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Nashi N, Chan DKW, Goh GJX, Loo SC, Soong JTY. Enhanced Comprehensive Care Programme: a retrospective study of patient empanelment by generalist-led multidisciplinary teams to reduce acute care utilisation. Singapore Med J 2024:00077293-990000000-00126. [PMID: 38993107 DOI: 10.4103/singaporemedj.smj-2023-049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 08/29/2023] [Indexed: 07/13/2024]
Abstract
INTRODUCTION Singapore faces an increasingly aged population with complex multimorbidity and psychosocial impairment. This change in demographic is challenging for existing healthcare systems. Breaks in care coordination and continuity result in poor health outcomes, increased acute care utilisation and higher healthcare costs. We proposed a patient empanelment approach adapted for the Singapore context based on the University of Chicago Comprehensive Care Physician model. METHODS This retrospective quasi-experimental, matched-controlled observational study sought to assess the effectiveness of the Enhanced Comprehensive Care Programme (ECCP) in reducing acute care utilisation at National University Hospital, Singapore. The primary outcomes were the number of hospitalisations and emergency department (ED) visits 6 months pre- and post-enrolment in ECCP. We used propensity score matching to balance prior healthcare utilisation between the intervention and control groups. RESULTS Fifty-seven participants were recruited in the programme between October 2019 and April 2020. There was a reduction in the mean number of hospitalisations after intervention compared to before intervention (0.58 ± 1.03 vs. 1.90 ± 1.07, P < 0.001). There was also a reduction in the mean number of ED visits (0.77 ± 1.05 vs. 1.96 ± 1.14, P < 0.001). In the propensity-matched cohort, the mean number of hospitalisations was reduced in the intervention group (from 1.92 ± 1.07 to 0.58 ± 1.03, P < 0.001) compared to the control group (from 1.85 ± 0.99 to 1.06 ± 1.17, P = 0.04). CONCLUSION This observational study shows the potential benefits of ECCP healthcare redesign to reduce acute care utilisation.
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Affiliation(s)
- Norshima Nashi
- Department of Medicine, National University Hospital, Singapore
| | | | | | - Swee Chin Loo
- Department of Medicine, National University Hospital, Singapore
| | - John Tshon Yit Soong
- Department of Medicine, National University Hospital, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Fleury MJ, Cao Z, Grenier G. Emergency Department Use among Patients with Mental Health Problems: Profiles, Correlates, and Outcomes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:864. [PMID: 39063441 PMCID: PMC11276606 DOI: 10.3390/ijerph21070864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 06/28/2024] [Accepted: 06/29/2024] [Indexed: 07/28/2024]
Abstract
Patients with mental health (MH) problems are known to use emergency departments (EDs) frequently. This study identified profiles of ED users and associated these profiles with patient characteristics and outpatient service use, and with subsequent adverse outcomes. A 5-year cohort of 11,682 ED users was investigated (2012-2017), using Quebec (Canada) administrative databases. ED user profiles were identified through latent class analysis, and multinomial logistic regression used to associate patients' characteristics and their outpatient service use. Cox regressions were conducted to assess adverse outcomes 12 months after the last ED use. Four ED user profiles were identified: "Patients mostly using EDs for accessing MH services" (Profile 1, incident MDs); "Repeat ED users" (Profile 2); "High ED users" (Profile 3); "Very high and recurrent high ED users" (Profile 4). Profile 4 and 3 patients exhibited the highest ED use along with severe conditions yet received the most outpatient care. The risk of hospitalization and death was higher in these profiles. Their frequent ED use and adverse outcomes might stem from unmet needs and suboptimal care. Assertive community treatments and intensive case management could be recommended for Profiles 4 and 3, and more extensive team-based GP care for Profiles 2 and 1.
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Affiliation(s)
- Marie-Josée Fleury
- Department of Psychiatry, McGill University, 1033, Pine Avenue West, Montreal, QC H3A 1A1, Canada
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Blvd., Montreal, QC H4H 1R3, Canada; (Z.C.); (G.G.)
| | - Zhirong Cao
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Blvd., Montreal, QC H4H 1R3, Canada; (Z.C.); (G.G.)
| | - Guy Grenier
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Blvd., Montreal, QC H4H 1R3, Canada; (Z.C.); (G.G.)
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Fleury MJ, Cao Z, Grenier G, Rahme E. Profiles of quality of outpatient care among individuals with mental disorders based on survey and administrative data. J Eval Clin Pract 2024. [PMID: 39031622 DOI: 10.1111/jep.14052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 05/24/2024] [Accepted: 06/03/2024] [Indexed: 07/22/2024]
Abstract
RATIONALE Though it is crucial to contribute to patient recovery through access, diversity, continuity and regularity of outpatient care, still today most of these are deemed nonoptimal. Identifying patient profiles based on outpatient service use and quality of care indicators might help formulate more personalized interventions and reduce adverse outcomes. AIMS AND OBJECTIVES This study aimed to identify profiles of individuals with mental disorders (MDs) patterned after their outpatient care use and quality of care received, and to link those profiles to individual characteristics and subsequent outcomes. METHODS A cohort of 5669 individuals with MDs was considered based on data from the 2013-2014 and 2015-2016 Canadian Community Health Survey, which were linked to administrative data from the Quebec health insurance registry. Latent class analysis generated profiles based on service use over the 12 months preceding each respondent's interview, and comparative analyses were used to associate profiles with sociodemographic and clinical characteristics, and health outcomes over the three following months. RESULTS Four profiles were identified. Profile 1 (P-1) was labelled 'Low service use'; P-2 'Moderate general practitioner (GP) care and continuity and regularity of care'; P-3 'High GP care, continuity and regularity of care, and low psychiatrist care'; and P-4 'High psychiatrist care and regularity of care, and low GP care'. Profiles 3 and 4 (~50% of the cohort) were provided with better care, but showed worse outcomes, mainly acute care use due to more complex conditions and unmet needs. Profiles 1 and 2 had better outcomes as they showed fewer risk factors such as being younger and having better social conditions. CONCLUSION Intensity, diversity and regularity of care were higher in profiles with more complex MDs, chronic physical illnesses, and worse perceived health conditions. Adapting specific interventions for each profile, such as assertive community treatment or intensive case management for Profile 4, is recommended.
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Affiliation(s)
| | - Zhirong Cao
- Douglas Hospital Research Centre, Montreal, Quebec, Canada
| | - Guy Grenier
- Douglas Hospital Research Centre, Montreal, Quebec, Canada
| | - Elham Rahme
- Department of Medicine, McGill University, Montreal, Quebec, Canada
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Abstract
Objectives: Patient trust in physicians is associated with patient satisfaction with healthcare, patients engaging in follow-up care, and positive health-related outcomes. The current study investigated whether age moderated the relation between trust in physicians and four health outcome variables, including patient satisfaction, doctor visits, emergency room visits, and hospital admissions. Methods: 398 English-speaking, community-dwelling adults completed measures of physician trust and important health outcome variables via Amazon Mechanical Turk. Results: Age significantly moderated relations between trust in physicians and hospital admissions, and trust in physicians and patient satisfaction, with both positive relations becoming stronger with increasing age. Discussion: The results highlight the need for a lifespan approach to the study of physician trust and related health outcomes. They offer an avenue for increasing physician trust, engagement with the healthcare system prior to the need for hospitalization, and the reduction of healthcare costs.
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Affiliation(s)
- Emma Katz
- Behavioral Medicine, VA Boston Healthcare System, Boston, MA, USA
| | - Barry Edelstein
- Department of Psychology, West Virginia University, Morgantown, WV, USA
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Bastholm-Rahmner P, Bergqvist M, Modig K, Gustafsson LL, Schmidt-Mende K. Homecare workers - an untapped resource in preventing emergency department visits among older individuals? A qualitative interview study from Sweden. BMC Geriatr 2024; 24:350. [PMID: 38637752 PMCID: PMC11027288 DOI: 10.1186/s12877-024-04906-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 03/20/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Older individuals with functional decline and homecare are frequent visitors to emergency departments (ED). Homecare workers (HCWs) interact regularly with their clients and may play a crucial role in their well-being. Therefore, this study explores if and how HCWs perceive they may contribute to the prevention of ED visits among their clients. METHODS In this qualitative study, 12 semi-structured interviews were conducted with HCWs from Sweden between July and November 2022. Inductive thematic analysis was used to identify barriers and facilitators to prevent ED visits in older home-dwelling individuals. RESULTS HCWs want to actively contribute to the prevention of ED visits among clients but observe many barriers that hinder them from doing so. Barriers refer to care organisation such as availability to primary care staff and information transfer; perceived attitudes towards HCWs as co-workers; and client-related factors. Participants suggest that improved communication and collaboration with primary care and discharge information from the ED to homecare services could overcome barriers. Furthermore, they ask for support and geriatric education from primary care nurses which may result in increased respect towards them as competent staff members. CONCLUSIONS HCWs feel that they have an important role in the health management of older individuals living at home. Still, they feel as an untapped resource in the prevention of ED visits. They deem that improved coordination and communication between primary care, ED, and homecare organisations as well as proactive care would enable them to add significantly to the prevention of ED visits.
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Affiliation(s)
- Pia Bastholm-Rahmner
- Academic Primary Healthcare Center, Region Stockholm, Sweden.
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet, Karolinska Institutet, Stockholm, Sweden.
| | - Monica Bergqvist
- Academic Primary Healthcare Center, Region Stockholm, Sweden
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Stockholm, Sweden
| | - Karin Modig
- Institute of Environmental Medicine, Unit of Epidemiology, Karolinska Institutet, Stockholm, Sweden
| | - Lars L Gustafsson
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet, Karolinska Institutet, Stockholm, Sweden
| | - Katharina Schmidt-Mende
- Academic Primary Healthcare Center, Region Stockholm, Sweden
- Department of Neurobiology and Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
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Bammert P, Schüttig W, Novelli A, Iashchenko I, Spallek J, Blume M, Diehl K, Moor I, Dragano N, Sundmacher L. The role of mesolevel characteristics of the health care system and socioeconomic factors on health care use - results of a scoping review. Int J Equity Health 2024; 23:37. [PMID: 38395914 PMCID: PMC10885500 DOI: 10.1186/s12939-024-02122-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 02/04/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Besides macrolevel characteristics of a health care system, mesolevel access characteristics can exert influence on socioeconomic inequalities in healthcare use. These reflect access to healthcare, which is shaped on a smaller scale than the national level, by the institutions and establishments of a health system that individuals interact with on a regular basis. This scoping review maps the existing evidence about the influence of mesolevel access characteristics and socioeconomic position on healthcare use. Furthermore, it summarizes the evidence on the interaction between mesolevel access characteristics and socioeconomic inequalities in healthcare use. METHODS We used the databases MEDLINE (PubMed), Web of Science, Scopus, and PsycINFO and followed the 'Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols extension for scoping reviews (PRISMA-ScR)' recommendations. The included quantitative studies used a measure of socioeconomic position, a mesolevel access characteristic, and a measure of individual healthcare utilisation. Studies published between 2000 and 2020 in high income countries were considered. RESULTS Of the 9501 potentially eligible manuscripts, 158 studies were included after a two-stage screening process. The included studies contained a wide spectrum of outcomes and were thus summarised to the overarching categories: use of preventive services, use of curative services, and potentially avoidable service use. Exemplary outcomes were screening uptake, physician visits and avoidable hospitalisations. Access variables included healthcare system characteristics such as physician density or distance to physician. The effects of socioeconomic position on healthcare use as well as of mesolevel access characteristics were investigated by most studies. The results show that socioeconomic and access factors play a crucial role in healthcare use. However, the interaction between socioeconomic position and mesolevel access characteristics is addressed in only few studies. CONCLUSIONS Socioeconomic position and mesolevel access characteristics are important when examining variation in healthcare use. Additionally, studies provide initial evidence that moderation effects exist between the two factors, although research on this topic is sparse. Further research is needed to investigate whether adapting access characteristics at the mesolevel can reduce socioeconomic inequity in health care use.
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Affiliation(s)
- Philip Bammert
- Chair of Health Economics, Technical University of Munich, Munich, Germany.
| | - Wiebke Schüttig
- Chair of Health Economics, Technical University of Munich, Munich, Germany
| | - Anna Novelli
- Chair of Health Economics, Technical University of Munich, Munich, Germany
| | - Iryna Iashchenko
- Chair of Health Economics, Technical University of Munich, Munich, Germany
| | - Jacob Spallek
- Department of Public Health, Brandenburg University of Technology Cottbus-Senftenberg, Senftenberg, Germany
- Lausitz Center for Digital Public Health, Brandenburg University of Technology, Senftenberg, Germany
| | - Miriam Blume
- Department of Epidemiology and Health Monitoring, Robert-Koch-Institute, Berlin, Germany
| | - Katharina Diehl
- Department of Medical Informatics, Biometry and Epidemiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Irene Moor
- Institute of Medical Sociology, Interdisciplinary Center for Health Sciences, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Nico Dragano
- Institute of Medical Sociology, Centre for Health and Society, University Hospital and Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Leonie Sundmacher
- Chair of Health Economics, Technical University of Munich, Munich, Germany
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Chou YJ, Goh V, Ma MC, Lee CC, Hsieh CC, Lin CH. Comparison of Outpatient Department-Referred and Self-Referred Patients in the Emergency Department. J Emerg Med 2024; 66:249-257. [PMID: 38262784 DOI: 10.1016/j.jemermed.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 07/25/2023] [Accepted: 10/01/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND Patients present to emergency departments (EDs) from a variety of backgrounds, which may help inform decision making. OBJECTIVE This study investigated the clinical characteristics and outcomes of outpatient department (OPD)-referred patients and self-referred patients in the ED. METHODS We selected nontrauma ED adult patients from a tertiary teaching hospital in Taiwan between August 1, 2020, and October 31, 2020. The acuity levels were determined by dichotomizing the triage classification scores. After propensity score matching, we compared the hospitalization, mortality, and length of ED stay of OPD-referred and self-referred patients. We categorized the patients into "emergency" or "urgent" subgroups according to their triage information and then analyzed the effects of different severity levels. Statistical significance was set at p < 0.05. RESULTS A total of 564 OPD-referred and 11,959 self-referred patients were included. After propensity score matching, the OPD-referred patients (n = 564), compared with self-referred patients (n = 564), had a higher admission rate (49.8% vs. 28.9%; p < 0.001; odds ratio [OR] 2.44). Among the emergency subgroup patients, there was no significant difference between OPD-referred patients (n = 131) and self-referred patients (n = 138) regarding the admission rate (p = 0.257) or the mortality rate (p = 0.253). Among the urgent subgroup patients, OPD-referred patients (n = 433), compared with self-referred patients (n = 426), had a significantly higher admission rate (46.0% vs. 20.2%; p < 0.001; OR 3.36), but not mortality rate (2.1% vs. 0.5%; p = 0.064). Regarding the length of ED stay, OPD-referred and self-referred patients had a significant difference only in the "urgent and discharged" subgroup (5.8 vs. 2.3 h; p < 0.001). CONCLUSIONS OPD-referred ED patients might have more severe and complex conditions and need comprehensive care management.
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Affiliation(s)
- Yu-Jung Chou
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Vivian Goh
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Mi-Chia Ma
- Department of Statistics, College of Management, National Cheng Kung University, Tainan, Taiwan
| | - Ching-Chi Lee
- Clinical Medicine Research Centre, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Chia Hsieh
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Hao Lin
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Lapointe-Shaw L, Salahub C, Austin PC, Bai L, Bhatia RS, Bird C, Glazier RH, Hedden L, Ivers NM, Martin D, Shuldiner J, Spithoff S, Tadrous M, Kiran T. Virtual Visits With Own Family Physician vs Outside Family Physician and Emergency Department Use. JAMA Netw Open 2023; 6:e2349452. [PMID: 38150254 PMCID: PMC10753397 DOI: 10.1001/jamanetworkopen.2023.49452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/13/2023] [Indexed: 12/28/2023] Open
Abstract
Importance Virtual visits became more common after the COVID-19 pandemic, but it is unclear in what context they are best used. Objective To investigate whether there was a difference in subsequent emergency department use between patients who had a virtual visit with their own family physician vs those who had virtual visits with an outside physician. Design, Setting, and Participants This propensity score-matched cohort study was conducted among all Ontario residents attached to a family physician as of April 1, 2021, who had a virtual family physician visit in the subsequent year (to March 31, 2022). Exposure The type of virtual family physician visit, with own or outside physician, was determined. In a secondary analysis, own physician visits were compared with visits with a physician working in direct-to-consumer telemedicine. Main Outcome and Measure The primary outcome was an emergency department visit within 7 days after the virtual visit. Results Among 5 229 240 Ontario residents with a family physician and virtual visit, 4 173 869 patients (79.8%) had a virtual encounter with their own physician (mean [SD] age, 49.3 [21.5] years; 2 420 712 females [58.0%]) and 1 055 371 patients (20.2%) had an encounter with an outside physician (mean [SD] age, 41.8 [20.9] years; 605 614 females [57.4%]). In the matched cohort of 1 885 966 patients, those who saw an outside physician were 66% more likely to visit an emergency department within 7 days than those who had a virtual visit with their own physician (30 748 of 942 983 patients [3.3%] vs 18 519 of 942 983 patients [2.0%]; risk difference, 1.3% [95% CI, 1.2%-1.3%]; relative risk, 1.66 [95% CI, 1.63-1.69]). The increase in the risk of emergency department visits was greater when comparing 30 216 patients with definite direct-to-consumer telemedicine visits with 30 216 patients with own physician visits (risk difference, 4.1% [95% CI, 3.8%-4.5%]; relative risk, 2.99 [95% CI, 2.74-3.27]). Conclusions and Relevance In this study, patients whose virtual visit was with an outside physician were more likely to visit an emergency department in the next 7 days than those whose virtual visit was with their own family physician. These findings suggest that primary care virtual visits may be best used within an existing clinical relationship.
