The effect of the doctor-patient relationship on emergency department use among the elderly

Disruptions to the patient-provider relationship and patient utilization and outcomes: Evidence from medicaid managed care

The patient-provider relationship is considered a cornerstone to delivering high-value healthcare. However, in Medicaid managed care settings, disruptions to this relationship are disproportionately common. In this paper, I evaluate the impact of a primary provider's exit from a Medicaid managed care plan on adult beneficiary healthcare utilization and outcomes. Using an event study approach, I estimate a 5% decrease in the number of beneficiaries with primary care visits in the year following the exit, with slightly larger effects in terms of percentage points for patients with chronic conditions. Additionally, I observe a nearly 50% increase in the number of beneficiaries with a chronic condition who are hospitalized following a disruption.

Older patients' perspectives on factors contributing to frequent visits to the emergency department: a qualitative interview study

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.

Potentially inappropriate prescriptions: Associations with the health insurance contract and the quality of the patient-physician relationship?

CONTEXT

Potentially Inappropriate Prescriptions (PIP) are often used as an indicator of potential drug overuse or misuse to limit adverse drug events in older people.

OBJECTIVE

To determine whether PIP exposure differs as a function of the patient's health insurance scheme and the patient-physician relationship.

METHODS

Our dataset was collected from two surveys delivered to two cohorts of the Swiss Lc65+ study, together with a stratified random sample of older people in the Swiss canton of Vaud. The study sample consisted of 1,595 people aged 68 years and older living in the community and reporting at least one prescription drug. Logit regression models of PIP risk were run for various categories of variables: health related, socioeconomic, health insurance scheme and patient-physician relationship.

RESULTS

17% of our respondents had at least one PIP. Our results suggested that being enrolled in a health plan with restriction in the patient's choice of providers and having higher deductibles were associated with lower PIP risk. PIP risk did not differ as a function of the quality of the patient-physician relationship.

CONCLUSION

Our study helps to raise awareness about the organizational risk factors of PIP and, more specifically, how health insurance contracts could play a role in improving the management of drug consumption among community-dwelling older people.

Complex Patients Have More Emergency Visits: Don't Punish the Systems That Serve Them

IMPORTANCE

Better patient management can reduce emergency department (ED) use. Performance measures should reward plans for reducing utilization by predictably high-use patients, rather than rewarding plans that shun them.

OBJECTIVE

The objective of this study was to develop a quality measure for ED use for people diagnosed with serious mental illness or substance use disorder, accounting for both medical and social determinants of health (SDH) risks.

DESIGN

Regression modeling to predict ED use rates using diagnosis-based and SDH-augmented models, to compare accuracy overall and for vulnerable populations.

SETTING

MassHealth, Massachusetts' Medicaid and Children's Health Insurance Program.

PARTICIPANTS

MassHealth members ages 18-64, continuously enrolled for the calendar year 2016, with a diagnosis of serious mental illness or substance use disorder.

EXPOSURES

Diagnosis-based model predictors are diagnoses from medical encounters, age, and sex. Additional SDH predictors describe housing problems, behavioral health issues, disability, and neighborhood-level stress.

MAIN OUTCOME AND MEASURES

We predicted ED use rates: (1) using age/sex and distinguishing between single or dual diagnoses; (2) adding summarized medical risk (DxCG); and (3) further adding social risk (SDH).

RESULTS

Among 144,981 study subjects, 57% were women, 25% dually diagnosed, 67% White/non-Hispanic, 18% unstably housed, and 37% disabled. Utilization was higher by 77% for those dually diagnosed, 50% for members with housing problems, and 18% for members living in the highest-stress neighborhoods. SDH modeling predicted best for these high-use populations and was most accurate for plans with complex patients.

CONCLUSION

To set appropriate benchmarks for comparing health plans, quality measures for ED visits should be adjusted for both medical and social risks.

Changes in Health Care Use and Outcomes After Turnover in Primary Care

IMPORTANCE

Disruptions of continuity of care may harm patient outcomes, but existing studies of continuity disruption are limited by an inability to separate the association of continuity disruption from that of other physician-related factors.

OBJECTIVES

To examine changes in health care use and outcomes among patients whose primary care physician (PCP) exited the workforce and to directly measure the association of this primary care turnover with patients' health care use and outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used nationally representative Medicare billing claims for a random sample of 359 470 Medicare fee-for-service beneficiaries with at least 1 PCP evaluation and management visit from January 1, 2008, to December 31, 2017. Primary care physicians who stopped practicing were identified and matched with PCPs who remained in practice. A difference-in-differences analysis compared health care use and clinical outcomes for patients who did lose PCPs with those who did not lose PCPs using subgroup analyses by practice size. Subgroup analyses were done on visits from January 1, 2008, to December 31, 2017.

EXPOSURE

Patients' loss of a PCP.

MAIN OUTCOMES AND MEASURES

Primary care, specialty care, urgent care, emergency department, and inpatient visits, as well as overall spending for patients, were the primary outcomes. Receipt of appropriate preventive care and prescription fills were also examined.

RESULTS

During the study period, 9491 of 90 953 PCPs (10.4%) exited Medicare. We matched 169 870 beneficiaries whose PCP exited (37.2% women; mean [SD] age, 71.4 [6.1] years) with 189 600 beneficiaries whose PCP did not exit (36.9% women; mean [SD] age, 72.0 [5.0] years). The year after PCP exit, beneficiaries whose PCP exited had 18.4% (95% CI, -19.8% to -16.9%) fewer primary care visits and 6.2% (95% CI, 5.4%-7.0%) more specialty care visits compared with beneficiaries who did not lose a PCP. This outcome persisted 2 years after PCP exit. Beneficiaries whose PCP exited also had 17.8% (95% CI, 6.0%-29.7%) more urgent care visits, 3.1% (95% CI, 1.6%-4.6%) more emergency department visits, and greater spending ($189 [95% CI, $30-$347]) per beneficiary-year after PCP exit. These shifts were most pronounced for patients of exiting PCPs in solo practice, whose beneficiaries had 21.5% (95% CI, -23.8% to -19.3%) fewer primary care visits, 8.8% (95% CI, 7.6%-10.0%) more specialty care visits, 4.4% more emergency department visits (95% CI, 2.1%-6.7%), and $260 (95% CI, $12-$509) in increased spending.

