of ADLs may be potentially prone to confounding and bias and case-mix adjustment for hip fracture outcomes should include ADL measures where these are available.