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Affiliation(s)
- Lauren Lapointe-Shaw
- University Health Network, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Women’s College Institute for Health System Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Division of General Internal Medicine and Geriatrics, University Health Network and Sinai Health System, Toronto, Ontario, Canada
| | | | - Peter C. Austin
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Li Bai
- ICES, Toronto, Ontario, Canada
| | - R. Sacha Bhatia
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Cardiology, University Health Network, Toronto, Ontario, Canada
| | | | - Richard H. Glazier
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Lindsay Hedden
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Noah M. Ivers
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Women’s College Institute for Health System Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Department of Family Medicine, Women’s College Hospital, Toronto, Ontario, Canada
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
| | - Danielle Martin
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family Medicine, Women’s College Hospital, Toronto, Ontario, Canada
| | - Jennifer Shuldiner
- Women’s College Institute for Health System Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
| | - Sheryl Spithoff
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family Medicine, Women’s College Hospital, Toronto, Ontario, Canada
| | - Mina Tadrous
- ICES, Toronto, Ontario, Canada
- Women’s College Institute for Health System Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Tara Kiran
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, St Michael’s Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
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Umgelter A, Faust M, Wenske S, Umgelter K, Schmid RM, Walter G. Do patients referred to emergency departments after being assessed in primary care differ from other ED patients? Retrospective analysis of a random sample from two German metropolitan EDs. Int J Emerg Med 2023; 16:64. [PMID: 37752441 PMCID: PMC10523768 DOI: 10.1186/s12245-023-00542-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 09/19/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND To assess differences between patients referred to emergency departments by a primary care physician (PCP) and those presenting directly and the impact of referral on the likelihood of admission. DESIGN OF STUDY Retrospective cohort study. SETTING EDs of two nonacademic general hospitals in a German metropolitan region. PARTICIPANTS Random sample of 1500 patients out of 80,845 presentations during the year 2019. RESULTS Age was 55.8 ± 22.9 years, and 51.4% was female. A total of 34.7% presented by emergency medical services (EMS), and 47.7% were walk-ins. One-hundred seventy-four (11.9%) patients were referred by PCPs. Referrals were older (62.4 ± 20.1 vs 55.0 ± 23.1 years, p < .001) and had a higher Charlson Comorbidity Index (CCI) (3 (1-5) vs 2 (0-4); p < .001). Referrals received more ultrasound examinations independently from their admission status (27.6% vs 15.7%; p < .001) and more CT and laboratory investigations. There were no differences in sex, Manchester Triage System (MTS) category, or pain-scale values. Referrals presented by EMS less often (9.2% vs 38.5%; p < .001). Admission rates were 62.6% in referrals and 37.1% in non-referrals (p < .001). Referral (OR 3.976 95% CI: 2.595-6.091), parenteral medication in ED (OR 2.674 (1.976-3.619)), higher MTS category (1.725 (1.421-2.093)), transport by EMS (1.623 (1.212-2.172)), abnormal vital parameters (1.367 (0.953-1.960)), higher CCI (1.268 (1.196-1.344)), and trauma (1.268 (1.196-1.344)) were positively associated with admission in multivariable analysis, whereas ultrasound in ED (0.450 (0.308-0.658)) and being a nursing home resident (0.444 (0.270-0.728)) were negatively associated. CONCLUSION Referred patients were more often admitted. They received more laboratory investigations, ultrasound examinations, and computed tomographies. Difficult decisions regarding the necessity of admission requiring typical resources of EDs may be a reason for PCP referrals.
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Affiliation(s)
- Andreas Umgelter
- II. Medizinische Klinik, Klinikum Rechts Der Isar der Technischen Universität München, Munich, Germany.
- Zentrale Notfallversorgung, Vivantes Humboldt Klinikum, 13509, Berlin, Germany.
| | - Markus Faust
- II. Medizinische Klinik, Klinikum Rechts Der Isar der Technischen Universität München, Munich, Germany
- Zentrale Notfallversorgung, Vivantes Humboldt Klinikum, 13509, Berlin, Germany
| | - Slatomir Wenske
- Zentrale Notfallversorgung, Vivantes Humboldt Klinikum, 13509, Berlin, Germany
| | - Katrin Umgelter
- Klinik Für Interdisziplinäre Intensivmedizin, Vivantes Humboldt Klinikum, Berlin, Germany
| | - Roland M Schmid
- II. Medizinische Klinik, Klinikum Rechts Der Isar der Technischen Universität München, Munich, Germany
| | - Georg Walter
- Zentrale Notfallversorgung, Vivantes Klinikum Spandau, Berlin, Germany
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10
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Smeekes OS, Willems HC, Blomberg I, Buurman BM. A causal loop diagram of older persons' emergency department visits and interactions of its contributing factors: a group model building approach. Eur Geriatr Med 2023; 14:837-849. [PMID: 37391681 PMCID: PMC10447269 DOI: 10.1007/s41999-023-00816-8] [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: 03/15/2023] [Accepted: 06/05/2023] [Indexed: 07/02/2023]
Abstract
PURPOSE Understanding the etiology of older persons' emergency department (ED) visits is highly needed. Many contributing factors have been identified, however, the role their interactions play remains unclear. Causal loop diagrams (CLDs), as conceptual models, can visualize these interactions and therefore may elucidate their role. This study aimed to better understand why people older than 65 years of age visit the ED in Amsterdam by capturing the interactions of contributing factors as perceived by an expert group in a CLD through group model building (GMB). METHODS Six qualitative online focus group like sessions, known as GMB, were conducted with a purposefully recruited interdisciplinary expert group of nine that resulted in a CLD that depicted their shared view. RESULTS The CLD included four direct contributing factors, 29 underlying factors, 66 relations between factors and 18 feedback loops. The direct factors included, 'acute event', 'frailty', 'functioning of the healthcare professional' and 'availability of alternatives for the ED'. All direct factors showed direct as well as indirect contribution to older persons' ED visits in the CLD through interaction. CONCLUSION Functioning of the healthcare professional and availability of alternatives for the ED were considered pivotal factors, together with frailty and acute event. These factors, as well as many underlying factors, showed extensive interaction in the CLD, thereby contributing directly and indirectly to older persons' ED visits. This study helps to better understand the etiology of older persons' ED visits and in specific the way contributing factors interact. Furthermore, its CLD can help to find solutions for the increasing numbers of older adults in the ED.
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Affiliation(s)
- Oscar S Smeekes
- Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Hanna C Willems
- Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Ilse Blomberg
- Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Bianca M Buurman
- Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Medicine for Older People, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, De Boelelaan 117, Amsterdam, The Netherlands
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Lampe D, Grosser J, Gensorowsky D, Witte J, Muth C, van den Akker M, Dinh TS, Greiner W. The Relationship of Continuity of Care, Polypharmacy and Medication Appropriateness: A Systematic Review of Observational Studies. Drugs Aging 2023; 40:473-497. [DOI: 10.1007/s40266-023-01022-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2023] [Indexed: 03/29/2023]
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Lapointe-Shaw L, Kiran T, Salahub C, Austin PC, Berthelot S, Desveaux L, Lofters A, Maclure M, Martin D, McBrien KA, McCracken RK, Rahman B, Schultz SE, Shuldiner J, Tadrous M, Bird C, Paterson JM, Bhatia RS, Thakkar NA, Na Y, Ivers NM. Walk-in clinic patient characteristics and utilization patterns in Ontario, Canada: a cross-sectional study. CMAJ Open 2023; 11:E345-E356. [PMID: 37171909 PMCID: PMC10139081 DOI: 10.9778/cmajo.20220095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/14/2023] Open
Abstract
BACKGROUND Walk-in clinics are common in North America and are designed to provide acute episodic care without an appointment. We sought to describe a sample of walk-in clinic patients in Ontario, Canada, which is a setting with high levels of primary care attachment. METHODS We performed a cross-sectional study using health administrative data from 2019. We compared the sociodemographic characteristics and health care utilization patterns of patients attending 1 of 72 walk-in clinics with those of the general Ontario population. We examined the subset of patients who were enrolled with a family physician and compared walk-in clinic visits to family physician visits. RESULTS Our study found that 562 781 patients made 1 148 151 visits to the included walk-in clinics. Most (70%) patients who attended a walk-in clinic had an enrolling family physician. Walk-in clinic patients were younger (mean age 36 yr v. 41 yr, standardized mean difference [SMD] 0.24), yet had greater health care utilization (moderate and high use group 74% v. 65%, SMD 0.20) than the general Ontario population. Among enrolled Ontarians, walk-in patients had more comorbidities (moderate and high count 50% v. 45%, SMD 0.10), lived farther from their enrolling physician (median 8 km v. 6 km, SMD 0.21) and saw their enrolling physician less in the previous year (any visit 67% v. 80%, SMD 0.30). Walk-in encounters happened more often after hours (16% v. 9%, SMD 0.20) and on weekends (18% v. 5%, SMD 0.45). Walk-in clinics were more often within 3 km of patients' homes than enrolling physicians' offices (0 to < 3 km: 32% v. 22%, SMD 0.21). INTERPRETATION Our findings suggest that proximity of walk-in clinics and after-hours access may be contributing to walk-in clinic use among patients enrolled with a family physician. These findings have implications for policy development to improve the integration of walk-in clinics and longitudinal primary care.
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Affiliation(s)
- Lauren Lapointe-Shaw
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont.
| | - Tara Kiran
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Christine Salahub
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Peter C Austin
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Simon Berthelot
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Laura Desveaux
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Aisha Lofters
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Malcolm Maclure
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Danielle Martin
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Kerry A McBrien
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Rita K McCracken
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Bahram Rahman
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Susan E Schultz
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Jennifer Shuldiner
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Mina Tadrous
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Cherryl Bird
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - J Michael Paterson
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - R Sacha Bhatia
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Niels A Thakkar
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Yingbo Na
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Noah M Ivers
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
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Profiles, correlates, and risk of death among patients with mental disorders hospitalized for psychiatric reasons. Psychiatry Res 2023; 321:115093. [PMID: 36764119 DOI: 10.1016/j.psychres.2023.115093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 09/19/2022] [Accepted: 02/03/2023] [Indexed: 02/07/2023]
Abstract
This study identified profiles of hospitalized patients with mental disorders (MD) based on their 3-year hospitalization patterns and clinical characteristics and compared sociodemographic profiles and other service use correlates as well as risk of death within 12 months after hospitalization. Quebec (Canada) medical administrative databases were used to investigate a 5-year cohort of 4,400 patients hospitalized for psychiatric reasons. Latent class analysis, chi-square tests and survival analysis were produced. Three profiles of hospitalized patients were identified based on hospitalization patterns and other patient characteristics. Profile 3 patients had multiple hospitalizations and early readmissions, worst health and social conditions, and used the most outpatient services. Profiles 2 and 1 patients had only one hospitalization, of brief duration in the case of Profile 2 patients, who had mainly common MD and made least use of psychiatric care. All Profile 1 patients were hospitalized for serious MD but received least continuity of physician care and fewest biopsychosocial interventions. Risk of death was higher for Profiles 3 and 2 versus Profile 1 patients. Interventions like early follow-up care after hospitalization for Profile 3, collaborative care between general practitioners and psychiatrists for Profile 2, and continuous biopsychosocial care for Profile 1 could be greatly improved.
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Bartels SA, MacKenzie M, Douglas SL, Collier A, Pritchard J, Purkey E, Messenger D, Walker M. Emergency department care experiences among members of equity-deserving groups: quantitative results from a cross-sectional mixed methods study. BMC Emerg Med 2023; 23:21. [PMID: 36809981 PMCID: PMC9942657 DOI: 10.1186/s12873-023-00792-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 02/15/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND Emergency departments (EDs) serve an integral role in healthcare, particularly for vulnerable populations. However, marginalized groups often report negative ED experiences, including stigmatizing attitudes and behaviours. We engaged with historically marginalized patients to better understand their ED care experiences. METHOD Participants were invited to complete an anonymous mixed-methods survey about a previous ED experience. We analysed quantitative data including controls and equity-deserving groups (EDGs) - those who self-identified as: (a) Indigenous; (b) having a disability; (c) experiencing mental health issues; (d) a person who uses substances; (e) a sexual and gender minority; (f) a visible minority; (g) experiencing violence; and/or (h) facing homelessness - to identify differences in their perspectives. Differences between EDGs and controls were calculated with chi squared tests, geometric means with confidence ellipses, and the Kruskal-Wallis H test. RESULTS We collected a total of 2114 surveys from 1973 unique participants, 949 controls and 994 who identified as equity-deserving. Members of EDGs were more likely to attribute negative feelings to their ED experience (p < 0.001), to indicate that their identity impacted the care received (p < 0.001), and that they felt disrespected and/or judged while in the ED (p < 0.001). Members of EDGs were also more likely to indicate that they had little control over healthcare decisions (p < 0.001) and that it was more important to be treated with kindness/respect than to receive the best possible care (p < 0.001). CONCLUSION Members of EDGs were more likely to report negative ED care experiences. Equity-deserving individuals felt judged and disrespected by ED staff and felt disempowered to make decisions about their care. Next steps will include contextualizing findings using participants' qualitative data and identifying how to improve ED care experiences among EDGs to make it more inclusive and better able to meet their healthcare needs.
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Affiliation(s)
- Susan A Bartels
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada. .,Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.
| | - Meredith MacKenzie
- Department of Family Medicine, Queen's University, Kingston, ON, Canada.,Street Health Centre, part of Kingston Community Health Centres, Kingston, ON, Canada
| | - Stuart L Douglas
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada.,Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Amanda Collier
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
| | - Jodie Pritchard
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
| | - Eva Purkey
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.,Department of Family Medicine, Queen's University, Kingston, ON, Canada
| | - David Messenger
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada.,Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Melanie Walker
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada.,Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
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Gruneir A, Youngson E, Dobbs B, Wagg A, Williamson T, Duerksen K, Garies S, Soos B, Forst B, Bakal J, Manca DP, Drummond N. Older persons living with dementia and their use of acute care services over 2 years in Alberta. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2023; 69:114-124. [PMID: 36813522 PMCID: PMC9945888 DOI: 10.46747/cfp.6902114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
OBJECTIVE To characterize transitions to acute and residential care and identify variables associated with specific transitions among community-based persons living with dementia (PLWD). DESIGN Retrospective cohort study using primary care electronic medical record data linked with health administrative data. SETTING Alberta. PARTICIPANTS Adults aged 65 years or older living in the community who had been diagnosed with dementia and who saw a Canadian Primary Care Sentinel Surveillance Network contributor between January 1, 2013, and February 28, 2015. MAIN OUTCOME MEASURES All emergency department visits, hospitalizations, residential care (supportive living and long-term care) admissions, and deaths within a 2-year follow-up period. RESULTS In total, 576 PLWD were identified who had a mean (SD) age of 80.4 (7.7) years; 55% were female. In 2 years, 423 (73.4%) had at least 1 transition and, of these, 111 (26.2%) had 6 or more. Emergency department visits, including multiple visits, were common (71.4% had ≥1, 12.1% had ≥4). Of those hospitalized (43.8%), nearly all were admitted from the emergency department; the average (SD) length of stay was 23.6 (35.8) days, and 32.9% had at least 1 alternate level of care day. In total, 19.3% entered residential care, most admitted from hospital. Those admitted to hospital and those admitted to residential care were older and had greater historical health system use, including home care. One-quarter of the sample did not have any transitions (or die) during follow-up; they were typically younger and had limited historical health system use. CONCLUSION Older PLWD experienced frequent, and frequently compound, transitions that have implications for them, their family members, and the health system. There was also a large proportion without transitions suggesting that appropriate supports enable PLWD to do well in their own communities. The identification of PLWD who are at risk of or who make frequent transitions may allow for more proactive implementation of community-based supports and smoother transitions to residential care.