CONCLUSIONS AND RELEVANCE

Loss of a PCP was associated with lower use of primary care and increased use of specialty, urgent, and emergency care among Medicare beneficiaries. Interrupting primary care relationships may negatively impact health outcomes and future engagement with primary care.

The Role of Primary Care in a Pandemic: Reflections During the COVID-19 Pandemic in Canada

As COVID-19 cases began to rise in Ontario, Canada, in March 2020, increasing surge capacity in hospitals and intensive care units became a large focus of preparations. As part of these preparations, primary care physicians were ready to be redeployed to the hospitals. However, due to the effective implementation of community-wide public health measures, the hospital system was not overwhelmed. As Ontario prepares now for a potential second wave of COVID-19, primary care physicians have an opportunity to consider the full breadth and depth of scope for primary care during a pandemic. From planning to surveillance to vaccination, primary care physicians are positioned to play a unique and vital role in a pandemic. Nevertheless, there are specific barriers that will need to be overcome.

Health TAPESTRY Ontario: protocol for a randomized controlled trial to test reproducibility and implementation

BACKGROUND

Health TAPESTRY (Health Teams Advancing Patient Experience: STRengthening qualitY) aims to help people stay healthier for longer where they live by providing person-focused care through the integration of four key program components: (1) trained volunteers who visit clients in their homes, (2) an interprofessional primary health care team, (3) use of technology to collect and share information, and (4) improved connections to community health and social services. The initial randomized controlled trial of Health TAPESTRY found promising results in terms of health care use and patient outcomes, indicating a shift from reactive to preventive care. The trial was based on one clinical academic center, thus limiting generalizability. The study objectives are (1) to test reproducibility of the established effectiveness of Health TAPESTRY on physical activity and hospitalizations, (2) to test the feasibility of, and understand the contributing factors to, the implementation of Health TAPESTRY in six diverse communities across Ontario, Canada, and (3) to determine the value for money of implementing Health TAPESTRY.

METHODS

This planned study is a pragmatic parallel randomized controlled trial with a delayed intervention for control participants at 6 months. This trial will simultaneously assess effectiveness and implementation in a real-world setting (type II hybrid) in six diverse communities across Ontario. Participants 70 years of age and older will be randomized into the Health TAPESTRY intervention or the control group (usual care). Intervention clients will receive an individualized plan of care from an interprofessional care team. The plan will be based on a client's goals and current health risks identified through volunteer visits. The study's outcomes are mapped onto the RE-AIM framework, with levels of physical activity and number of hospitalizations as the co-primary outcomes. The main analysis will be a comparison at 6 months.

DISCUSSION

It is important to evaluate the effectiveness and implementation of Health TAPESTRY in multiple communities prior to scaling or widespread adoption.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03397836 . Registered on 12 January 2018.

What role does the GP play for emergency department utilizers? A qualitative exploration of respiratory patients' perspectives in Berlin, Germany

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.

Association of Patients' Perception of Primary Care Provider Listening With Emergency Department Use

Introduction

This study examined whether patients' perceptions of their primary care providers' (PCP) listening frequency were associated with emergency department (ED) utilization, including a comparison to patients without PCPs.

Methods

Data were obtained from the 2015 California Health Interview Survey. Respondents were asked if they had a PCP and how often their PCPs listened, resulting in five groups: patients without a PCP (n=4,407), and patients with a PCP who perceived the PCP's listening frequency to be never (n=254), sometimes (n=1,282), usually (n=3,440), or always (n=11,651). Multiple linear regression was performed to determine if patient-perceived listening frequency of the PCP was associated with the patient's number of ED visits in the prior year, adjusting for various demographic, social, and health factors.

Results

Compared to patients without a PCP, patients with a PCP had on average 0.15 more ED visits in a year, highest among those whose PCPs were perceived as listening the least: never=0.55 more visits per year (95% CI: 0.09-1.02, P=.02), sometimes=0.26 (0.01-0.51, P=.04), usually=0.03 (-0.17-0.24, P=.73), and always=0.16 (-0.05-0.36, P=.13). Other significant increases in ED visits were associated with public insurance, African-American race, English proficiency, younger age, self-rated fair-to-poor health, asthma, and hypertension.

Conclusions

Patients who perceived their PCP as listening less frequently had more ED visits than patients whose PCPs were perceived as listening more frequently, and compared to patients without a PCP.

Envisioning a Better U.S. Health Care System for All: Health Care Delivery and Payment System Reforms

The American College of Physicians (ACP) has long advocated for universal access to high-quality health care in the United States. Yet, it is essential that the U.S. health system goes beyond ensuring coverage, efficient delivery systems, and affordability. Fundamental restructuring of payment policies and delivery systems is required to achieve a health care system that puts patients' interests first and supports physicians and their care teams to deliver high-value, patient- and family-centered care. The ACP calls for reform of U.S. payment, delivery, and information technology systems to achieve this vision. The ACP's recommendations include increased investment in primary care; alignment of financial incentives to achieve better patient outcomes, lower costs, reduce inequities in health care, and facilitate team-based care; freeing patients and physicians of inefficient administrative and billing tasks and documentation requirements; and development of health information technologies that enhance the patient-physician relationship.

Factors associated with frequent use of emergency-department services in a geriatric population: a systematic review

BACKGROUND

Frequent geriatric users of emergency departments (EDs) constitute a small group of individuals accounting for a disproportionately high number of ED visits. In addition to overcrowding, this situation might result in a less appropriate response to health needs and negative health impacts. Geriatric patients turn to EDs for a variety of reasons. A better understanding of the variables associated with frequent ED use will help implement interventions best suited for their needs.