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Affiliation(s)
- Andrea Gruneir
- Associate Professor in the Department of Family Medicine at the University of Alberta in Edmonton.
| | - Erik Youngson
- Biostatistician in the Data Platform of the Alberta SPOR (Strategy for Patient-Oriented Research) SUPPORT (Support for People and Patient-Oriented Research and Trials) Unit at the University of Alberta
| | - Bonnie Dobbs
- Professor in the Department of Family Medicine at the University of Alberta
| | - Adrian Wagg
- Professor in the Department of Medicine at the University of Alberta
| | - Tyler Williamson
- Associate Professor of Biostatistics in the Department of Community Health Sciences at the University of Calgary in Alberta
| | - Kim Duerksen
- Research Coordinator in the Department of Family Medicine at the University of Alberta
| | - Stephanie Garies
- Postdoctoral fellow at the MAP Centre for Urban Health Solutions in Toronto, Ont
| | - Boglarka Soos
- Doctoral student and Data Administrator in the Department of Family Medicine and the Department of Community Health Sciences at the University of Calgary
| | - Brian Forst
- Data Manager in the Department of Family Medicine at the University of Alberta
| | - Jeff Bakal
- Program Director for Provincial Research Data Services at Alberta Health Services
| | - Donna P Manca
- Professor in the Department of Family Medicine at the University of Alberta
| | - Neil Drummond
- Professor and Research Chair in Primary Care in the Department of Family Medicine at the University of Alberta
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Kukafka R, Salahub C, Bird C, Bhatia RS, Desveaux L, Glazier RH, Hedden L, Ivers NM, Martin D, Na Y, Spithoff S, Tadrous M, Kiran T. Characteristics and Health Care Use of Patients Attending Virtual Walk-in Clinics in Ontario, Canada: Cross-sectional Analysis. J Med Internet Res 2023; 25:e40267. [PMID: 36633894 PMCID: PMC9880810 DOI: 10.2196/40267] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 10/31/2022] [Accepted: 12/01/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Funding changes in response to the COVID-19 pandemic supported the growth of direct-to-consumer virtual walk-in clinics in several countries. Little is known about patients who attend virtual walk-in clinics or how these clinics contribute to care continuity and subsequent health care use. OBJECTIVE The objective of the present study was to describe the characteristics and measure the health care use of patients who attended virtual walk-in clinics compared to the general population and a subset that received any virtual family physician visit. METHODS This was a retrospective, cross-sectional study in Ontario, Canada. Patients who had received a family physician visit at 1 of 13 selected virtual walk-in clinics from April 1 to December 31, 2020, were compared to Ontario residents who had any virtual family physician visit. The main outcome was postvisit health care use. RESULTS Virtual walk-in patients (n=132,168) had fewer comorbidities and lower previous health care use than Ontarians with any virtual family physician visit. Virtual walk-in patients were also less likely to have a subsequent in-person visit with the same physician (309/132,168, 0.2% vs 704,759/6,412,304, 11%; standardized mean difference [SMD] 0.48), more likely to have a subsequent virtual visit (40,030/132,168, 30.3% vs 1,403,778/6,412,304, 21.9%; SMD 0.19), and twice as likely to have an emergency department visit within 30 days (11,003/132,168, 8.3% vs 262,509/6,412,304, 4.1%; SMD 0.18), an effect that persisted after adjustment and across urban/rural resident groups. CONCLUSIONS Compared to Ontarians attending any family physician virtual visit, virtual walk-in patients were less likely to have a subsequent in-person physician visit and were more likely to visit the emergency department. These findings will inform policy makers aiming to ensure the integration of virtual visits with longitudinal primary care.
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Affiliation(s)
| | - Christine Salahub
- Support, Systems, and Outcomes Department, University Health Network, Toronto, ON, Canada
| | | | - R Sacha Bhatia
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Laura Desveaux
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Women's College Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Institute for Better Health, Ontario Trillium Health Partners, Mississauga, ON, Canada
| | - Richard H Glazier
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Department of Family and Community Medicine and MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Lindsay Hedden
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Noah M Ivers
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Women's College Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Department of Family Medicine, Women's College Hospital, Toronto, ON, Canada
| | - Danielle Martin
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Department of Family Medicine, Women's College Hospital, Toronto, ON, Canada
| | | | - Sheryl Spithoff
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Department of Family Medicine, Women's College Hospital, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Mina Tadrous
- Women's College Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Tara Kiran
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Department of Family and Community Medicine and MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
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17
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Gentil L, Grenier G, Vasiliadis HM, Fleury MJ. Predictors of Length of Hospitalization and Impact on Early Readmission for Mental Disorders. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15127. [PMID: 36429846 PMCID: PMC9689971 DOI: 10.3390/ijerph192215127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 11/11/2022] [Accepted: 11/14/2022] [Indexed: 06/16/2023]
Abstract
Length of hospitalization, if inappropriate to patient needs, may be associated with early readmission, reflecting sub-optimal hospital treatment, and translating difficulties to access outpatient care after discharge. This study identified predictors of brief-stay (1-6 days), mid-stay (7-30 days) or long-stay (≥31 days) hospitalization, and evaluated how lengths of hospital stay impacted on early readmission (within 30 days) among 3729 patients with mental disorders (MD) or substance-related disorders (SRD). This five-year cohort study used medical administrative databases and multinomial logistic regression. Compared to patients with brief-stay or mid-stay hospitalization, more long-stay patients were 65+ years old, had serious MD, and had a usual psychiatrist rather than a general practitioner (GP). Predictors of early readmission were brief-stay hospitalization, residence in more materially deprived areas, more diagnoses of MD/SRD or chronic physical illnesses, and having a usual psychiatrist with or without a GP. Patients with long-stay hospitalization (≥31 days) and early readmission had more complex conditions, especially more co-occurring chronic physical illnesses, and more serious MD, while they tended to have a usual psychiatrist with or without a GP. For patients with more complex conditions, programs such as assertive community treatment, intensive case management or home treatment would be advisable, particularly for those living in materially deprived areas.
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Affiliation(s)
- Lia Gentil
- Department of Psychiatry, McGill University, 1033, Pine Avenue West, Montreal, QC H3A 1A1, Canada
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Blvd, Montreal, QC H4H 1R3, Canada
| | - Guy Grenier
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Blvd, Montreal, QC H4H 1R3, Canada
| | - Helen-Maria Vasiliadis
- Département Des Sciences de la Santé Communautaire, Université de Sherbrooke, Longueuil, QC J4K 0A8, Canada
- Centre de Recherche Charles-Le Moyne-Saguenay-Lac-Saint-Jean sur les Innovations en Santé (CR-CSIS), Campus de Longueuil-Université de Sherbrooke, 150 Place Charles-Lemoyne, Longueuil, QC J4K 0A8, Canada
| | - Marie-Josée Fleury
- Department of Psychiatry, McGill University, 1033, Pine Avenue West, Montreal, QC H3A 1A1, Canada
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Blvd, Montreal, QC H4H 1R3, Canada
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18
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Sourial N, Schuster T, Bronskill SE, Godard-Sebillotte C, Etches J, Vedel I. Interprofessional Primary Care and Acute Care Hospital Use by People With Dementia: A Population-Based Study. Ann Fam Med 2022; 20:512-518. [PMID: 36443085 PMCID: PMC9705048 DOI: 10.1370/afm.2881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 05/31/2022] [Accepted: 06/20/2022] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Interprofessional primary care has the potential to optimize hospital use for acute care among people with dementia. We compared 1-year emergency department (ED) visits and hospitalizations among people with dementia enrolled in a practice having an interprofessional primary care team with those enrolled in a physician-only group practice. METHODS A population-based, repeated cohort study design was used to extract yearly cohorts of 95,323 community-dwelling people in Ontario, Canada, newly identified in administrative data with dementia between April 1, 2005 and March 31, 2015. Patient enrollment in an interprofessional practice or a physician-only practice was determined at the time of dementia diagnosis. We used propensity score-based inverse probability weighting to compare study groups on overall and nonurgent ED visits as well as on overall and potentially avoidable hospitalizations in the 1 year following dementia diagnosis. RESULTS People with dementia enrolled in a practice having an interprofessional primary care team were more likely to have ED visits (relative risk = 1.03; 95% CI, 1.01-1.05) and nonurgent ED visits (relative risk = 1.22; 95% CI, 1.18-1.28) compared with those enrolled in a physician-only primary care practice. There was no evidence of an association between interprofessional primary care and hospitalization outcomes. CONCLUSIONS Interprofessional primary care was associated with increased ED use but not hospitalizations among people newly identified as having dementia. Although interprofessional primary care may be well suited to manage the growing and complex dementia population, a better understanding of the optimal characteristics of team-based care and the reasons leading to acute care hospital use by people with dementia is needed.
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Affiliation(s)
- Nadia Sourial
- Department of Health Management, Evaluation and Policy, School of Public Health, University of Montreal, Montreal, Quebec, Canada .,University of Montreal Hospital Research Center, Montreal, Quebec, Canada
| | - Tibor Schuster
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Susan E Bronskill
- ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Isabelle Vedel
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada.,Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
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19
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Dai M, Pavletic D, Shuemaker JC, Solid CA, Phillips RL. Measuring the Value Functions of Primary Care: Physician-Level Continuity of Care Quality Measure. Ann Fam Med 2022; 20:535-540. [PMID: 36443072 PMCID: PMC9705031 DOI: 10.1370/afm.2880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 07/06/2022] [Accepted: 07/29/2022] [Indexed: 12/05/2022] Open
Abstract
PURPOSE Care continuity is foundational to the clinician/patient relationship; however, little has been done to operationalize continuity of care (CoC) as a clinical quality measure. The American Board of Family Medicine developed the Primary Care CoC clinical quality measure as part of the Measures That Matter to Primary Care initiative. METHODS Using 12-month Optum Clinformatics Data Mart claims data, we calculated the Bice-Boxerman Continuity of Care Index for each patient, which we rolled up to create an aggregate, physician-level CoC score. The physician quality score is the percent of patients with a Bice-Boxerman Index ≥0.7 (70%). We tested validity in 2 ways. First, we explored the validity of using 0.7 as a threshold for patient CoC within the Optum claims database to validate its use for reflecting patient-level continuity. Second, we explored the validity of the physician CoC measure by examining its association with patient outcomes. We assessed reliability using signal-to-noise methodology. RESULTS Mean performance on the measure was 27.6%; performance ranged from 0% to 100% (n = 555,213 primary care physicians). Higher levels of CoC were associated with lower levels of care utilization. The measure indicated acceptable levels of validity and reliability. CONCLUSIONS Continuity is associated with desirable health and cost outcomes as well as patient preference. The CoC clinical quality measure meets validity and reliability requirements for implementation in primary care payment and accountability. Care continuity is important and complementary to access to care, and prioritizing this measure could help shift physician and health system behavior to support continuity.
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Affiliation(s)
- Mingliang Dai
- American Board of Family Medicine, Lexington, Kentucky
| | - Denise Pavletic
- Center for Professionalism and Value in Health Care, American Board of Family Medicine Foundation, Washington, DC
| | - Jill C Shuemaker
- Center for Professionalism and Value in Health Care, American Board of Family Medicine Foundation, Washington, DC
| | | | - Robert L Phillips
- Center for Professionalism and Value in Health Care, American Board of Family Medicine Foundation, Washington, DC
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20
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Smithman MA, Haggerty J, Gaboury I, Breton M. Improved access to and continuity of primary care after attachment to a family physician: longitudinal cohort study on centralized waiting lists for unattached patients in Quebec, Canada. BMC PRIMARY CARE 2022; 23:238. [PMID: 36114464 PMCID: PMC9482231 DOI: 10.1186/s12875-022-01850-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 09/08/2022] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Having a regular family physician is associated with many benefits. Formal attachment – an administrative patient-family physician agreement – is a popular feature in primary care, intended to improve access to and continuity of care with a family physician. However, little evidence exists about its effectiveness. In Quebec, Canada, where over 20% of the population is unattached, centralized waiting lists help attach patients. This provides a unique opportunity to observe the influence of attachment in previously unattached patients. The aim was to evaluate changes in access to and continuity of primary care associated with attachment to a family physician through Quebec’s centralized waiting lists for unattached patients.
Methods
We conducted an observational longitudinal population cohort study, using medical services billing data from public health insurance in the province of Québec, Canada. We included patients attached through centralized waiting lists for unattached patients between 2012 and 2014 (n = 410,140). Our study was informed by Aday and Andersen’s framework for the study of access to health services. We compared outcomes during four 12-month periods: two periods before and two periods after attachment, with T0–2 years as the reference period. Outcome measures were number of primary care visits and Bice-Boxerman Concentration of Care Index at the physician and practice level (for patients with ≥2 visits in a given period). We included age, sex, region remoteness, medical vulnerability, and Charlson Comorbidity Index as covariates in regression models fitted with generalized estimating equations.
Results
The number of primary care visits increased by 103% in the first post attachment year and 29% in the second year (p < 0.001). The odds of having all primary care visits concentrated with a single physician increased by 53% in the first year and 22% (p < 0.001) in the second year after attachment. At the practice level, the odds of perfect concentration of care increased by 19% (p < 0.001) and 15% (p < 0.001) respectively, in first and second year after attachment.
Conclusion
Our results show an increase in patients’ number of primary care visits and concentration of care at the family physician and practice level after attachment to a family physician. This suggests that attachment may help improve access to and continuity of primary care.
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21
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Organization of primary care. Prim Health Care Res Dev 2022; 23:e49. [PMID: 36047002 PMCID: PMC9472237 DOI: 10.1017/s1463423622000275] [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] [Indexed: 11/17/2022] Open
Abstract
Strong primary care does not develop spontaneously but requires a well-developed organizational planning between levels of care. Primary care-oriented health systems are required to effectively tackle unmet health needs of the population, and efficient primary care organization (PCO) is crucial for this aim. Via strong primary care, health delivery, health outcomes, equity, and health security could be improved. There are several theoretical models on how primary care can be organized. In this position paper, the key aspects and benchmarks of PCO will be explored based on previously mentioned frameworks and domains. The aim of this position paper is to assist primary care providers, policymakers, and researchers by discussing the current context of PCO and providing guidance for implementation, development, and evaluation of it in a particular setting. The conceptual map of this paper consists of structural and process (PC service organization) domains and is adapted from frameworks described in literature and World Health Organization resources. Evidence we have gathered for this paper shows that for establishing a strong PCO, it is crucial to ensure accessible, continuous, person-centered, community-oriented, coordinated, and integrated primary care services provided by competent and socially accountable multiprofessional teams working in a setting where clear policy documents exist, adequate funding is available, and primary care is managed by dedicated units.
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22
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Kaneko M, Shinoda S, Shimizu S, Kuroki M, Nakagami S, Chiba T, Goto A. Fragmentation of ambulatory care among older adults: an exhaustive database study in an ageing city in Japan. BMJ Open 2022; 12:e061921. [PMID: 35953252 PMCID: PMC9379480 DOI: 10.1136/bmjopen-2022-061921] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES Continuity of care is a core dimension of primary care, and better continuity is associated with better patient outcomes. Therefore, care fragmentation can be an indicator to assess the quality of primary care, especially in countries without formal gatekeeping system, such as Japan. Thus, this study aimed to describe care fragmentation among older adults in an ageing city in Japan. DESIGN Cross-sectional study. SETTING The most populated basic municipality in Japan. PARTICIPANTS Older adults aged 75 years and older. INTERVENTIONS This study used a health claims database, including older adults who visited medical facilities at least four times a year in an urban city in Japan. The Fragmentation of Care Index (FCI) was used as an indicator of fragmentation. The FCI was developed from the Continuity of Care Index and is based on the total number of visits, different institutions visited and proportion of visits to each institution. We employed Tobit regression analysis to examine the association between the FCI and age, sex, type of insurance and most frequently visited facility. RESULTS The total number of participants was 413 600. The median age of the study population was 81 years, and 41.6% were men. The study population visited an average of 3.42 clinics/hospitals, and the maximum number of visited institutions was 20. The proportion of patients with FCI >0 was 85.0%, with a mean of 0.583. Multivariable analysis showed that patients receiving public assistance had a lower FCI compared with patients not receiving public assistance, with a coefficient of 0.137. CONCLUSIONS To our knowledge, this is the first study to demonstrate care fragmentation in Japan. Over 80% of the participants visited two or more medical facilities, and their mean FCI was 0.583. The FCI could be a basic indicator for assessing the quality of primary care.
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Affiliation(s)
- Makoto Kaneko
- Department of Health Data Science, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Satoru Shinoda
- Department of Health Data Science, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Sayuri Shimizu
- Department of Health Data Science, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Makoto Kuroki
- Department of Health Data Science, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Sachiko Nakagami
- Medical Policy Division, Medical Care Bureau, City of Yokohama, Yokohama, Kanagawa, Japan
| | - Taiga Chiba
- Medical Policy Division, Medical Care Bureau, City of Yokohama, Yokohama, Kanagawa, Japan
| | - Atsushi Goto
- Department of Health Data Science, Yokohama City University, Yokohama, Kanagawa, Japan
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23
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Calais-Ferreira L, Butler A, Dent S, Preen DB, Young JT, Kinner SA. Multimorbidity and quality of primary care after release from prison: a prospective data-linkage cohort study. BMC Health Serv Res 2022; 22:876. [PMID: 35799190 PMCID: PMC9264593 DOI: 10.1186/s12913-022-08209-6] [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: 11/09/2021] [Accepted: 06/07/2022] [Indexed: 11/10/2022] Open
Abstract
Background The period after release from prison can be challenging, especially due to a higher risk of morbidity and mortality despite commonly increased use of healthcare services. However, little is known about the quality of the healthcare offered to this population, which limits the possibility of addressing this important health inequity. This study characterised multimorbidity and investigated the relationship between multimorbidity and quality of primary healthcare in adults within 2 years after release from prison. Methods This was a prospective cohort study of 1046 participants of a service brokerage intervention after release from prison between August 2008 and July 2010 in Queensland, Australia. Participants had their baseline survey and clinical data linked prospectively with their medical, correctional and death records. Multimorbidity was ascertained using the Cumulative Illness Rating Scale and classified into three categories: none, moderate (morbidity in 2–3 domains) and complex (morbidity in 4 or more domains). Outcomes were Usual Provider Continuity Index (UPCI), Continuity of Care (COC) Index, and having at least one extended primary care consultation (> 20 minutes). Descriptive statistics and logistic regression were used in the analyses. Results Multimorbidity was present for 761 (73%) participants, being more prevalent among females (85%) than males (69%), p < 0.001. Moderate multimorbidity was not associated with UPCI or COC, but was associated with having at least one long consultation (AOR = 1.64; 95% CI:1.14–2.39), after adjusting for covariates. Complex multimorbidity was positively associated with all outcomes in the adjusted models. Indigenous status was negatively associated with UPCI (AOR = 0.54; 95% CI: 0.37–0.80) and COC (AOR = 0.53; 95% CI: 0.36–0.77), and people younger than 25 years were at 36% lower odds (AOR = 0.64; 95% CI: 0.44–0.93) of having a long consultation than the middle-aged group (25–44 years) in the adjusted models. Conclusion Moderate multimorbidity was associated with having at least one extended primary care consultation, but not with adequate continuity of care, for adults within 2 years of being released from prison. Nearly half of those with complex multimorbidity did not receive adequate continuity of care. The quality of primary care is inadequate for a large proportion of adults released from prison, constituting an important and actionable health inequity. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08209-6.
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Affiliation(s)
- Lucas Calais-Ferreira
- Justice Health Unit, Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, Level 3, 207 Bouverie St, Carlton, Melbourne, Victoria, 3070, Australia. .,Centre for Adolescent Health, Murdoch Children's Research Institute, Level 3, 207 Bouverie St, Carlton, Melbourne, Victoria, 3070, Australia. .,Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Level 3, 207 Bouverie St, Carlton, Melbourne, Victoria, 3070, Australia.
| | - Amanda Butler
- Justice Health Unit, Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, Level 3, 207 Bouverie St, Carlton, Melbourne, Victoria, 3070, Australia.,Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Stephan Dent
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - David B Preen
- Centre for Health Services Research, School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Jesse T Young
- Justice Health Unit, Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, Level 3, 207 Bouverie St, Carlton, Melbourne, Victoria, 3070, Australia.,Centre for Adolescent Health, Murdoch Children's Research Institute, Level 3, 207 Bouverie St, Carlton, Melbourne, Victoria, 3070, Australia.,Centre for Health Services Research, School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia.,National Drug Research Institute, Curtin University, Perth, Western Australia, Australia
| | - Stuart A Kinner
- Justice Health Unit, Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, Level 3, 207 Bouverie St, Carlton, Melbourne, Victoria, 3070, Australia.,Centre for Adolescent Health, Murdoch Children's Research Institute, Level 3, 207 Bouverie St, Carlton, Melbourne, Victoria, 3070, Australia.,School of Population Health, Curtin University, Perth, Western Australia, Australia.,Griffith Criminology Institute, Griffith University, Brisbane, Queensland, Australia
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Gabet M, Gentil L, Lesage A, Fleury MJ. Investigating characteristics of patients with mental disorders to predict out-patient physician follow-up within 30 days of emergency department discharge. BJPsych Open 2022; 8:e95. [PMID: 35579032 PMCID: PMC9169501 DOI: 10.1192/bjo.2022.64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Prompt follow-up at emergency department discharge is a key indicator of healthcare quality and patient recovery. To improve services, better knowledge of predictors for out-patient physician follow-up within 30 days after discharge is needed. AIMS We investigated clinical and sociodemographic characteristics and service use to predict patients with mental disorders with or without physician follow-up after emergency department use. METHOD This study used data extracted from clinical administrative databases for 9514 patients who attended an emergency department in Quebec (Canada) in 2014-2015 (index visit) for mental health reasons. Patient clinical and sociodemographic characteristics from 2012-2013 to 2014-2015, and service use 12 months before the index visit, were investigated as predictors for patients with or without prompt follow-up, using hierarchical logistic regression. RESULTS Two-thirds of patients did not receive prompt physician follow-up. Patients with level 1-2 illness acuity at emergency department triage (needing immediate or urgent care); those with adjustment or bipolar disorders, but without alcohol-related disorders (clinical characteristics); and patients with higher continuity of physician care, more psychosocial interventions in community healthcare centres and prior hospital admission (service use characteristics) were more likely to receive prompt out-patient follow-up. CONCLUSIONS Access to medical care was poor, considering the high needs of this population. The role of the emergency department as a gateway for accessing out-patient care may be strengthened by strategies like screening, brief intervention including motivational treatments, brief case management offered by emergency department staff, timely referral to services and better post-discharge planning. Collaborative care for patients attending emergency departments should also be improved.
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Affiliation(s)
- Morgane Gabet
- Department of Health Administration, School of Public Health, Université de Montréal, Canada; and Douglas Hospital Research Center, Canada
| | - Lia Gentil
- Douglas Hospital Research Center, Canada; and Department of Psychiatry, McGill University, Canada
| | - Alain Lesage
- Department of Psychiatry, Université de Montréal, Canada; and Centre de recherche Fernand-Séguin, Institut universitaire en santé mentale de Montréal, Canada
| | - Marie-Josée Fleury
- Department of Health Administration, School of Public Health, Université de Montréal, Canada; Douglas Hospital Research Center, Canada; and Department of Psychiatry, McGill University, Canada
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25
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Yang Z, Ganguli I, Davis C, Dai M, Shuemaker J, Peterson L, Bazemore A, Phillips R, Chung YK. Physician versus Practice-Level Primary Care Continuity and Association with Outcomes in Medicare Beneficiaries. Health Serv Res 2022; 57:914-929. [PMID: 35522231 PMCID: PMC9264477 DOI: 10.1111/1475-6773.13999] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To compare physician versus practice-level primary care continuity and their association with expenditure and acute care utilization among Medicare beneficiaries and evaluate if continuity of outpatient primary care at either/both physician or/and practice level could be useful quality measures. DATA SOURCE Medicare Fee-For-Service claims data for community dwelling beneficiaries without End-Stage Renal Disease who were attributed to a national random sample of primary care practices billing Medicare (2011-2017). STUDY DESIGN Retrospective secondary data analysis at per Medicare beneficiary per year level. We used multivariable linear regression with practice-level fixed effects to estimate continuity of care score at physician vs. practice level and their associations with outcomes. DATA COLLECTION/EXTRACTION METHOD We calculated clinician and practice level Bice-Boxerman continuity of care index scores, ranging from 0 to 1, using primary care outpatient claims. Medicare expenditures, hospital admissions, emergency department visits, and readmissions were obtained from the Medicare Beneficiary Summary File: Cost and Utilization Segment. Ambulatory care sensitive conditions (ACSC) were defined using diagnosis codes on inpatient claims. PRINCIPAL FINDINGS We studied 2,359,400 beneficiaries who sought care from 13,926 physicians. Every 0.1 increase in physician continuity score was associated with a $151 reduction in expenditures per beneficiary per year (P<0.01), and every 0.1 increase in practice continuity score was associated with $282 decrease (P<0.01) per beneficiary per year. Both physician- and practice-level continuity were associated with lower Medicare expenditures among small, medium, and large practices. Both physician- and practice-level continuity were associated with lower probabilities of hospitalization, emergency department visit, admissions for ACSC, and readmission. CONCLUSIONS Primary care continuity of care could serve as a potent value-based care quality metric. Physician-level continuity is a unique value center that cannot be supplanted by practice level continuity.
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Affiliation(s)
- Zhou Yang
- Omada Health, 500 Sansome St #200, San Francisco, CA
| | - Ishani Ganguli
- Brigham and Women's Hospital, Medicine, 1620 Tremont Street BC3-2M, Boston, MA
| | - Caitlin Davis
- Inova Fairfax Family Medicine, Residency Program, Fairfax, VA
| | - Mingliang Dai
- American Board of Family Medicine, 1648 McGrathiana Parkway Lexington, KY
| | - Jill Shuemaker
- The Center for Professionalism and Value in Health Care, 1016 16th Street NW Suite 700, Washington, DC
| | - Lars Peterson
- American Board of Family Medicine, 1648 McGrathiana Parkway Lexington, KY
| | - Andrew Bazemore
- The Center for Professionalism and Value in Health Care, 1016 16th Street NW Suite 700, Washington, DC
| | - Robert Phillips
- The Center for Professionalism and Value in Health Care, 1016 16th Street NW Suite 700, Washington, DC
| | - Yoon Kyung Chung
- The Robert Graham Center, 1133 Connecticut Avenue, NW Suite 1100, Washington, DC
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Lavergne MR, Loyal JP, Shirmaleki M, Kaoser R, Nicholls T, Schütz CG, Vaughan A, Samji H, Puyat JH, Kaulius M, Jones W, Small W. The relationship between outpatient service use and emergency department visits among people treated for mental and substance use disorders: analysis of population-based administrative data in British Columbia, Canada. BMC Health Serv Res 2022; 22:477. [PMID: 35410219 PMCID: PMC8996395 DOI: 10.1186/s12913-022-07759-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 03/07/2022] [Indexed: 01/02/2023] Open
Abstract
Background Research findings on the association between outpatient service use and emergency department (ED) visits for mental and substance use disorders (MSUDs) are mixed and may differ by disorder type. Methods We used population-based linked administrative data in British Columbia, Canada to examine associations between outpatient primary care and psychiatry service use and ED visits among people ages 15 and older, comparing across people treated for three disorder categories: common mental disorders (MDs) (depressive, anxiety, and/or post-traumatic stress disorders), serious MDs (schizophrenia spectrum and/or bipolar disorders), and substance use disorders (SUDs) in 2016/7. We used hurdle models to examine the association between outpatient service use and odds of any ED visit for MSUDs as well count of ED visits for MSUDs, stratified by cohort in 2017/8. Results Having had one or more MSUD-related primary care visit was associated with lower odds of any ED visit among people treated for common MDs and SUDs but not people treated for serious MDs. Continuity of primary care was associated with slightly lower ED use in all cohorts. One or more outpatient psychiatrist visits was associated with lower odds of ED visits among people treated for serious MDs and SUDs, but not among people with common MDs. Conclusion Findings highlight the importance of expanded access to outpatient specialist mental health services, particularly for people with serious MDs and SUDs, and collaborative models that can support primary care providers treating people with MSUDs. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07759-z.
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Affiliation(s)
- M Ruth Lavergne
- Department of Family Medicine, Faculty of Medicine, Primary Care Research Unit, Dalhousie University, 1465 Brenton Street, Suite 402, Halifax, NS, B3J 3T4, Canada.
| | - Jackson P Loyal
- Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Vancouver, BC, Canada.,BC Centre for Disease Control, Vancouver, BC, Canada
| | - Mehdi Shirmaleki
- Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Vancouver, BC, Canada
| | - Ridhwana Kaoser
- Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Vancouver, BC, Canada
| | - Tonia Nicholls
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada.,Department of Psychology, Simon Fraser University, Burnaby, BC, Canada.,BC Mental Health and Substance Use Services, Vancouver, BC, Canada
| | - Christian G Schütz
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada.,BC Mental Health and Substance Use Services, Vancouver, BC, Canada.,Centre for Health Evaluation and Outcome Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Adam Vaughan
- School of Criminal Justice and Criminology, Texas State University, San Marcos, TX, Canada
| | - Hasina Samji
- BC Centre for Disease Control, Vancouver, BC, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Joseph H Puyat
- Centre for Health Evaluation and Outcome Sciences, University of British Columbia, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Megan Kaulius
- Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Vancouver, BC, Canada
| | - Wayne Jones
- Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Vancouver, BC, Canada
| | - William Small
- Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Vancouver, BC, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada.,BC Centre on Substance Use, Vancouver, BC, Canada
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Marshall EG, Breton M, Green M, Edwards L, Ayn C, Smithman MA, Ryan Carson S, Ashcroft R, Bayoumi I, Burge F, Deslauriers V, Lawson B, Mathews M, McPherson C, Moritz LR, Nesto S, Stock D, Wong ST, Andrew M. CUP study: protocol for a comparative analysis of centralised waitlist effectiveness, policies and innovations for connecting unattached patients to primary care providers. BMJ Open 2022; 12:e049686. [PMID: 35256440 PMCID: PMC8905966 DOI: 10.1136/bmjopen-2021-049686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Access to a primary care provider is a key component of high-functioning healthcare systems. In Canada, 15% of patients do not have a regular primary care provider and are classified as 'unattached'. In an effort to link unattached patients with a provider, seven Canadian provinces implemented centralised waitlists (CWLs). The effectiveness of CWLs in attaching patients to regular primary care providers is unknown. Factors influencing CWLs effectiveness, particularly across jurisdictional contexts, have yet to be confirmed. METHODS AND ANALYSIS A mixed methods case study will be conducted across three Canadian provinces: Ontario, Québec and Nova Scotia. Quantitatively, CWL data will be linked to administrative and provider billing data to assess the rates of patient attachment over time and delay of attachment, stratified by demographics and compared with select indicators of health service utilisation. Qualitative interviews will be conducted with policymakers, patients, and primary care providers to elicit narratives regarding the administration, use, and access of CWLs. An analysis of policy documents will be used to identify contextual factors affecting CWL effectiveness. Stakeholder dialogues will be facilitated to uncover causal pathways and identify strategies for improving patient attachment to primary care. ETHICS AND DISSEMINATION Approval to conduct this study has been granted in Ontario (Queens University Health Sciences and Affiliated Teaching Hospitals Research Ethics Board, file number 6028052; Western University Health Sciences Research Ethics Board, project 116591; University of Toronto Health Sciences Research Ethics Board, protocol number 40335), Québec (Centre intégré universitaire de santé et de services sociaux de l'Estrie, project number 2020-3446) and Nova Scotia (Nova Scotia Health Research Ethics Board, file number 1024979).
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Affiliation(s)
- Emily Gard Marshall
- Primary Care Research Unit, Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Mylaine Breton
- Department of Community Health Sciences, Université de Sherbrooke, Longueuil, Québec, Canada
| | | | - Lynn Edwards
- Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Caitlyn Ayn
- Primary Care Research Unit, Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Mélanie Ann Smithman
- Centre de recherche Charles-LeMoyne, Université de Sherbrooke, Longueuil, Québec, Canada
| | | | | | | | - Frederick Burge
- Primary Care Research Unit, Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Véronique Deslauriers
- Centre de recherche Charles-LeMoyne, Université de Sherbrooke, Longueuil, Québec, Canada
| | - Beverley Lawson
- Primary Care Research Unit, Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Maria Mathews
- Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | | | - Lauren R Moritz
- Primary Care Research Unit, Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sue Nesto
- Primary Care Research Unit, Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - David Stock
- Primary Care Research Unit, Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sabrina T Wong
- School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada
| | - Melissa Andrew
- Division of Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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28
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Sandvik H, Hetlevik Ø, Blinkenberg J, Hunskaar S. Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care: a registry-based observational study in Norway. Br J Gen Pract 2022; 72:e84-e90. [PMID: 34607797 PMCID: PMC8510690 DOI: 10.3399/bjgp.2021.0340] [Citation(s) in RCA: 99] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 08/20/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Continuity, usually considered a quality aspect of primary care, is under pressure in Norway, and elsewhere. AIM To analyse the association between longitudinal continuity with a named regular general practitioner (RGP) and use of out-of-hours (OOH) services, acute hospital admission, and mortality. DESIGN AND SETTING Registry-based observational study in Norway covering 4 552 978 Norwegians listed with their RGPs. METHOD Duration of RGP-patient relationship was used as explanatory variable for the use of OOH services, acute hospital admission, and mortality in 2018. Several patient-related and RGP-related covariates were included in the analyses by individual linking to high-quality national registries. Duration of RGP-patient relationship was categorised as 1, 2-3, 4-5, 6-10, 11-15, or >15 years. Results are given as adjusted odds ratio (OR) with 95% confidence intervals (CI) resulting from multilevel logistic regression analyses. RESULTS Compared with a 1-year RGP-patient relationship, the OR for use of OOH services decreased gradually from 0.87 (95% CI = 0.86 to 0.88) after 2-3 years' duration to 0.70 (95% CI = 0.69 to 0.71) after >15 years. OR for acute hospital admission decreased gradually from 0.88 (95% CI = 0.86 to 0.90) after 2-3 years' duration to 0.72 (95% CI = 0.70 to 0.73) after >15 years. OR for dying decreased gradually from 0.92 (95% CI = 0.86 to 0.98) after 2-3 years' duration, to 0.75 (95% CI = 0.70 to 0.80) after an RGP-patient relationship of >15 years. CONCLUSION Length of RGP-patient relationship is significantly associated with lower use of OOH services, fewer acute hospital admissions, and lower mortality. The presence of a dose-response relationship between continuity and these outcomes indicates that the associations are causal.