OBJECTIVE

This review aimed at identifying variables associated with frequent ED use by older adults.

METHODS

For this systematic review, we searched Medline, CINAHL, Healthstar, and PsyINFO (before June 2018). Articles written in English or French meeting these criteria were included: targeting a population aged 65 years or older, reporting on frequent ED use, using an observational study design and multivariate regression analysis. The search was supplemented by manually examining the reference lists of relevant studies. Independent reviewers identified articles for inclusion, extracted data, and assessed quality with the JBI Critical Appraisal Checklist for Studies Reporting Prevalence. A narrative synthesis was done to combine the study results. A sensitivity analysis was performed to evaluate the effect of removing the studies not meeting the quality criteria.

RESULTS

Out of 5096 references, 8 met our inclusion criteria. A high number of past hospital and ED admissions, living in a rural area adjacent to an urban center, low income, a high number of prescribed drugs, and a history of heart disease were associated with frequent ED use among older adults. In addition, having a principal-care physician and living in a remote rural area were associated with fewer ED visits. Some variables recognized in the literature as influencing ED use among older adults received scant consideration, such as comorbidity, dementia, and considerations related to primary-care and community settings.

CONCLUSION

Further studies should bridge the gap in understanding and give a more global portrait by adding important personal variables such as dementia, organizational variables such as use of community and primary care, and contextual variables such as social and economic frailty.

Acesso ao cuidado na Atenção Primária à Saúde brasileira: situação, problemas e estratégias de superação

RESUMO Sistemas de saúde universais orientados pela Atenção Primária à Saúde (APS) apresentam melhores resultados para a população. Este artigo apresenta a situação do acesso ao cuidado na APS brasileira, seus problemas, desafios e estratégias para sua superação. Realizou-se uma revisão narrativa, incluindo estudos quali e quantitativos. O acesso na APS aumentou com a expansão da Estratégia Saúde da Família (ESF), mas ainda permanece insuficiente. As principais barreiras ao acesso incluem: subdimensionamento/subfinanciamento da APS, excesso de usuários vinculados às equipes da ESF, número reduzido de Médicos de Família e Comunidade (MFC), com pouca interiorização/fixação, burocratização e problemas funcionais dos serviços, como rigidez nos agendamentos e priorização de grupos específicos (hipertensos, puericultura etc.). Para melhorar o acesso, é necessário aumentar o investimento federal na ESF, priorizando-a e expandindo-a, reduzir os usuários vinculados às equipes, ampliar a formação médica em MFC, explorar a clínica da enfermagem, diversificar os meios de comunicação com usuários, explorar a cogestão da equipe e flexibilizar as agendas dos profissionais. Conclui-se que, para fortalecer a APS, é estratégico estimular o acesso na ESF vinculado ao cuidado longitudinal.

A Multilevel Analysis of the determinants of emergency care visits by the elderly in France

BACKGROUND

Rising numbers of visits to emergency departments (EDs), especially amongst the elderly, is a source of pressure on hospitals and on the healthcare system. This study aims to establish the determinants of ED visits in France at a territorial level with a focus on the impact of ambulatory care organisation on ED visits by older adults aged 65 years and over.

METHODS

We use multilevel regressions to analyse how the organisation of healthcare provision at municipal and wider 'department' levels impacts ED utilisation by the elderly while controlling for the local demographic, socioeconomic and health context of the area in which patients live.

RESULTS

ED visits vary significantly by health context and economic level of municipalities. Controlling for demand-side factors, ED rates by the elderly are lower in areas where accessibility to primary care is high, measured as availability of primary care professionals, out-of-hours care and home visits in an area. Proximity (distance) and size of ED are drivers of ED use.

CONCLUSION

High rates of ED visits are partly linked to inadequate accessibility of health services provided in ambulatory settings. Redesigning ambulatory care at local level, in particular by improving accessibility and continuity of primary and social care services for older adults could reduce ED visits and, therefore, improve the efficient use of available healthcare resources.

A before-after study of hospital use in two frail populations receiving different home-based services over the same time in Vancouver, Canada

Background

As individuals age, they are more likely to experience increasing frailty and more frequent use of hospital services. First, we explored whether initiating home-based primary care in a frail homebound cohort, influenced hospital use. Second, we explored whether initiating regular home care support for personal care with usual primary care, in a second somewhat less frail cohort, influenced hospital use.

Methods

This was a before-after retrospective cohort study of two frail populations in Vancouver, Canada using administrative data to assess the influence of two different services started in two different cohorts over the same time period. The participants were 246 recipients of integrated home-based primary care and 492 recipients of home care followed between July 1st, 2008 and June 30th, 2013 before and after starting their respective services. Individuals in each group were linked to their hospital emergency department visit and discharge abstract records. The main outcome measures were mean emergency department visit and hospital admission rates per 1000 patient days for 21 months before versus the period after receipt of services, and the adjusted incidence rate ratios (IRRs) on these outcomes post receipt of service.

Results

Before versus after starting integrated home-based primary care, emergency department visit rates per 1000 patient days (95% confidence intervals) were 4.1 (3.8, 4.4) versus 3.7 (3.3, 4.1), and hospital admissions rates were 2.3 (2.1, 2.5) versus 2.2 (1.9, 2.5). Before versus after starting home care, emergency department visit rates per 1000 patient days (95% confidence intervals) were 3.0 (2.8, 3.2) versus 4.0 (3.7, 4.3) visits and hospital admissions rates were 1.3 (1.2, 1.4) versus 1.9 (1.7, 2.1). Home-based primary care IRRs were 0.91 (0.72, 1.15) and 0.99 (0.76, 1.27) and home care IRRs were 1.34 (1.15, 1.56) and 1.46 (1.22, 1.74) for emergency department visits and hospital admissions respectively.

Conclusions

After enrollment in integrated home-based primary care, emergency department visit and hospital admission rates stabilized. After starting home care with usual primary care, emergency department visit and hospital admission rates continued to rise.

Living alone and unplanned hospitalizations among older adults: a population-based longitudinal study

Background

The association of living alone with hospitalization among the general elderly population has been rarely investigated, and the influence of common disorders on this association remains unknown.

Methods

We used data on participants in the Swedish National study on Aging and Care in Kungsholmen ( n = 3130). Risk and number of unplanned hospitalizations and length of hospital stays were studied over a period of 2 years. We used Cox proportional hazard models to estimate hazard ratios (HRs) of incident hospitalization and zero-inflated negative binomial regression models adjusted for potential confounders to estimate incident rate ratios (IRR) of the number of hospitalizations and total length of stay associated with living alone.

Results

A total of 1768 participants (56.5%) lived alone. Five hundred and sixty-one (31.7%) of those who lived alone had at least one unplanned hospitalization. In the multivariate analyses, living alone was significantly associated with the risk of unplanned hospitalization (HR = 1.21, 95% confidence interval [CI] 1.01-1.45) and the number of hospitalizations (IRR = 1.35, 95% CI 1.04-1.76) but not with the length of hospital stays. In stratified analyses, the association between living alone and unplanned hospitalizations remained statistically significant only among men (HR = 1.52, 95% CI 1.17-1.99).

Conclusions

Living alone is associated with higher risks of unplanned hospitalization in elderly, especially for men.

Relationship Between Continuity of Ambulatory Care and Risk of Emergency Department Episodes Among Older Adults

STUDY OBJECTIVE

We determine whether visit patterns indicative of higher continuity are related to a lower risk of presenting at the emergency department (ED) among older adults.

METHODS

This study was a survival analysis between 2011 and 2013 of a 20% random sample of fee-for-service Medicare beneficiaries aged 66 years or older. Ambulatory visit patterns were measured starting in 2011 for up to 24 months using 2 continuity metrics measured on a 0 to 1 scale-Continuity of Care (COC) score and the Usual Provider Continuity (UPC) score. The composite outcome of an ED episode was defined as occurrence of an ED visit with discharge home, an observation stay, or hospital admission. Time-dependent Cox proportional hazards regression models controlled for patient demographic characteristics, comorbidities, previous use, and regional factors, with censoring for death or occurrence of the composite outcome. In a secondary analysis, continuity was measured in the 12 months preceding an ED episode to test whether it was associated with type of ED episode.

RESULTS

The relative rate of ED episodes decreased approximately 1% for every 0.1-point increase in the COC score (adjusted hazard ratio 0.99; 95% confidence interval 0.99 to 0.99; P<.001) and 2% for every 0.1-point increase in the UPC score (adjusted hazard ratio 0.98; 95% CI 0.98 to 0.99; P<.001), or up to a 10% lower rate between the lowest and highest COC score and a 20% lower rate for the UPC score. Among beneficiaries with an ED episode, higher continuity was associated with a 1% lower risk of observation stay but a 3% to 4% higher risk of hospital admission relative to an ED visit with discharge home.

CONCLUSION

Ambulatory visit patterns exhibiting more continuity were associated with a lower rate of ED utilization for older adults with fee-for-service Medicare coverage. The association of higher continuity with lower risk of ED use but differences in outcome when an ED visit does occur may reflect more appropriate referral to the ED when outpatient management is no longer adequate.

Quantifying the Health Benefits of Primary Care Physician Supply in the United States

This analysis addresses the question, Would increasing the number of primary care physicians improve health outcomes in the United States? A search of the PubMed database for articles containing “primary care physician supply” or “primary care supply” in the title, published between 1985 and 2005, identified 17 studies, and 10 met all inclusion criteria. Results were reanalyzed to assess primary care effect size and the predicted effect on health outcomes of a one-unit increase in primary care physicians per 10,000 population. Primary care physician supply was associated with improved health outcomes, including all-cause, cancer, heart disease, stroke, and infant mortality; low birth weight; life expectancy; and self-rated health. This relationship held regardless of the year (1980–1995) or level of analysis (state, county, metropolitan statistical area (MSA), and non-MSA levels). Pooled results for all-cause mortality suggest that an increase of one primary care physician per 10,000 population was associated with an average mortality reduction of 5.3 percent, or 49 per 100,000 per year.

How Do We Talk About the Physician-Patient Relationship? What the Nonempirical Literature Tells Us

The physician-patient relationship is an important ideal, and a construct central to discussions regarding health systems change and innovation. This review examines the nonempirical literature focused on the physician-patient relationship published over the past 15 years. The review's results show a literature that is heavily context bound, relies on a combination of informational and emotional appeals to influence readers, and is mostly focused on portraying the state of this relationship in negative ways. Characteristics of the relationship such as trust, communication, and information are particularly focused on, while other important features like empathy remain less addressed. The review's findings suggest broadening the perspective regarding how the physician-patient relationship is construed, in order to take advantage of its increased importance in the modern health care marketplace, and to account for new relational dynamics between providers and patients suggested by innovations in care delivery.

The association between office-based provider visits and emergency department utilization among Medicaid beneficiaries

The purpose of our study was to describe the relationship between office-based provider visits and emergency department (ED) utilization by adult Medicaid beneficiaries. Data were extracted from the publicly-available Medical Expenditure Panel Survey, a nationally representative sample of the civilian non-institutionalized population in the United States. The sample included 1,497 respondents who had full year Medicaid coverage in 2009. Study variables included insurance coverage type, usual source of care, chronic illnesses, and beneficiary demographics. Multivariate analyses were conducted to describe associations between individual characteristics and (a) likelihood of any ED utilization, and (b) number of ED visits by those who utilized the ED at least once in the study year. The analysis was adjusted for demographic characteristics and chronic health conditions. A greater number of office-based provider visits was associated with a higher likelihood of ED utilization. Among those with at least one ED visit, a greater number of office-based visits was associated with a higher number of ED visits. A respondent's age, history of hypertension or myocardial infarction, and Hispanic/Latino ethnicity were associated with having one or more ED visits; age and Hispanic/Latino ethnicity were associated with total number of ED visits among those with at least one. In this representative sample of adult Medicaid beneficiaries, there was no evidence that office-based provider visits reduced ED utilization. Office visits were associated with higher ED utilization, as were certain chronic conditions, older age, and Hispanic/Latino ethnicity. Findings do not support efforts to reduce ED utilization by increasing office-based visits alone.