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Affiliation(s)
- Hogne Sandvik
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen
| | - Øystein Hetlevik
- Department of Global Public Health and Primary Care, University of Bergen, Bergen
| | - Jesper Blinkenberg
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen; Department of Global Public Health and Primary Care, University of Bergen, Bergen
| | - Steinar Hunskaar
- NORCE Norwegian Research Centre, Bergen; Department of Global Public Health and Primary Care, University of Bergen, Bergen
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29
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Lavergne MR, Shirmaleki M, Loyal JP, Jones W, Nicholls TL, Schütz CG, Vaughan A, Samji H, Puyat JH, Kaoser R, Kaulius M, Small W. Emergency department use for mental and substance use disorders: descriptive analysis of population-based, linked administrative data in British Columbia, Canada. BMJ Open 2022; 12:e057072. [PMID: 35027424 PMCID: PMC8762129 DOI: 10.1136/bmjopen-2021-057072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES Information on emergency department (ED) visits for mental and substance use disorders (MSUDs) is important for planning services but has not been explored in British Columbia (BC), Canada. We describe all MSUD ED visits for people ages 15 and older in the province of BC in 2017/2018 and document trends in MSUD ED visits between 2007/2008 and 2017/2018 by disorder group. DESIGN Population-based linked administrative data comprised of ED records and physician billings capturing all MSUD ED visits in BC. SETTING BC is Canada's westernmost province with a population of approximately 5 million. Permanent residents receive first-dollar coverage for all medically necessary services provided by licensed physicians or in hospitals, including ED services. POPULATION All people age >15 with MSUD ED visits during the study period. MEASURES All claims with a service location in the ED or corresponding to fee items billed only in the ED were examined alongside ED visits reported through a national reporting system. Patient characteristics (sex/gender, age, location of residence, income, treated disorders and comorbidities) and previous outpatient service use for all ED visits by visit diagnosis are also described. RESULTS A total of 72 363 people made 134 063 visits to the ED in 2017/2018 for needs related to MSUD. MSUD ED visits have increased since 2010, particularly visits for substance use and anxiety disorders. People with more frequent visits were more likely to be male, on public prescription drug plans for income assistance, prescribed psychiatric medications, and living in lower-income neighbourhoods. They used more community-based primary care and psychiatry services and had lower continuity of primary care. CONCLUSIONS MSUD ED visits are substantial and growing in BC. Findings underscore a need to strengthen and target community healthcare services and adequately resource and support EDs to manage growing patient populations.
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Affiliation(s)
- M Ruth Lavergne
- Department of Family Medicine, Dalhousie University Faculty of Medicine, Halifax, Nova Scotia, Canada
- Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Mehdi Shirmaleki
- Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Jackson P Loyal
- Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Vancouver, British Columbia, Canada
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Wayne Jones
- Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Tonia L Nicholls
- Department of Psychiatry, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
- Department of Psychology, Simon Fraser University, Burnaby, British Columbia, Canada
- British Columbia Mental Health and Substance Use Services, Vancouver, British Columbia, Canada
| | - Christian G Schütz
- Department of Psychiatry, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
- British Columbia Mental Health and Substance Use Services, Vancouver, British Columbia, Canada
- Centre for Health Evaluation and Outcome Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Adam Vaughan
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- School of Criminal Justice and Criminology, Texas State University San Marcos, San Marcos, Texas, USA
| | - Hasina Samji
- Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Vancouver, British Columbia, Canada
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Joseph H Puyat
- Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Vancouver, British Columbia, Canada
- Centre for Health Evaluation and Outcome Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Ridhwana Kaoser
- Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Megan Kaulius
- Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Will Small
- Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
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30
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Junek ML, Jones A, Heckman G, Demers C, Griffith LE, Costa AP. The predictive utility of functional status at discharge: a population-level cohort analysis. BMC Geriatr 2022; 22:8. [PMID: 34979946 PMCID: PMC8722185 DOI: 10.1186/s12877-021-02652-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 11/23/2021] [Indexed: 11/18/2022] Open
Abstract
Background Functional status is a patient-important, patient-centered measurement. The utility of functional status measures to inform post-discharge patient needs is unknown. We sought to examine the utility of routinely collected functional status measures gathered from older hospitalized patients to predict a panel of post-discharge outcomes. Methods In this population-based retrospective cohort study, Adults 65+ discharged from an acute hospitalization between 4 November 2008 and 18 March 2016 in Ontario, Canada and received an assessment of functional status at discharge using the Health Outcomes for Better Information and Care tool were included. Multivariable regression analysis was used to determine the relationship between functional status and emergency department (ED) re-presentation, hospital readmission, long term care facility (LTCF) admission or wait listing (‘LTCF readiness’), and death at 180 days from discharge. Results A total of 80 020 discharges were included. 38 928 (48.6%) re-presented to the ED, 24 222 (30.3%) were re-admitted, 5 037 (6.3%) were LTCF ready, and 9 047 (11.3%) died at 180 days. Beyond age, diminished functional status at discharge was the factor most associated with LTCF readiness (adjusted Odds Ratio [OR] 4.11 for those who are completely dependent for activities of daily living compared to those who are independent; 95% Confidence Interval [CI]: 3.70-4.57) and death (OR 3.99; 95% CI: 3.67-4.35). Functional status also had a graded relationship with each outcome and improved the discriminability of the models predicting death and LTCF readiness (p<0.01) but not ED re-presentation or hospital re-admission. Conclusion Routinely collected functional status at discharge meaningfully improves the prediction of long term care home readiness and death. The routine assessment of functional status can inform post-discharge care and planning for older adults. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02652-6.
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Affiliation(s)
- Mats L Junek
- Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada. .,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
| | - Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - George Heckman
- Schlegel Research Institute on Aging, Waterloo, Ontario, Canada.,University of Waterloo, School of Public Health and Health Systems, Waterloo, Ontario, Canada
| | - Catherine Demers
- Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Lauren E Griffith
- Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada.,McMaster Institute for Research on Aging, Hamilton, Ontario, Canada
| | - Andrew P Costa
- Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Schlegel Research Institute on Aging, Waterloo, Ontario, Canada.,McMaster Institute for Research on Aging, Hamilton, Ontario, Canada
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31
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Kato K, Tomita M, Kato M, Goto T, Nishizono K. Prospective cohort study on the incidence and risk factors of emergency home visits among Japanese home care patients. J Gen Fam Med 2021; 22:334-340. [PMID: 34754711 PMCID: PMC8561101 DOI: 10.1002/jgf2.461] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 04/13/2021] [Accepted: 05/03/2021] [Indexed: 11/11/2022] Open
Abstract
Background Population aging requires more physician home visits, and various measures need to be taken to reduce the burden on visiting physicians. However, the incidence and associated factors of burdensome emergency home visits remain unclear. We aimed to reveal the incidences of emergency home visits among cancer and noncancer patients and examine how visiting nurses affect those. Methods We performed a prospective cohort study across three clinics in Japan and enrolled the patients receiving home visits within a 3-month study period. We calculated the incidence rates using person-time at risk and conducted a Cox regression in the analysis of risks for emergency home visits. Results A total of 278 patients were analyzed. The incidences of emergency home visits among the overall, the cancer, and the noncancer home care patients were 1.61, 7.23, and 1.37 per 10 person-months, respectively. The adjusted hazard ratios of a cancer-bearing state and visiting nurse service use were 4.71 (95% confidence interval [CI], 2.60-8.52) and 1.85 (95% CI, 1.77-1.94), respectively. Conclusions The incidence of emergency home visits among cancer patients was around five times greater than noncancer patients. Our study did not demonstrate that visiting nurses prevent emergency home visits. Further studies are needed to clarify how visiting nurses reduce physicians' burden.
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Affiliation(s)
- Koki Kato
- Madoka Family Clinic Fukuoka Japan.,Hokkaido Centre for Family Medicine Academic and Research Centre Hokkaido Japan
| | | | - Moe Kato
- Sakuragaoka Clinic Hokkaido Japan
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32
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Kolk D, Kruiswijk AF, MacNeil-Vroomen JL, Ridderikhof ML, Buurman BM. Older patients' perspectives on factors contributing to frequent visits to the emergency department: a qualitative interview study. BMC Public Health 2021; 21:1709. [PMID: 34544405 PMCID: PMC8454044 DOI: 10.1186/s12889-021-11755-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 09/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Older patients are at high risk of unplanned revisits to the emergency department (ED) because of their medical complexity. To reduce the number of ED visits, we need more knowledge about the patient-level, environmental, and healthcare factors involved. The aim of this study was to describe older patients' perspectives and experiences before and after an ED visit, and to identify factors that possibly contribute to frequent ED revisits. METHODS This was a qualitative description study. We performed semi-structured individual interviews with older patients who frequently visited the ED and were discharged home after an acute visit. Patients were enrolled in the ED of a university medical centre using purposive sampling. Interviews were recorded, transcribed, and coded independently by two researchers. Theoretical analysis was used to identify recurring patterns and themes in the data. Interviews were conducted until thematic saturation was reached. RESULTS In-depth interviews were completed with 13 older patients. Three main themes emerged: 1) medical events leading to feelings of crisis, 2) patients' untreated health problems, and 3) persistent problems in health and daily functioning post discharge. Participants identified problems before and after their ED visit that possibly contributed to further ED visits. These problems included increasing symptoms leading to feelings of crisis, the relationship with the general practitioner, incomplete discharge information at the ED, and inadequate follow-up and lack of recovery after an ED visit. CONCLUSIONS This qualitative study identified multiple factors that may contribute to frequent ED visits among older patients. Older patients in need of acute care might benefit from hospital-at-home interventions, or acute care provided by geriatric emergency teams in the primary care setting. Identifying frailty in the ED is needed to improve discharge communication and adequate follow-up is needed to improve recovery after an acute ED visit.
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Affiliation(s)
- Daisy Kolk
- Amsterdam UMC, University of Amsterdam, Emergency Medicine, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, Netherlands. .,Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC, University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health, Meibergdreef 9, Amsterdam, Netherlands.
| | - Anton F Kruiswijk
- Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC, University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health, Meibergdreef 9, Amsterdam, Netherlands.,OLVG Hospital, Department of Geriatric Medicine, Amsterdam, the Netherlands
| | - Janet L MacNeil-Vroomen
- Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC, University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health, Meibergdreef 9, Amsterdam, Netherlands
| | - Milan L Ridderikhof
- Amsterdam UMC, University of Amsterdam, Emergency Medicine, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, Netherlands
| | - Bianca M Buurman
- Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC, University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health, Meibergdreef 9, Amsterdam, Netherlands.,ACHIEVE - Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, Netherlands
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33
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Zhang T, Wang X. Association of Continuity of General Practitioner Care with Utilisation of General Practitioner and Specialist Services in China: A Mixed-Method Study. Healthcare (Basel) 2021; 9:healthcare9091206. [PMID: 34574980 PMCID: PMC8465206 DOI: 10.3390/healthcare9091206] [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: 07/13/2021] [Revised: 08/31/2021] [Accepted: 09/09/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Continuity of general practitioner (GP) care, widely known as the core value of high-quality patient care, has a positive association with health outcomes. Evidence about the relationship between continuity and health service utilisation has so far been lacking in China. This study aimed to analyse the association of continuity of GP care with utilisation of general practitioner and specialist services in China. Method: A cross-sectional mixed methods study was conducted in 10 urban communities in Hangzhou. Quantitative data were collected from a random sample of 624 residents adopting the self-developed questionnaire. Measurement of continuity of GP care included informational continuity (IC), managerial continuity (MC) and relational continuity (RC). With adjustment for characteristics of residents, multivariate regression models were established to examine the association of continuity of GP care with the intention to visit GP, frequency of GP and specialist visitations. Qualitative data were collected from 26 respondents using an in-depth interview, and thematic content analysis for qualitative data was conducted. Results: Quantitative analysis showed that the IC was positively associated with the intention to visit GP and frequency of GP visitations. Those people who gave a high rating for RC also used GP services more frequently than their counterparts. MC was negatively associated with frequency of specialist visitations. Qualitative analysis indicated that service capabilities, doctor-patient interaction and time provision were regarded as three important reasons why patients chose GPs or specialists. Conclusions: Overall, high IC and RC are independently associated with more GP service utilisation, but a high MC might reduce specialist visitations. Continuity of GP care should be highlighted in designing a Chinese GP system.
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34
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Perrault-Sequeira L, Torti J, Appleton A, Mathews M, Goldszmidt M. Discharging the complex patient - changing our focus to patients' networks of care providers. BMC Health Serv Res 2021; 21:950. [PMID: 34507571 PMCID: PMC8431846 DOI: 10.1186/s12913-021-06841-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 07/30/2021] [Indexed: 11/18/2022] Open
Abstract
Background A disconnect exists between the idealized model of every patient having a family physician (FP) who acts as the central hub for care, and the reality of health care where patients must navigate a network of different providers. This disconnect is particularly evident when hospitalized multimorbid patients transition back into the community. These discharges are identified as high-risk due to lapses in care continuity. The aim of this study was to identify and explore the networks of care providers in a sample of hospitalized, complex patients, and better understand the nature of their attachments to these providers as a means of discovering novel approaches for improving discharge planning. Methods This was a constructivist grounded theory study. Data included interviews from 30 patients admitted to an inpatient internal medicine service of a midsized academic hospital in Ontario, Canada. Analysis and data collection proceeded iteratively with sampling progressing from purposive to theoretical. Results We identified network of care configurations commonly found in patients with multiple medical comorbidities receiving care from multiple different providers admitted to an internal medicine service. FPs and specialists form the network’s scaffold. The involvement of physicians in the network dictated not only how patients experienced transitions in care but the degree of reliance on social supports and personal capacities. The ideal for the multimorbid patient is an optimally involved FP that remains at the centre, even when patients require more subspecialized care. However, in cases where a rostered FP is non-existent or inadequate, increased involvement and advocacy from specialists is crucial. Conclusions Our results have implications for transition planning in hospitalized complex patients. Recognizing salient network features can help identify patients who would benefit from enhanced discharge support. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06841-2.
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Affiliation(s)
| | - Jacqueline Torti
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.,Centre for Education Research & Innovation - Western University, London, ON, Canada
| | - Andrew Appleton
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Maria Mathews
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Mark Goldszmidt
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.,Centre for Education Research & Innovation - Western University, London, ON, Canada
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Bischof T, Kaiser B. Who cares when you close down? The effects of primary care practice closures on patients. HEALTH ECONOMICS 2021; 30:2004-2025. [PMID: 34046966 DOI: 10.1002/hec.4287] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 04/13/2021] [Accepted: 04/29/2021] [Indexed: 06/12/2023]
Abstract
This paper investigates the consequences that patients face when their regular general practitioner (GP) closes down her practice, typically due to retirement. We estimate the causal impact of closures on patients' utilization patterns, healthcare expenditures, hospitalizations, mortality, and health plan choices. Employing a difference-in-difference framework, we find that patients who experience a discontinuity of care persistently adjust their ambulatory utilization pattern by shifting visits away from GPs (-12%) toward specialists (+11%) and hospital outpatient facilities (+6%). In contrast, we find no evidence on adverse health effects as measured by hospitalizations and mortality. The impact on utilization is heterogeneous along several dimensions. In particular, we find geographic disparities between regions with high and low availability of primary care. We also observe that patients with chronic conditions substitute more strongly toward other providers. Our results have potential implications for health policy in at least two dimensions: first, practice closures lead to more fragmented care which may entail inefficiencies, and second, closures deteriorate access to primary care in regions with low physician density.