Impact of potentially inappropriate medication and continuity of care in a sample of Taiwan elderly patients with diabetes mellitus who have also experienced heart failure

AIMS

Continuity of care (COC) and potentially inappropriate medication (PIM) can affect the elderly healthcare outcome. We evaluated the COC and PIM effects in older diabetes mellitus (DM) patients with heart failure (HF).

METHODS

The Longitudinal Health Insurance Database of 2005 was multiple-year claim data collected from 2005 to 2010 in Taiwan. There were both 823 DM and non-DM subjects aged 65 years and older in this observational study. The COC index and 2012 Beers criteria were applied to evaluate the COC and HF-PIM in older DM patients with heart failure. The dependent variables were either hospital admissions or emergency department visits. Generalized estimating equation was used to adjust all covariates.

RESULTS

During 2005-2010, the rate of HF-PIM in the elderly DM group was 86.1%, the mean COC index was 0.28 ± 0.19, the admission rate was 31.9% and the emergency department rate was 38.8 %. Lower COC index was associated with HF-PIM and HF-PIM duration in older DM patients with HF. Lower COC index was associated with hospitalizations (OR 0.07, 95% CI 0.05-0.11) and ED visits (OR 0.10, 95% CI 0.07-0.13), but HF-PIM was not significant. The duration of HF-PIM was related with poor health outcomes over 90 and 180 days for hospitalization and emergency department visit, respectively.

CONCLUSION

Among elderly DM patients with HF, COC had positive effects on healthcare outcomes. Improving COC and reducing PIM duration for elderly DM patients with HF seems warranted. Geriatr Gerontol Int 2016; 16: 1117-1126.

Disentangling the Linkage of Primary Care Features to Patient Outcomes: A Review of Current Literature, Data Sources, and Measurement Needs

Primary care plays a central role in the provision of health care, and is an organizing feature for health care delivery systems in most Western industrialized democracies. For a variety of reasons, however, the practice of primary care has been in decline in the U.S. This paper reviews key primary care concepts and their definitions, notes the increasingly complex interplay between primary care and the broader health care system, and offers research priorities to support future measurement, delivery and understanding of the role of primary care features on health care costs and quality.

Impact of 4 + 1 block scheduling on patient care continuity in resident clinic

BACKGROUND

Leaders in medical education have called for redesign of internal medicine training to improve ambulatory care training. 4 + 1 block scheduling is one innovative approach to enhance ambulatory education.

AIM

To determine the impact of 4 + 1 scheduling on resident clinic continuity.

SETTING

Resident continuity clinic in traditional scheduling in which clinics are scheduled intermittently one-half day per week, compared to 4 + 1 in which residents alternate 1 week of clinic with 4 weeks of an inpatient rotation or elective.

PARTICIPANTS

First-year internal medicine residents.

PROGRAM DESCRIPTION

We measured patient-provider visit continuity, phone triage encounter continuity, and lab follow-up continuity.

PROGRAM EVALUATION

In traditional scheduling as opposed to 4 + 1 scheduling, patients saw their primary resident provider a greater percentage; 71.7% vs. 63.0% (p = 0.008). In the 4 + 1 model, residents saw their own patients a greater percentage; 52.1% vs. 37.1% (p = 0.0001). Residents addressed their own labs more often in 4 + 1 model; 90.7% vs. 75.6% (p = 0.001). There was no significant difference in handling of triage encounters; 42.3% vs. 35.8% (p = 0.12).

DISCUSSION

4 + 1 schedule improves visit continuity from a resident perspective, and may compromise visit continuity from the patient perspective, but allows for improved laboratory follow-up, which we pose should be part of an emerging modern definition of continuity.

Primary care access and emergency room use among older veterans

BACKGROUND

Patient access to primary care is often noted to be poor. Improving access may reduce emergency room (ER) visits.

OBJECTIVE

To examine the relationship between primary care access and ER use and to test whether this relationship is moderated by having a continuous relationship with a Primary Care Provider (PCP) (or if the PCP is the near-sole provider of care for patients).

DESIGN AND PATIENTS

A longitudinal retrospective study of 627,276 patients receiving primary care from 6,398 primary care providers (PCPs) nationally within the Veterans Health Administration (VHA) in 2009. We tracked weekly changes in PCP-level appointment availability.

MEASUREMENTS

The number of a PCP's patients who went to the ER in a given week.

RESULTS

Among all PCPs, being absent from patient care for the week had no effect on whether that PCP's patients used the ER in that week (incident rate ratio (IRR) 0.997, p = 0.70). However, among PCPs who were near-sole providers of care, a PCP's absence for a week or more had a statistically significant effect on ER visits (IRR 1.04, p = 0.01). The percentage of a PCP's weekly appointment slots that were fully booked (booking density) had no significant effect on whether their patients used the ER in that week among all PCPs. However, among near-sole providers of care, a 10-percentage point increase in the booking density changed the IRR of ER visits in that week by 1.005 (p = 0.08) and by 1.006 on weekdays (p = 0.07).

CONCLUSIONS

Patients' access to their PCP had a small effect on whether those patients used the ER among PCPs whose patients rarely saw another PCP. Among other PCPs, there was no effect of PCP access on ER use. These results suggest that sharing patient-care responsibilities across PCPs may be effective in improving access to care and decreasing unnecessary ER use.

Usual source of care and outcomes following acute myocardial infarction

BACKGROUND

The quality of the relationship between a patient and their usual source of care may impact outcomes, especially after an acute clinical event requiring regular follow-up.

OBJECTIVE

To examine the association between the presence and strength of a usual source of care with mortality and readmission after hospitalization for acute myocardial infarction (AMI).

DESIGN

Prospective Registry Evaluating Myocardial Infarction: Event and Recovery (PREMIER), an observational, 19-center study.

PATIENTS

AMI patients discharged between January 2003 and June 2004.

MAIN MEASURES

The strength of the usual source of care was categorized as none, weak, or strong based upon the duration and familiarity of the relationship. Main outcome measures were readmissions and mortality at 6 months and 12 months post-AMI, examined in multivariable analysis adjusting for socio-demographic characteristics, access and barriers to care, financial status, baseline risk factors, and AMI severity.

KEY RESULTS

Among 2,454 AMI patients, 441 (18.0 %) reported no usual source of care, whereas 247 (10.0 %) and 1,766 (72.0 %) reported weak and strong usual sources of care, respectively. When compared with a strong usual source of care, adults with no usual source of care had higher 6-month mortality rates [adjusted hazard ratio (aHR) = 3.15, 95 % CI, 1.79-5.52; p < 0.001] and 12-month mortality rates (aHR = 1.92, 95 % CI, 1.19-3.12; p = 0.01); adults with a weak usual source of care trended toward higher mortality at 6 months (aHR = 1.95, 95 % CI, 0.98-3.88; p = 0.06), but not 12 months (p = 0.23). We found no association between the usual source of care and readmissions.

CONCLUSIONS

Adults with no or weak usual sources of care have an increased risk for mortality following AMI, but not for readmission.

Associations between primary healthcare and unplanned medical admissions in Norway: a multilevel analysis of the entire elderly population

OBJECTIVE

To examine if individual risk of unplanned medical admissions (UMAs) was associated with municipality general practitioner (GP) or long-term care (LTC) volume among the entire Norwegian elderly population.

DESIGN

Cross-sectional population-based study.

SETTING

428 of 430 Norwegian municipalities in 2009.

PARTICIPANTS

All Norwegians aged ≥65 years (n=721 915; 56% women-15% of the total population).

MAIN OUTCOME MEASURE

Individual risk of UMA.

RESULTS

Using a multilevel analytical framework, consisting of individuals (N=722 464) nested within municipalities (N=428), nested within local hospital areas (N=52) we found no association between municipality GP or LTC volume and UMAs. However, we found that higher LTC levels of provision were associated with fewer hospitalisations among the older age groups. A modest geographical variability was observed for UMA in adjusted analysis.

CONCLUSIONS

A higher primary healthcare volume was only associated with fewer UMAs among the oldest old in a universally accessible healthcare system.

Testing a two step nursing intervention focused on decreasing rehospitalizations and nursing home admission post discharge from acute care

Older adults are at high risk of readmission on discharge from the Acute Medical and Emergency Department (ED). This study examines the effect of a two-stage nursing assessment and intervention to address older adults' uncompensated problems and thus intend to prevent readmission and functional decline. A randomized controlled study was conducted. Included were 271 patients aged 70 and over admitted to an ED. A brief standardized nursing assessment and intervention was carried out after discharge and at follow-up. No effect was found on readmission to hospital, admission to nursing home, or death but the intervention group was less likely to be at risk of depression after 180 days. Whether this method can be recommended needs further study as well as knowledge is needed as to the organization and to reveal older adults' experiences on follow-up after ED stay.

Continuity of care, potentially inappropriate medication, and health care outcomes among the elderly: evidence from a longitudinal analysis in Taiwan

BACKGROUND

Better continuity of care (COC) is associated with improved health care outcomes, such as decreased hospitalization and emergency department visit. However, little is known about the effect of COC on potentially inappropriate medication.

OBJECTIVES

This study aimed to investigate the association between COC and the likelihood of receiving inappropriate medication, and to examine the existence of a mediating effect of inappropriate medication on the relationship between COC and health care outcomes and expenses.

METHODS

A longitudinal analysis was conducted using claim data from 2004 to 2009 under universal health insurance in Taiwan. Participants aged 65 years and older were categorized into 3 equal tertiles by the distribution of COC scores. This study used a propensity score matching approach to assign subjects to 1 of 3 COC groups to increase the comparability among groups. Generalized estimating equations were used to examine the association between COC, potentially inappropriate medication, and health care outcomes and expenses.

RESULTS

The results revealed that patients with the best COC were less likely to receive drugs that should be avoided [odd ratios (OR), 0.44; 95% confidence interval (CI), 0.43-0.45) or duplicated medication (OR, 0.22; 95% CI, 0.22-0.23) than those with the worst COC. The findings also indicated that potentially inappropriate medication was a partial mediator in the association between COC and health care outcomes and expenses.

CONCLUSION

Better COC is associated with fewer negative health care outcomes and lower expenses, partially through the reduction of potentially inappropriate medication. Improving COC deserves more attention in future health care reforms.

How community members and health professionals conceptualize medical emergencies: implications for primary care promotion

Access to continuous care through a primary care provider is associated with improved health outcomes, but many communities rely on emergency departments (EDs) for both emergent and non-emergent health problems. This article describes one portion of a community-based participatory research project and investigates the type of education that might be needed as part of a larger intervention to encourage use of a local primary care clinic. In this article we examine how people who live in a low-income urban community and the healthcare workers who serve them conceptualize 'emergency medical condition'. We conducted forum and focus group discussions with 52 community members and individual interviews with 32 healthcare workers. Our findings indicate that while community members share a common general definition of what constitutes a medical emergency, they also desire better guidelines for how to assess health problems as requiring emergency versus primary care. Pain, uncertainty and anxiety tend to influence their choice to use EDs rather than availability of primary care. Implications for increasing primary care use are discussed.

Does better access to FPs decrease the likelihood of emergency department use? Results from the Primary Care Access Survey

OBJECTIVE

To determine whether better access to FP services decreases the likelihood of emergency department (ED) use among the Ontario population.

DESIGN

Population-based telephone survey.

SETTING

Ontario.

PARTICIPANTS

A total of 8502 Ontario residents aged 16 years and older.