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Affiliation(s)
- Tamara Bischof
- Department of Economics, University of Bern, Bern, Switzerland
| | - Boris Kaiser
- BSS Volkswirtschaftliche Beratung, Basel, Switzerland
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Lehto M, Mustonen K, Raina M, Kauppila T. Differences between recorded diagnoses of patients of an emergency department and office-hours primary care doctors: a register-based study in a Finnish town. Int J Circumpolar Health 2021; 80:1935593. [PMID: 34077332 PMCID: PMC8174484 DOI: 10.1080/22423982.2021.1935593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
To determine the extent to which it is possible to provide continuity of primary care for those who visit Emergency Departments (EDs) we studied how recorded diagnoses in primary care differ, depending on whether the patient is met in an ED or a primary care office-hours practice. In the present, 12-year follow-up study a report generator of the Electronic Health Record-system provided monthly figures for the number of different recorded diagnoses using the International Classification of Diagnoses (10thedition, ICD-10) and the total number of ED doctors and office-hour visits to General Practitioners (GPs). The 20 most common diagnoses covered 48.1% of the visits with recorded diagnoses to the office hour GPs and 45.9% of the visits to the doctors of the ED. Of these 20 diagnoses, 10 were common in both systems. These 10 diagnoses constituted about 30% of the diagnoses given by ED doctors. Furthermore, five out of the six most common diagnoses were the same in the ED and office-hours practices. The doctors in EDs and office-hour GPs treat quite similar patient material. This may provide organisational ways to reorganise the work of primary care and to guarantee continuity of care for those who may benefit from it.
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Affiliation(s)
- Mika Lehto
- City of Vantaa, Vantaa, Finland.,Department of General Practice, University of Helsinki, Helsinki, Finland
| | - Katri Mustonen
- Department of General Practice, University of Helsinki, Helsinki, Finland
| | | | - Timo Kauppila
- Department of General Practice, University of Helsinki, Helsinki, Finland.,Department of Oral and Maxillofacial Diseases, Head and Neck Center, University of Helsinki, Helsinki, Finland.,Department of General Practice, University of Tampere, Tampere, Finland
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Bye EK, Bogstrand ST, Rossow I. The importance of alcohol in elderly's hospital admissions for fall injuries: a population case-control study. NORDIC STUDIES ON ALCOHOL AND DRUGS 2021; 39:38-49. [PMID: 35308463 PMCID: PMC8899276 DOI: 10.1177/14550725211015836] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 04/20/2021] [Indexed: 12/27/2022] Open
Abstract
Background: Fall injuries account for a substantial part of the health burden among elderly persons, and they often affect life quality severely and impose large societal costs. Alcohol intoxication is a well-known risk factor for accidental injuries, but less is known about this association among elderly people. In this study, our aim was to assess whether risk of fall injuries among the elderly is elevated with an intoxication-oriented drinking pattern. Method: We applied a population case-control design and data from persons aged 60 years and over in Norway. Cases comprised patients with fall injuries admitted to a hospital emergency department ( n = 424), and controls were participants in general population surveys ( n = 1859). Drinking pattern was assessed from self-reports of drinking frequency and intoxication frequency. Age and gender-adjusted association between fall injury and drinking pattern was estimated in logistic regression models. Fall injuries were considered alcohol-related if blood alcohol concentration exceeded 0.01% and/or the patient reported alcohol intake within six hours prior to injury. Results: The risk of fall injuries was highly elevated among those reporting drinking to intoxication monthly or more often ( OR = 10.2, 95% CI 5.5–19.0). Among cases, the vast majority of those with alcohol-related fall injuries (64 of 68) reported drinking to intoxication. Conclusions: A drinking pattern comprising alcohol intoxication elevated the risk of fall injuries among elderly people. As alcohol use is a modifiable risk factor, the findings suggest a potential to curb the number of fall injuries and their consequences by employing effective strategies to prevent intoxication drinking among the elderly.
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Affiliation(s)
- Elin K. Bye
- Norwegian Institute of Public Health, Oslo, Norway
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Gentil L, Grenier G, Vasiliadis HM, Huỳnh C, Fleury MJ. Predictors of Recurrent High Emergency Department Use among Patients with Mental Disorders. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18094559. [PMID: 33923112 PMCID: PMC8123505 DOI: 10.3390/ijerph18094559] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/16/2021] [Accepted: 04/17/2021] [Indexed: 11/23/2022]
Abstract
Few studies have examined predictors of recurrent high ED use. This study assessed predictors of recurrent high ED use over two and three consecutive years, compared with high one-year ED use. This five-year longitudinal study is based on a cohort of 3121 patients who visited one of six Quebec (Canada) ED at least three times in 2014–2015. Multinomial logistic regression was performed. Clinical, sociodemographic and service use variables were identified based on data extracted from health administrative databases for 2012–2013 to 2014–2015. Of the 3121 high ED users, 15% (n = 468) were recurrent high ED users for a two-year period and 12% (n = 364) over three years. Patients with three consecutive years of high ED use had more personality disorders, anxiety disorders, alcohol or drug related disorders, chronic physical illnesses, suicidal behaviors and violence or social issues. More resided in areas with high social deprivation, consulted frequently with psychiatrists, had more interventions in local community health service centers, more prior hospitalizations and lower continuity of medical care. Three consecutive years of high ED use may be a benchmark for identifying high users needing better ambulatory care. As most have multiple and complex health problems, higher continuity and adequacy of medical care should be prioritized.
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Affiliation(s)
- Lia Gentil
- Department of Psychiatry, McGill University, 1033, Pine Avenue West, Montreal, QC H3A 1A1, Canada;
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Blvd, Montreal, QC H4H 1R3, Canada;
- Centre Intégré Universitaire de Santé et des Services Sociaux du Centre-Sud-de-l’Île-de-Montréal, Institut Universitaire sur les Dépendances, 950 Louvain Est, Montréal, QC H2M 2E8, Canada;
| | - Guy Grenier
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Blvd, Montreal, QC H4H 1R3, Canada;
| | - Helen-Maria Vasiliadis
- Département Des Sciences de la Santé Communautaire, Université de Sherbrooke, Longueuil, QC J4K 0A8, Canada;
- Centre de Recherche Charles-Le Moyne-Saguenay–Lac-Saint-Jean sur les Innovations en Santé (CR-CSIS), Campus de Longueuil-Université de Sherbrooke, 150 Place Charles-Lemoyne, Longueuil, QC J4K 0A8, Canada
| | - Christophe Huỳnh
- Centre Intégré Universitaire de Santé et des Services Sociaux du Centre-Sud-de-l’Île-de-Montréal, Institut Universitaire sur les Dépendances, 950 Louvain Est, Montréal, QC H2M 2E8, Canada;
| | - Marie-Josée Fleury
- Department of Psychiatry, McGill University, 1033, Pine Avenue West, Montreal, QC H3A 1A1, Canada;
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Blvd, Montreal, QC H4H 1R3, Canada;
- Correspondence:
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Do interventions promoting medical homes in FQHCs improve continuity of care for Medicare beneficiaries? J Public Health (Oxf) 2021. [DOI: 10.1007/s10389-019-01090-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Mbuya-Bienge C, Simard M, Gaulin M, Candas B, Sirois C. Does socio-economic status influence the effect of multimorbidity on the frequent use of ambulatory care services in a universal healthcare system? A population-based cohort study. BMC Health Serv Res 2021; 21:202. [PMID: 33676497 PMCID: PMC7937264 DOI: 10.1186/s12913-021-06194-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 02/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Frequent healthcare users place a significant burden on health systems. Factors such as multimorbidity and low socioeconomic status have been associated with high use of ambulatory care services (emergency rooms, general practitioners and specialist physicians). However, the combined effect of these two factors remains poorly understood. Our goal was to determine whether the risk of being a frequent user of ambulatory care is influenced by an interaction between multimorbidity and socioeconomic status, in an entire population covered by a universal health system. METHODS Using a linkage of administrative databases, we conducted a population-based cohort study of all adults in Quebec, Canada. Multimorbidity (defined as the number of different diseases) was assessed over a two-year period from April 1st 2012 to March 31st 2014 and socioeconomic status was estimated using a validated material deprivation index. Frequents users for a particular category of ambulatory services had a number of visits among the highest 5% in the total population during the 2014-15 fiscal year. We used ajusted logistic regressions to model the association between frequent use of health services and multimorbidity, depending on socioeconomic status. RESULTS Frequent users (5.1% of the population) were responsible for 25.2% of all ambulatory care visits. The lower the socioeconomic status, the higher the burden of chronic diseases, and the more frequent the visits to emergency departments and general practitioners. Socioeconomic status modified the association between multimorbidity and frequent visits to specialist physicians: those with low socioeconomic status visited specialist physicians less often. The difference in adjusted proportions of frequent use between the most deprived and the least deprived individuals varied from 0.1% for those without any chronic disease to 5.1% for those with four or more chronic diseases. No such differences in proportions were observed for frequent visits to an emergency room or frequent visits to a general practitioner. CONCLUSION Even in a universal healthcare system, the gap between socioeconomic groups widens as a function of multimorbidity with regard to visits to the specialist physicians. Further studies are needed to better understand the differential use of specialized care by the most deprived individuals.
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Affiliation(s)
- Cynthia Mbuya-Bienge
- Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Quebec, QC, Canada.
- Quebec National Institute of Public Health, Quebec, QC, Canada.
- Centre de Recherche Sur les Soins et les Services de Première Ligne de l'Université Laval, Québec, Canada.
| | - Marc Simard
- Quebec National Institute of Public Health, Quebec, QC, Canada
| | - Myles Gaulin
- Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Quebec, QC, Canada
- Quebec National Institute of Public Health, Quebec, QC, Canada
| | - Bernard Candas
- National Institute of Excellence in Health and Social Services, Quebec, QC, Canada
| | - Caroline Sirois
- Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Quebec, QC, Canada
- Quebec National Institute of Public Health, Quebec, QC, Canada
- Centre de Recherche Sur les Soins et les Services de Première Ligne de l'Université Laval, Québec, Canada
- Centre d'excellence sur le vieillissement de Québec, Centre de recherche du CHU de Québec, Quebec, QC, Canada
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Moe J, O'Sullivan F, McGregor MJ, Schull MJ, Dong K, Holroyd BR, Grafstein E, Hohl CM, Trimble J, McGrail KM. Identifying subgroups and risk among frequent emergency department users in British Columbia. J Am Coll Emerg Physicians Open 2021; 2:e12346. [PMID: 33532752 PMCID: PMC7823092 DOI: 10.1002/emp2.12346] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 12/01/2020] [Accepted: 12/11/2020] [Indexed: 01/25/2023] Open
Abstract
Objective: Frequent emergency department (ED) users are heterogeneous. We aimed to identify subgroups and assess their mortality. Methods: We identified patients ≥18 years with ≥1 ED visit in British Columbia from April 1, 2012 to March 31, 2015, and linked to hospitalization, physician billing, prescription, and mortality data. Frequent users were the top 10% of patients by ED visits. We employed cluster analysis to identify frequent user subgroups. We assessed 365-day mortality using Kaplan-Meier curves and conducted Cox regressions to assess mortality risk factors within subgroups. Results: We identified 4 subgroups. Subgroup 1 ("Elderly") had median age 77 years (interquartile range [IQR]: 66-85), 5 visits/year (IQR: 4-6), median 8 prescription medications (IQR: 5-11), and 24.7% mortality. Subgroup 2 ("Mental Health and Alcohol Use") had median age 48 years (IQR: 34-61), 13 visits/year (IQR: 10-16), and 12.3% mortality. They made a median 31 general practitioner visits (IQR: 19-51); however, only 23.7% received a majority of services from 1 primary care physician. Subgroup 3 ("Young Mental Health") had median age 39 years (IQR: 28-51), 5 visits/year (IQR: 4-6), and 2.2% mortality. Subgroup 4 ("Short-term") had median age 50 years (IQR: 34-65), 4 visits/year (IQR: 4-5) regularly spaced over a short term, and 1.4% mortality. Male sex (all subgroups), long-term care ("Mental Health and Alcohol Use;" "Young Mental Health"), and rural residence ("Elderly" in long-term care; "Young Mental Health") were associated with increased mortality. Conclusions: Our results identify frequent user subgroups with varying mortality. Future research should explore subgroups' unmet needs and tailor interventions toward them.
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Affiliation(s)
- Jessica Moe
- Department of Emergency Medicine, University of British ColumbiaDepartment of Emergency Medicine, Vancouver General HospitalVancouverBritish ColumbiaCanada
| | - Fiona O'Sullivan
- Department of Emergency MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Margaret J. McGregor
- Department of Family PracticeUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Michael J. Schull
- Institute for Clinical Evaluative SciencesDepartment of MedicineUniversity of TorontoTorontoOntarioCanada
| | - Kathryn Dong
- Department of Emergency MedicineUniversity of AlbertaEdmontonAlbertaCanada
| | - Brian R. Holroyd
- Department of Emergency MedicineEmergency Strategic Clinical Networ, Alberta Health ServicesUniversity of AlbertaEdmontonAlbertaCanada
| | - Eric Grafstein
- Department of Emergency MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Corinne M. Hohl
- Department of Emergency Medicine, University of British ColumbiaDepartment of Emergency Medicine, Vancouver General HospitalVancouverBritish ColumbiaCanada
| | - Johanna Trimble
- Patients for Patient Safety CanadaRoberts CreekVancouverBritish ColumbiaCanada
| | - Kimberlyn M. McGrail
- Population Data BCSchool of Population and Public Health, University of British ColumbiaVancouverBritish ColumbiaCanada
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Moe J, O'Sullivan F, McGregor MJ, Schull MJ, Dong K, Holroyd BR, Grafstein E, Hohl CM, Trimble J, McGrail KM. Characteristics of frequent emergency department users in British Columbia, Canada: a retrospective analysis. CMAJ Open 2021; 9:E134-E141. [PMID: 33653768 PMCID: PMC8034376 DOI: 10.9778/cmajo.20200168] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Frequent emergency department users disproportionately account for rising health care costs. We aimed to characterize frequent emergency department users in British Columbia, Canada. METHODS We performed a retrospective analysis using health administrative databases. We included patients aged 18 years or more with at least 1 emergency department visit from 2012/13 to 2015/16, linked to hospital, physician billing, prescription and mortality data. We used annual emergency department visits made by the top 10% of patients to define frequent users (≥ 3 visits/year). RESULTS Over the study period, 13.8%-15.3% of patients seen in emergency departments were frequent users. We identified 205 136 frequent users among 1 196 353 emergency department visitors. Frequent users made 40.3% of total visits in 2015/16. From 2012/13 to 2015/16, their visit rates per 100 000 BC population showed a relative increase of 21.8%, versus 13.1% among all emergency department patients. Only 1.8% were frequent users in all study years. Mental illness accounted for 8.2% of visits among those less than 60 years of age, and circulatory or respiratory diagnoses for 13.3% of visits among those aged 60 or more. In 2015/16, frequent users were older and had lower household incomes than nonfrequent users; the sex distribution was similar. Frequent users had more prescriptions (median 9, interquartile range [IQR] 5-14 v. 1, IQR 1-3), primary care visits (median 15, IQR 9-27 v. 7, IQR 4-12) and hospital admissions (median 2, IQR 1-3 v. 1, IQR 1-1), and higher 1-year mortality (10.2% v. 3.5%) than nonfrequent users. INTERPRETATION Emergency department use by frequent users increased in BC between 2012/13 and 2015/16; these patients were heterogenous, had high mortality and rarely remained frequent users over multiple years. Our results suggest that interventions must account for heterogeneity and address triggers of frequent use episodes.