MAIN OUTCOME MEASURES

Emergency department use in the 12 months before the survey.

RESULTS

Among the general population, having a regular FP was associated with having better access to FPs for immediate care (P < .001) but was not associated with a decreased likelihood of ED visits (odds ratio [OR] = 1.49, P = .03). Better actual access to FP services for immediate care was associated with a decreased likelihood of ED use (OR = 0.62, P < .001) among the general population. Among those with chronic diseases, having a regular FP was associated with a decreased likelihood of ED use (OR = 0.47, P = .01). Of the Ontario population, 39.3% wanted to see FPs for immediate care at least once a year; 63.1% of them had seen FPs without difficulties and were significantly less likely to use EDs than those who did not see FPs or had difficulties accessing physicians when needed (OR = 0.62, P < .001). Having a chronic health condition, recent immigrant status, residence in rural and northern parts of Ontario, and lower educational and income levels were significant predictors of a higher likelihood of ED use, independent of access to FPs (P < .05).

CONCLUSION

A decreased likelihood of ED use is strongly associated with having a regular FP among those with chronic diseases and with having access to FPs for immediate care among the general population. Further research is needed to understand what accounts for a higher likelihood of ED use among those with regular FPs, new immigrants, residents of northern and rural areas of Ontario, and people with low socioeconomic status when actual access and sociodemographic characteristics have been taken into consideration. More important, this study demonstrates a need of distinguishing between potential and actual access to care, as having a regular FP and having timely and effective access to FP care might mean different things and have different effects on ED use.

Factors predicting patient use of the emergency department: a retrospective cohort study

BACKGROUND

Many studies have shown the tendency for people without a regular care provider or primary physician to make greater use of emergency departments. We sought to determine the effects of three aspects of care provided by primary physicians (physician specialty, continuity of care and comprehensiveness of care) on their patients' use of the emergency department.

METHODS

Using provincial administrative databases, we created a cohort of 367,315 adults aged 18 years and older. Participants were residents of urban areas of Quebec. Affiliation with a primary physician, the specialty of this physician (i.e., family physician v. specialist), continuity of care (as measured using the Usual Provider Continuity index) and comprehensiveness of care (i.e., number of complete annual examinations) were measured among participants (n = 311,701) who had visited a physician three or more times during a two-year baseline period. We used multivariable negative binomial regression to investigate the relationships between measures of care and the number of visits to emergency departments during a 12-month follow-up period.

RESULTS

Among participants under 65 years of age, emergency department use was higher for those not affiliated than for those affiliated with a family physician (incidence rate ratio [IRR] 1.11, 95% confidence interval [CI] 1.05-1.16) or a specialist (IRR 1.10, 95% CI 1.04-1.17). Among patients aged 65 years and older, having a specialist primary physician, as opposed to a family physician, predicted increased use of the emergency department (IRR 1.13, 95% CI 1.09-1.17). Greater continuity of care with a family physician predicted less use of the emergency department only among participants who made 25 or more visits to a physician during the baseline period. Greater continuity of care with a specialist predicted less use of the emergency department overall, particularly among participants with intermediate numbers of multimorbidities and admissions to hospital. Greater comprehensiveness of care by family physicians predicted less use of the emergency department.

INTERPRETATION

Efforts to increase the proportion of adults affiliated with a family physician should target older adults, people who visit physicians more frequently and people with multiple comorbidities and admissions to hospital.

[Characteristics of the emergency health service demand in Southern Brazil]

This study evaluated the demand of emergency health service. It was performed a descriptive analyses of 1647 adults that consulted at emergency public service of Pelotas, Brazil. Older subjects, non white skin color, lower schooling, without partner, and smokers presented higher prevalence of consultations at this service when compared with the general population. Individuals waited, on average, 15 minutes to have their consultations, exams were requested in more than 40% of the visits, and intravenous medication were administered in one third of the visits. Elderly waited longer before searching the service, but they had lowest awaiting time after arriving at emergency service and had higher percentage of regular doctor and social support. Elderly had more diagnosis related to circulatory system, while among the youngest, external causes were the most frequent. The low waiting average for consultation suggest this service provide an immediate care while the great number of ill-defined signs or symptoms indicate that the provided care is provisional. It is necessary to train emergency professionals to reduce the number of tests requested and to assure that either professional as the population is conscious about the importance of a continuity of care.

Factors associated with emergency department use among the rural elderly

CONTEXT

Emergency Department (ED) use among the rural elderly may present a different pattern from the urban elderly, thus requiring different policy initiatives. However, ED use among the rural elderly has seldom been studied and is little understood.

PURPOSE

To characterize factors associated with having any versus no ED use among the rural elderly.

METHODS

A cross-sectional and observational study of 1,736 Medicare beneficiaries age 65 and older who live in nonmetropolitan areas. The data are from the 2002 to 2005 Medical Expenditure Panel Survey (MEPS). A logistic regression model was estimated that included measures of predisposing characteristics, enabling factors, need variables, and health behavior as suggested by Anderson's behavioral model of health service utilization.

FINDINGS

During a 1-year period, 20.8% of the sample had at least 1 ED visit. Being widowed, more educated, enrolled in Medicaid, with fair/poor self-perceived physical health, respiratory diseases, and heart disease were associated with a higher likelihood of having any ED visits. However, residing in the western and southern United States and being enrolled in Medicaid managed care were associated with lower probability of having any ED visits. While Medicaid enrollees who reported excellent, very good, good, or fair physical health were more likely to have at least 1 ED visit than those not on Medicaid, Medicaid enrollees reporting poor physical health may be less likely to have any ED visits.

CONCLUSION

Policy makers and hospital administrators should consider these factors when managing the need for emergency care, including developing interventions to provide needed care through alternate means.

The 4∶1 schedule: a novel template for internal medicine residencies

BACKGROUND

It is widely acknowledged that there is need for redesign of internal medicine training. Duty hour restrictions, an increasing focus on patient safety, the possibility of inadequate training in ambulatory care, and a growing shortage of primary care physicians are some factors that fuel this redesign movement.