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Affiliation(s)
- Jessica Moe
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Fiona O'Sullivan
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Margaret J McGregor
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Michael J Schull
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Kathryn Dong
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Brian R Holroyd
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Eric Grafstein
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Corinne M Hohl
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Johanna Trimble
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Kimberlyn M McGrail
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
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Moorin RE, Youens D, Preen DB, Wright CM. The association between general practitioner regularity of care and 'high use' hospitalisation. BMC Health Serv Res 2020; 20:915. [PMID: 33023571 PMCID: PMC7541210 DOI: 10.1186/s12913-020-05718-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 09/07/2020] [Indexed: 12/02/2022] Open
Abstract
Background In Australia, as in many high income countries, there has been a movement to improve out-of-hospital care. If primary care improvements can yield appropriately lower hospital use, this would improve productive efficiency. This is especially important among ‘high cost users’, a small group of patients accounting for disproportionately high hospitalisation costs. This study aimed to assess the association between regularity of general practitioner (GP) care and ‘high use’ hospitalisation. Methods This retrospective, cohort study used linked administrative and survey data from the 45 and Up Study, conducted in New South Wales, Australia. The exposure was regularity of GP care between 1 July 2005 and 30 June 2009, categorised by quintile (lowest to highest). Outcomes were ‘high use’ of hospitalisation (defined as ≥3 and ≥ 5 admissions within 12 months), extended length of stay (LOS, ≥30 days), a combined metric (≥3 hospitalisations in a 12 month period where ≥1 hospitalisation was ≥30 days) and 30-day readmission between 1 July 2009 and 31 December 2017. Associations were assessed using multivariable logistic regression. Potential for outcome prevention in a hypothetical scenario where all individuals attain the highest GP regularity was estimated via the population attributable fraction (PAF). Results Of 253,500 eligible participants, 15% had ≥3 and 7% had ≥5 hospitalisations in a 12-month period. Five percent of the cohort had a hospitalisation lasting ≥30 days and 25% had a readmission within 30 days. Compared with lowest regularity, highest regularity was associated with between 6% (p < 0.001) and 11% (p = 0.027) lower odds of ‘high use’. There was a 7–8% reduction in odds for all regularity levels above ‘low’ regularity for LOS ≥30 days. Otherwise, there was no clear sequential reduction in ‘high use’ with increasing regularity. The PAF associated with a move to highest regularity ranged from 0.05 to 0.13. The number of individuals who could have had an outcome prevented was estimated to be between 269 and 2784, depending on outcome. Conclusions High GP regularity is associated with a decreased likelihood of ‘high use’ hospitalisation, though for most outcomes there was not an apparent linear association with regularity.
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Affiliation(s)
- Rachael E Moorin
- Health Economics and Data Analytics, School of Public Health, Faculty of Health Sciences, Curtin University, GPO Box U1987, Perth, Western Australia, 6845, Australia.,School of Population and Global Health, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - David Youens
- Health Economics and Data Analytics, School of Public Health, Faculty of Health Sciences, Curtin University, GPO Box U1987, Perth, Western Australia, 6845, Australia
| | - David B Preen
- School of Population and Global Health, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Cameron M Wright
- Health Economics and Data Analytics, School of Public Health, Faculty of Health Sciences, Curtin University, GPO Box U1987, Perth, Western Australia, 6845, Australia. .,School of Medicine, College of Health & Medicine, University of Tasmania, Hobart, Tasmania, Australia.
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44
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Cook LL, Golonka RP, Cook CM, Walker RL, Faris P, Spenceley S, Lewanczuk R, Wedel R, Love R, Andres C, Byers SD, Collins T, Oddie S. Association between continuity and access in primary care: a retrospective cohort study. CMAJ Open 2020; 8:E722-E730. [PMID: 33199505 PMCID: PMC7676991 DOI: 10.9778/cmajo.20200014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Continuity of care is a tenet of primary care. Our objective was to explore the relation between a change in access to a primary care physician and continuity of care. METHODS We conducted a retrospective cohort study among physicians in a primary care network in southwest Alberta who measured access consistently between 2009 and 2016. We used time to the third next available appointment as a measure of access to physicians. We calculated the provider and clinic continuity, discontinuity and emergency department use based on the physicians' own panels. Physicians who improved, worsened or maintained their level of access within a given year were assessed in multilevel models to determine the association with continuity of care at the physician and clinic levels and the emergency department. RESULTS We analyzed data from 190 primary care physicians. Physicians with improved access increased provider continuity by 6.8% per year, reduced discontinuity by 2.1% per year, and decreased emergency department encounters by 78 visits per 1000 patients per year compared to physicians with stable access. Physicians with worsening access had a 6.2% decrease in provider continuity and an increased number of emergency department encounters (64 visits per 1000 panelled patients per year) compared to physicians with stable access. INTERPRETATION Changes in access to primary care can affect whether patients seek care from their own physician, from another clinic or at the emergency department. Improving access by reducing the delay in obtaining an appointment with one's primary care physician may be one mechanism to improve continuity of care.
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Affiliation(s)
- Lisa L Cook
- Applied Research & Evaluation Services, Primary Health Care (L. Cook, C. Cook), Alberta Health Services; Faculty of Health Sciences (L. Cook, Spenceley), University of Lethbridge, Lethbridge, Alta.; Applied Research & Evaluation Services, Primary Health Care (Golonka), Alberta Health Services, Edmonton, Alta.; Applied Research & Evaluation Services, Primary Health Care (Walker), Alberta Health Services; Cumming School of Medicine (Walker, Faris), University of Calgary; Health Services Statistical & Analytics Methods, Analytics, Data Integration, Measurement & Reporting (Faris), Alberta Health Services, Calgary, Alta.; Enhancing Care in the Community (Lewanczuk), Alberta Health Services; Department of Medicine (Lewanczuk), University of Alberta, Edmonton, Alta.; Chinook Primary Care Network (Wedel, Byers, Collins); Primary Health Care Integration Network (Love), Alberta Health Services; Public & Primary Health Care (Andres), Alberta Health Services, Lethbridge, Alta.; Applied Research & Evaluation Services, Primary Health Care (Oddie), Alberta Health Services, Red Deer, Alta.; Faculty of Social Sciences (Oddie), University of Calgary, Calgary, Alta.
| | - Richard P Golonka
- Applied Research & Evaluation Services, Primary Health Care (L. Cook, C. Cook), Alberta Health Services; Faculty of Health Sciences (L. Cook, Spenceley), University of Lethbridge, Lethbridge, Alta.; Applied Research & Evaluation Services, Primary Health Care (Golonka), Alberta Health Services, Edmonton, Alta.; Applied Research & Evaluation Services, Primary Health Care (Walker), Alberta Health Services; Cumming School of Medicine (Walker, Faris), University of Calgary; Health Services Statistical & Analytics Methods, Analytics, Data Integration, Measurement & Reporting (Faris), Alberta Health Services, Calgary, Alta.; Enhancing Care in the Community (Lewanczuk), Alberta Health Services; Department of Medicine (Lewanczuk), University of Alberta, Edmonton, Alta.; Chinook Primary Care Network (Wedel, Byers, Collins); Primary Health Care Integration Network (Love), Alberta Health Services; Public & Primary Health Care (Andres), Alberta Health Services, Lethbridge, Alta.; Applied Research & Evaluation Services, Primary Health Care (Oddie), Alberta Health Services, Red Deer, Alta.; Faculty of Social Sciences (Oddie), University of Calgary, Calgary, Alta
| | - Charles M Cook
- Applied Research & Evaluation Services, Primary Health Care (L. Cook, C. Cook), Alberta Health Services; Faculty of Health Sciences (L. Cook, Spenceley), University of Lethbridge, Lethbridge, Alta.; Applied Research & Evaluation Services, Primary Health Care (Golonka), Alberta Health Services, Edmonton, Alta.; Applied Research & Evaluation Services, Primary Health Care (Walker), Alberta Health Services; Cumming School of Medicine (Walker, Faris), University of Calgary; Health Services Statistical & Analytics Methods, Analytics, Data Integration, Measurement & Reporting (Faris), Alberta Health Services, Calgary, Alta.; Enhancing Care in the Community (Lewanczuk), Alberta Health Services; Department of Medicine (Lewanczuk), University of Alberta, Edmonton, Alta.; Chinook Primary Care Network (Wedel, Byers, Collins); Primary Health Care Integration Network (Love), Alberta Health Services; Public & Primary Health Care (Andres), Alberta Health Services, Lethbridge, Alta.; Applied Research & Evaluation Services, Primary Health Care (Oddie), Alberta Health Services, Red Deer, Alta.; Faculty of Social Sciences (Oddie), University of Calgary, Calgary, Alta
| | - Robin L Walker
- Applied Research & Evaluation Services, Primary Health Care (L. Cook, C. Cook), Alberta Health Services; Faculty of Health Sciences (L. Cook, Spenceley), University of Lethbridge, Lethbridge, Alta.; Applied Research & Evaluation Services, Primary Health Care (Golonka), Alberta Health Services, Edmonton, Alta.; Applied Research & Evaluation Services, Primary Health Care (Walker), Alberta Health Services; Cumming School of Medicine (Walker, Faris), University of Calgary; Health Services Statistical & Analytics Methods, Analytics, Data Integration, Measurement & Reporting (Faris), Alberta Health Services, Calgary, Alta.; Enhancing Care in the Community (Lewanczuk), Alberta Health Services; Department of Medicine (Lewanczuk), University of Alberta, Edmonton, Alta.; Chinook Primary Care Network (Wedel, Byers, Collins); Primary Health Care Integration Network (Love), Alberta Health Services; Public & Primary Health Care (Andres), Alberta Health Services, Lethbridge, Alta.; Applied Research & Evaluation Services, Primary Health Care (Oddie), Alberta Health Services, Red Deer, Alta.; Faculty of Social Sciences (Oddie), University of Calgary, Calgary, Alta
| | - Peter Faris
- Applied Research & Evaluation Services, Primary Health Care (L. Cook, C. Cook), Alberta Health Services; Faculty of Health Sciences (L. Cook, Spenceley), University of Lethbridge, Lethbridge, Alta.; Applied Research & Evaluation Services, Primary Health Care (Golonka), Alberta Health Services, Edmonton, Alta.; Applied Research & Evaluation Services, Primary Health Care (Walker), Alberta Health Services; Cumming School of Medicine (Walker, Faris), University of Calgary; Health Services Statistical & Analytics Methods, Analytics, Data Integration, Measurement & Reporting (Faris), Alberta Health Services, Calgary, Alta.; Enhancing Care in the Community (Lewanczuk), Alberta Health Services; Department of Medicine (Lewanczuk), University of Alberta, Edmonton, Alta.; Chinook Primary Care Network (Wedel, Byers, Collins); Primary Health Care Integration Network (Love), Alberta Health Services; Public & Primary Health Care (Andres), Alberta Health Services, Lethbridge, Alta.; Applied Research & Evaluation Services, Primary Health Care (Oddie), Alberta Health Services, Red Deer, Alta.; Faculty of Social Sciences (Oddie), University of Calgary, Calgary, Alta
| | - Shannon Spenceley
- Applied Research & Evaluation Services, Primary Health Care (L. Cook, C. Cook), Alberta Health Services; Faculty of Health Sciences (L. Cook, Spenceley), University of Lethbridge, Lethbridge, Alta.; Applied Research & Evaluation Services, Primary Health Care (Golonka), Alberta Health Services, Edmonton, Alta.; Applied Research & Evaluation Services, Primary Health Care (Walker), Alberta Health Services; Cumming School of Medicine (Walker, Faris), University of Calgary; Health Services Statistical & Analytics Methods, Analytics, Data Integration, Measurement & Reporting (Faris), Alberta Health Services, Calgary, Alta.; Enhancing Care in the Community (Lewanczuk), Alberta Health Services; Department of Medicine (Lewanczuk), University of Alberta, Edmonton, Alta.; Chinook Primary Care Network (Wedel, Byers, Collins); Primary Health Care Integration Network (Love), Alberta Health Services; Public & Primary Health Care (Andres), Alberta Health Services, Lethbridge, Alta.; Applied Research & Evaluation Services, Primary Health Care (Oddie), Alberta Health Services, Red Deer, Alta.; Faculty of Social Sciences (Oddie), University of Calgary, Calgary, Alta
| | - Richard Lewanczuk
- Applied Research & Evaluation Services, Primary Health Care (L. Cook, C. Cook), Alberta Health Services; Faculty of Health Sciences (L. Cook, Spenceley), University of Lethbridge, Lethbridge, Alta.; Applied Research & Evaluation Services, Primary Health Care (Golonka), Alberta Health Services, Edmonton, Alta.; Applied Research & Evaluation Services, Primary Health Care (Walker), Alberta Health Services; Cumming School of Medicine (Walker, Faris), University of Calgary; Health Services Statistical & Analytics Methods, Analytics, Data Integration, Measurement & Reporting (Faris), Alberta Health Services, Calgary, Alta.; Enhancing Care in the Community (Lewanczuk), Alberta Health Services; Department of Medicine (Lewanczuk), University of Alberta, Edmonton, Alta.; Chinook Primary Care Network (Wedel, Byers, Collins); Primary Health Care Integration Network (Love), Alberta Health Services; Public & Primary Health Care (Andres), Alberta Health Services, Lethbridge, Alta.; Applied Research & Evaluation Services, Primary Health Care (Oddie), Alberta Health Services, Red Deer, Alta.; Faculty of Social Sciences (Oddie), University of Calgary, Calgary, Alta
| | - Robert Wedel
- Applied Research & Evaluation Services, Primary Health Care (L. Cook, C. Cook), Alberta Health Services; Faculty of Health Sciences (L. Cook, Spenceley), University of Lethbridge, Lethbridge, Alta.; Applied Research & Evaluation Services, Primary Health Care (Golonka), Alberta Health Services, Edmonton, Alta.; Applied Research & Evaluation Services, Primary Health Care (Walker), Alberta Health Services; Cumming School of Medicine (Walker, Faris), University of Calgary; Health Services Statistical & Analytics Methods, Analytics, Data Integration, Measurement & Reporting (Faris), Alberta Health Services, Calgary, Alta.; Enhancing Care in the Community (Lewanczuk), Alberta Health Services; Department of Medicine (Lewanczuk), University of Alberta, Edmonton, Alta.; Chinook Primary Care Network (Wedel, Byers, Collins); Primary Health Care Integration Network (Love), Alberta Health Services; Public & Primary Health Care (Andres), Alberta Health Services, Lethbridge, Alta.; Applied Research & Evaluation Services, Primary Health Care (Oddie), Alberta Health Services, Red Deer, Alta.; Faculty of Social Sciences (Oddie), University of Calgary, Calgary, Alta
| | - Rebecca Love
- Applied Research & Evaluation Services, Primary Health Care (L. Cook, C. Cook), Alberta Health Services; Faculty of Health Sciences (L. Cook, Spenceley), University of Lethbridge, Lethbridge, Alta.; Applied Research & Evaluation Services, Primary Health Care (Golonka), Alberta Health Services, Edmonton, Alta.; Applied Research & Evaluation Services, Primary Health Care (Walker), Alberta Health Services; Cumming School of Medicine (Walker, Faris), University of Calgary; Health Services Statistical & Analytics Methods, Analytics, Data Integration, Measurement & Reporting (Faris), Alberta Health Services, Calgary, Alta.; Enhancing Care in the Community (Lewanczuk), Alberta Health Services; Department of Medicine (Lewanczuk), University of Alberta, Edmonton, Alta.; Chinook Primary Care Network (Wedel, Byers, Collins); Primary Health Care Integration Network (Love), Alberta Health Services; Public & Primary Health Care (Andres), Alberta Health Services, Lethbridge, Alta.; Applied Research & Evaluation Services, Primary Health Care (Oddie), Alberta Health Services, Red Deer, Alta.; Faculty of Social Sciences (Oddie), University of Calgary, Calgary, Alta
| | - Cheryl Andres
- Applied Research & Evaluation Services, Primary Health Care (L. Cook, C. Cook), Alberta Health Services; Faculty of Health Sciences (L. Cook, Spenceley), University of Lethbridge, Lethbridge, Alta.; Applied Research & Evaluation Services, Primary Health Care (Golonka), Alberta Health Services, Edmonton, Alta.; Applied Research & Evaluation Services, Primary Health Care (Walker), Alberta Health Services; Cumming School of Medicine (Walker, Faris), University of Calgary; Health Services Statistical & Analytics Methods, Analytics, Data Integration, Measurement & Reporting (Faris), Alberta Health Services, Calgary, Alta.; Enhancing Care in the Community (Lewanczuk), Alberta Health Services; Department of Medicine (Lewanczuk), University of Alberta, Edmonton, Alta.; Chinook Primary Care Network (Wedel, Byers, Collins); Primary Health Care Integration Network (Love), Alberta Health Services; Public & Primary Health Care (Andres), Alberta Health Services, Lethbridge, Alta.; Applied Research & Evaluation Services, Primary Health Care (Oddie), Alberta Health Services, Red Deer, Alta.; Faculty of Social Sciences (Oddie), University of Calgary, Calgary, Alta
| | - Susan D Byers
- Applied Research & Evaluation Services, Primary Health Care (L. Cook, C. Cook), Alberta Health Services; Faculty of Health Sciences (L. Cook, Spenceley), University of Lethbridge, Lethbridge, Alta.; Applied Research & Evaluation Services, Primary Health Care (Golonka), Alberta Health Services, Edmonton, Alta.; Applied Research & Evaluation Services, Primary Health Care (Walker), Alberta Health Services; Cumming School of Medicine (Walker, Faris), University of Calgary; Health Services Statistical & Analytics Methods, Analytics, Data Integration, Measurement & Reporting (Faris), Alberta Health Services, Calgary, Alta.; Enhancing Care in the Community (Lewanczuk), Alberta Health Services; Department of Medicine (Lewanczuk), University of Alberta, Edmonton, Alta.; Chinook Primary Care Network (Wedel, Byers, Collins); Primary Health Care Integration Network (Love), Alberta Health Services; Public & Primary Health Care (Andres), Alberta Health Services, Lethbridge, Alta.; Applied Research & Evaluation Services, Primary Health Care (Oddie), Alberta Health Services, Red Deer, Alta.; Faculty of Social Sciences (Oddie), University of Calgary, Calgary, Alta
| | - Tim Collins
- Applied Research & Evaluation Services, Primary Health Care (L. Cook, C. Cook), Alberta Health Services; Faculty of Health Sciences (L. Cook, Spenceley), University of Lethbridge, Lethbridge, Alta.; Applied Research & Evaluation Services, Primary Health Care (Golonka), Alberta Health Services, Edmonton, Alta.; Applied Research & Evaluation Services, Primary Health Care (Walker), Alberta Health Services; Cumming School of Medicine (Walker, Faris), University of Calgary; Health Services Statistical & Analytics Methods, Analytics, Data Integration, Measurement & Reporting (Faris), Alberta Health Services, Calgary, Alta.; Enhancing Care in the Community (Lewanczuk), Alberta Health Services; Department of Medicine (Lewanczuk), University of Alberta, Edmonton, Alta.; Chinook Primary Care Network (Wedel, Byers, Collins); Primary Health Care Integration Network (Love), Alberta Health Services; Public & Primary Health Care (Andres), Alberta Health Services, Lethbridge, Alta.; Applied Research & Evaluation Services, Primary Health Care (Oddie), Alberta Health Services, Red Deer, Alta.; Faculty of Social Sciences (Oddie), University of Calgary, Calgary, Alta
| | - Scott Oddie
- Applied Research & Evaluation Services, Primary Health Care (L. Cook, C. Cook), Alberta Health Services; Faculty of Health Sciences (L. Cook, Spenceley), University of Lethbridge, Lethbridge, Alta.; Applied Research & Evaluation Services, Primary Health Care (Golonka), Alberta Health Services, Edmonton, Alta.; Applied Research & Evaluation Services, Primary Health Care (Walker), Alberta Health Services; Cumming School of Medicine (Walker, Faris), University of Calgary; Health Services Statistical & Analytics Methods, Analytics, Data Integration, Measurement & Reporting (Faris), Alberta Health Services, Calgary, Alta.; Enhancing Care in the Community (Lewanczuk), Alberta Health Services; Department of Medicine (Lewanczuk), University of Alberta, Edmonton, Alta.; Chinook Primary Care Network (Wedel, Byers, Collins); Primary Health Care Integration Network (Love), Alberta Health Services; Public & Primary Health Care (Andres), Alberta Health Services, Lethbridge, Alta.; Applied Research & Evaluation Services, Primary Health Care (Oddie), Alberta Health Services, Red Deer, Alta.; Faculty of Social Sciences (Oddie), University of Calgary, Calgary, Alta
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Lei L, Intrator O, Conwell Y, Fortinsky RH, Cai S. Continuity of care and health care cost among community-dwelling older adult veterans living with dementia. Health Serv Res 2020; 56:378-388. [PMID: 32812658 DOI: 10.1111/1475-6773.13541] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To estimate the causal impact of continuity of care (COC) on total, institutional, and noninstitutional cost among community-dwelling older veterans with dementia. DATA SOURCES Combined Veterans Health Administration (VHA) and Medicare data in Fiscal Years (FYs) 2014-2015. STUDY DESIGN FY 2014 COC was measured by the Bice-Boxerman Continuity of Care (BBC) index on a 0-1 scale. FY 2015 total combined VHA and Medicare cost, institutional cost of acute inpatient, emergency department [ED], long-/short-stay nursing home, and noninstitutional long-term care (LTC) cost for medical (like skilled-) and social (like unskilled-) services were assessed controlling for covariates. An instrumental variable for COC (change of residence by more than 10 miles) was used to account for unobserved health confounders. DATA COLLECTION Community-dwelling veterans with dementia aged 66 and older, enrolled in Traditional Medicare (N = 102 073). PRINCIPAL FINDINGS Mean BBC in FY 2014 was 0.32; mean total cost in FY 2015 was $35 425. A 0.1 higher BBC resulted in (a) $4045 lower total cost; (b) $1597 lower acute inpatient cost, $119 lower ED cost, $4368 lower long-stay nursing home cost; (c) $402 higher noninstitutional medical LTC and $764 higher noninstitutional social LTC cost. BBC had no impact on short-stay nursing home cost. CONCLUSIONS COC is an effective approach to reducing total health care cost by supporting noninstitutional care and reducing institutional care.
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Affiliation(s)
- Lianlian Lei
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan.,Geriatrics & Extended Care Data Analysis Center (GECDAC), Canandaigua VA Medical Center, Canandaigua, New York
| | - Orna Intrator
- Geriatrics & Extended Care Data Analysis Center (GECDAC), Canandaigua VA Medical Center, Canandaigua, New York.,Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Richard H Fortinsky
- Center on Aging, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Shubing Cai
- Geriatrics & Extended Care Data Analysis Center (GECDAC), Canandaigua VA Medical Center, Canandaigua, New York.,Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York
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46
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Oslislo S, Heintze C, Möckel M, Schenk L, Holzinger F. What role does the GP play for emergency department utilizers? A qualitative exploration of respiratory patients' perspectives in Berlin, Germany. BMC FAMILY PRACTICE 2020; 21:154. [PMID: 32731862 PMCID: PMC7393893 DOI: 10.1186/s12875-020-01222-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 07/15/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND While motives for emergency department (ED) self-referrals have been investigated in a number of studies, the relevance of general practitioner (GP) care for these patients has not been comprehensively evaluated. Respiratory symptoms constitute an important utilization trigger in both EDs and in primary care. In this qualitative study, we aimed to explore the role of GP care for patients visiting EDs as outpatients for respiratory complaints and the relevance of the relationship between patient and GP in the decision making process leading up to an ED visit. METHODS Qualitative descriptive study. Semi-structured, face-to-face interviews with a sample of 17 respiratory ED patients in Berlin, Germany. Interviews were recorded and transcribed verbatim. Qualitative content analysis was performed. The study was embedded into the EMACROSS (Emergency and Acute Care for Respiratory Diseases beyond Sectoral Separation) cohort of ED patients with respiratory symptoms, which is part of EMANet (Emergency and Acute Medicine Network for Health Care Research). RESULTS Three patterns of GP utilization could be differentiated: long-term regular consulters, sporadic consulters and patients without GP. In sporadic consulters and patients without GP, an ambivalent or even aversive view of GP care was prevalent, with lack of confidence in GPs' competence and a deficit in trust as seemingly relevant influencing factors. Regardless of utilization or relationship type, patients frequently made contact with a GP before visiting an ED. CONCLUSIONS With regard to respiratory symptoms, our qualitative data suggest a hypothesis of limited relevance of patients' primary care utilization pattern and GP-patient relationship for ED consultation decisions.
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Affiliation(s)
- Sarah Oslislo
- Institute of General Practice, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
| | - Christoph Heintze
- Institute of General Practice, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Martin Möckel
- Division of Emergency Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.,Medical and Veterinary Sciences, James Cook University, The College of Public Health, 1 James Cook Dr, Townsville, Douglas, QLD, 4814, Australia
| | - Liane Schenk
- Institute of Medical Sociology and Rehabilitation Science, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Felix Holzinger
- Institute of General Practice, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
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47
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Shebeshi DS, Dolja‐Gore X, Byles J. Estimating unplanned and planned hospitalization incidents among older Australian women aged 75 years and over: The presence of death as a competing risk. Int J Health Plann Manage 2020; 35:1219-1231. [DOI: 10.1002/hpm.3030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 11/21/2019] [Accepted: 06/24/2020] [Indexed: 11/11/2022] Open
Affiliation(s)
- Dinberu S. Shebeshi
- Research Centre for Generational Health and Ageing (RCGHA), Faculty of Health and Medicine The University of Newcastle Callaghan NSW Australia
- Centre for Clinical Epidemiology and Biostatistics University of Newcastle Newcastle Australia
- Research Assets Division SAX Institute, Level 3, 30C Wentworth Street Glebe NSW Australia
| | - Xenia Dolja‐Gore
- Research Centre for Generational Health and Ageing (RCGHA), Faculty of Health and Medicine The University of Newcastle Callaghan NSW Australia
| | - Julie Byles
- Research Centre for Generational Health and Ageing (RCGHA), Faculty of Health and Medicine The University of Newcastle Callaghan NSW Australia
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48
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Xia T, Enticott J, Pearce C, Mazza D, Turner LR. Predictors of ED attendance in older patients with chronic disease: a data linkage study. AUST HEALTH REV 2020; 44:550-556. [PMID: 32674754 DOI: 10.1071/ah19169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 11/19/2019] [Indexed: 11/23/2022]
Abstract
Objective Older people represent a large proportion of emergency department (ED) presentations, with multiple comorbidities a strong predictor of frequent attendance. This study examined associations between the general practice management received by older patients with chronic disease and ED attendance. Methods This retrospective study examined linked data from general practice and ED for patients aged ≥65 years who presented to a general practitioner (GP) between 2010 and 2014. Data from the computerised medical records of patients attending 50 general practice clinics in the inner east Melbourne region ere linked with ED attendance data from the same region. Patients with chronic disease were identified and characteristics of ED versus non-ED attendees were compared. Poisson regression was used to explore factors associated with ED usage. Results During the study period, 67474 patients aged ≥65 years visited a GP, with 63.3% identified as having at least one chronic condition and 21.4% of these having at least one ED presentation. Over 70% of the ED presentations in this group resulted in hospital admissions. The most common diagnoses for ED presentation were cardiovascular disorders, pain and injuries. ED attendance was associated with being aged ≥85 years (incidence rate ratio (IRR) 2.09; 95% confidence interval (CI) 1.96-2.11), higher socioeconomic status (IRR 1.49; 95% CI 1.45-1.53), having a GP management plan (IRR 1.47; 95% CI 1.43-1.52), multimorbidity (IRR 1.53; 95% CI 1.46-1.60), more frequent GP visits (IRR 1.10; 95% CI 1.05-1.15) and having a higher numbers of prescriptions (IRR 1.51; 95% CI 1.44-1.57). Conclusion This study suggests that ED presentation is associated with greater frailty and multimorbidity in patients. Further research is necessary to determine why higher rates of chronic disease management through GP management plans and more frequent visits did not mediate higher rates of presentation and the reasons behind the socioeconomic differences in ED presentation for patients in this age group. What is known about the topic? Increases in the volume and rate of ED presentations by older people will markedly affect emergency and acute hospital care and patient flow as the proportion of older Australians increases. What does this paper add? We used a novel and highly transferable data linkage between data collected from the clinical records of general practice patients and their associated data from ED and hospital settings and examined the relationship between GP management received by older patients with chronic disease and ED attendance. What are the implications for practitioners? Increasing utilisation of GP services may not have an effect on reducing ED attendance, particularly for older patients who may experience poorer overall health.
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Affiliation(s)
- Ting Xia
- Department of General Practice, School of Primary and Allied Health Care, Monash University, 270 Ferntree Gully Road, Notting Hill, Vic. 3168, Australia. ; ; ; ; and Insurance Work and Health Group, Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Vic. 3004, Australia; and Corresponding author.
| | - Joanne Enticott
- Department of General Practice, School of Primary and Allied Health Care, Monash University, 270 Ferntree Gully Road, Notting Hill, Vic. 3168, Australia. ; ; ;
| | - Christopher Pearce
- Department of General Practice, School of Primary and Allied Health Care, Monash University, 270 Ferntree Gully Road, Notting Hill, Vic. 3168, Australia. ; ; ; ; and Melbourne East General Practice Network (trading as Outcome Health), 250 Mont Albert Road, Surrey Hills, Vic. 3127, Australia
| | - Danielle Mazza
- Department of General Practice, School of Primary and Allied Health Care, Monash University, 270 Ferntree Gully Road, Notting Hill, Vic. 3168, Australia. ; ; ;
| | - Lyle R Turner
- Department of General Practice, School of Primary and Allied Health Care, Monash University, 270 Ferntree Gully Road, Notting Hill, Vic. 3168, Australia. ; ; ; ; and The Institute for Urban Indigenous Health, 22 Cox Road, Windsor, Qld 4030, Australia
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49
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Staykov E, Qureshi D, Scott M, Talarico R, Hsu AT, Howard M, Costa AP, Fung C, Ip M, Liddy C, Tanuseputro P. Do Patients Retain their Family Physicians after Long-Term Care Entry? A Retrospective Cohort Study. J Am Med Dir Assoc 2020; 21:1951-1957. [PMID: 32586719 DOI: 10.1016/j.jamda.2020.04.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 04/17/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Older adults value and benefit from the long-standing relationship they have with their family physicians. This dynamic has not been researched in a long-term care (LTC, ie, nursing home) setting. We sought to determine the proportion of LTC residents who retain their community family physician within the first 180 days of LTC, and the resident, physician, and LTC home factors that may influence retention. DESIGN Population-based retrospective cohort study. SETTING AND PARTICIPANTS Individuals from Ontario, Canada, aged 60 years or older who were newly admitted to a LTC home between April 1, 2014 and March 31, 2017. METHODS Residents were indexed upon LTC admission, and their data was linked across ICES databases. Residents were matched to their rostered family physician, and physician retention was defined as having at least 1 visit by their matched physician within 0 to 90 days and 90 to 180 days of LTC admission. RESULTS Out of 50,089 LTC residents, 12.1% retained their family physicians post-LTC admission. Resident factors associated with reduced odds of retention included physical impairment [odds ratio OR (95% confidence interval, CI) = 0.59 (0.42‒0.83)], cognitive impairment [0.39 (0.33‒0.47)], and a dementia diagnosis [0.80 (0.74‒0.86)]. Physician factors associated with lower retention included a greater distance from the LTC home to the family physician's clinic [30+ kilometers 0.41 (0.35‒0.48)], having a physician who is female [0.90 (0.83‒0.98)], an international medical graduate [0.89 (0.81‒0.97)] or someone who practices in a capitation-based Family Health Organization [0.86 (0.78‒0.95)]. Factors associated with greater odds of retention were residing in a rural LTC home [2.23 (1.78‒2.79)], having a rural family physician [1.70 (1.52‒1.90)], or a family physician who has billed LTC fee codes in the past year [2.64 (2.45‒2.85)]. CONCLUSIONS AND IMPLICATIONS Few LTC residents retained their family physician post-LTC admission, underscoring this healthcare transition as a breakdown point in relational continuity. Factors that influenced retention included resident health, LTC home geography, and family physician demographics and practice patterns.
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Affiliation(s)
- Emiliyan Staykov
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Danial Qureshi
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Mary Scott
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Robert Talarico
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; ICES uOttawa, Ottawa, Ontario, Canada
| | - Amy T Hsu
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Michelle Howard
- ICES McMaster, Hamilton, Ontario, Canada; Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Celeste Fung
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada; St. Patrick's Home of Ottawa, Ottawa, Ontario, Canada
| | - Michael Ip
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Clare Liddy
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
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Rashidian A, Salavati S, Hajimahmoodi H. The Effect of Access to Primary Care Physicians on Avoidable Hospitalizations: A Time Series Study in Rural Areas of Tehran Province, Iran. Korean J Fam Med 2020; 41:282-290. [PMID: 32466631 PMCID: PMC7509124 DOI: 10.4082/kjfm.19.0028] [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: 03/26/2019] [Accepted: 08/30/2019] [Indexed: 11/07/2022] Open
Abstract
Background Avoidable hospitalizations (AHs) are defined as hospitalizations that could have been prevented through timely and effective services. AHs are, therefore, an indicator used to evaluate the access and effectiveness of primary health care services. Methods A retrospective time-series study spanning 8 years (2006–2013) was conducted to determine the relationship between AHs and gender, age, and access to primary health care physicians in rural areas in Tehran province, the capital of Iran. The total number of avoidable hospitalizations was 22,570; logistic regression was estimated for each year separately. Results Total hospitalizations and AHs increased during the study period, especially during the first 3 years of the study. AHs, as a percentage of total hospitalizations, did not change significantly throughout the study years. This value was 22.3% during the first year of study and varied between 17% and 19.6% from 2007 to 2013. No statistically significant relationship was seen between AH occurrence and access to a physician during the study years. Conclusion Increasing access to primary health care physicians cannot necessarily result in decreased AHs. Considering the factors influencing AHs while designing and implementing the family physicians program is important to achieve the expected results regarding the effectiveness of primary health care services.
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Affiliation(s)
- Arash Rashidian
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Sedigheh Salavati
- Department of Public Health, School of Nursery, Maragheh University of Medical Sciences, Maragheh, Iran
| | - Hanan Hajimahmoodi
- Department of Family Physician Program, Iran Health Insurance Organization, Tehran, Iran
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