INTERVENTION

We implemented a 4∶1 scheduling template that alternates traditional 4-week rotations with week-long ambulatory blocks. Annually, this provides 10 blocks of traditional rotations without continuity clinic sessions and 10 weeks of ambulatory experience without inpatient responsibilities. To ensure continuous resident presence in all areas, residents are divided into 5 groups, each staggered by 1 week.

EVALUATION

We surveyed residents and faculty before and after the intervention, with questions focused on attitudes toward ambulatory medicine and training. We also conducted focus groups with independent groups of residents and faculty, designed to assess the benefits and drawbacks of the new scheduling template and to identify areas for future improvement.

RESULTS

Overall, the scheduling template minimized the conflicts between inpatient and outpatient training, promoted a stronger emphasis on ambulatory education, allowed for focused practice during traditional rotations, and enhanced perceptions of team development. By creating an immersion experience in ambulatory training, the template allowed up to 180 continuity clinic sessions during 3 years of training and provided improved educational continuity and continuity of patient care.

CONCLUSION

Separating inpatient and ambulatory education allows for enhanced modeling of the evolving practice of internists and removes some of the conflict inherent in the present system.

Emergency department use by older adults: a literature review on trends, appropriateness, and consequences of unmet health care needs

Older adults use emergency departments (EDs) more than any other age group and are more prone to subsequent adverse events. This article reviews the literature on ED use by older adults within the context of evaluating their need for emergency care and the extent to which access to primary and supportive care services affect use. While a substantial research literature describes general patterns of ED use, there is much less research on ED use as a function of other health service use. Gaps in the research literature result in a limited understanding of the full scope of the issue and opportunities for practice and policy intervention.

Social determinants of emergency utilization associated with patterns of care

PURPOSE

To investigate the emergency room (ER) utilization among disabled Taiwanese older adults with different patterns of care arrangement.

METHOD

A national probability sample of 13,957 disabled older adults (aged 50 and above) was recruited. Individual interview data and National Health Insurance administrative data were used to examine the effects of care arrangements on ER utilization 1 year after the baseline interview.

RESULTS

One-third (33.5%) of the subjects used emergency room at least once in the follow-up year. The ER utilization rates among individuals living in institutions, in home with foreigner worker, in home with informal caregiver, and in home without caregiver, were 34.5%, 43%, 32.5% and 25% respectively. After controlling for other predisposing, enabling, need factors, and healthcare services use with multivariate logistic regression model, comparing with subjects staying home with informal caregivers, those who were institutionalized were less likely to use ER services during the study year (OR=0.64, 95%CI=0.54-0.76), those who staying home cared by foreigner worker were more likely to use ER services (OR=1.16, 95%CI=1.05-1.29), and those who staying home without caregiver were less likely to use ER services (OR=0.89, 95%CI=0.78-1.01).

CONCLUSIONS

Disabled older adults staying at home were more likely to use ER compared to institutionalized individuals. More research is needed to identify the unmet healthcare needs and the quality of home care that may explain the high ER utilization rate.

[Urgency attend to the older patient in primary health care]

The world population is making older increasing the sanitary resources consum. It makes the elderly patients are the main occupant of hospitalary beds, who generate more mortality, longer stays and more number of readmissions. Also they are who visit more the primary health care doctor and they are the first and the most numerous drugs consumer. The result rise the medical assistance demand in the different primary health care services. The chronic diseases that older patients suffer multiply in keeping with the age, existing one significative association between many chronic diseases and the urgences admissions in the older patients. To offer the necessary service, we must improve the primary health care centers autosufficiency, the resolutive capacity and the human resources management in agreement with the needs of each moment.

Inappropriate use of emergency services: a systematic review of prevalence and associated factors

This systematic review aimed to measure the prevalence of inappropriate emergency department (ED) use by adults and associated factors. The review included 31 articles published in the last 12 years. Prevalence of inappropriate ED use varied from 20 to 40% and was associated with age and income. Female patients, those without co-morbidities, without a regular physician, without a regular source of care, and those not referred to the ED by a physician also showed more inappropriate ED use, with the relative risk varying from 1.12 to 2.42. Difficulties in accessing primary health care (difficulties in setting appointments, longer waiting periods, and short business hours at the primary health care service) were also associated with inappropriate ED use. Thus, primary care requires fully qualified patient reception and efficient triage to promptly attend cases that cannot wait. It is also necessary to orient the population on situations in which they should go to the ED and on the disadvantages of consulting the ED when the case is not really urgent.

Impact of Medicaid cutbacks on emergency department use: the Oregon experience

STUDY OBJECTIVE

Federal policy changes and tightened state budgets may reduce Medicaid enrollment in many states. In March 2003, the Oregon Health Plan (Oregon's Medicaid expansion program) made substantial changes in its benefit package that resulted in the disenrollment of more than 50,000 beneficiaries. We sought to study the impact of these Oregon Health Plan policy changes on statewide emergency department (ED) use.

METHODS

In this observational study, hospital billing data on 2,680,954 visits to 26 Oregon EDs were obtained, sampled up to 24 months before and 24 months after the cutbacks. These visits represent approximately 62% of all visits to Oregon's 58 EDs. We ascertained counts of ED visits by payer group before and after the Oregon Health Plan cutback date, plus hospital admissions from the ED as a measure of acuity.

RESULTS

After the Oregon Health Plan policy changes, ED visits by the uninsured underwent an abrupt and sustained increase, from 6,682 per month in 2002 to 9,058 per month in 2004. Oregon Health Plan-sponsored and commercially insured visits decreased, resulting in a slight decrease in overall ED visits. Multivariable models adjusting for secular trends and seasonality showed a 20% (95% confidence interval 13% to 28%) increase in uninsured ED visits, whereas the adjusted number of Oregon Health Plan-sponsored visits decreased. The proportion of uninsured ED visits resulting in hospital admission increased (odds ratio 1.50; 95% confidence interval 1.39 to 1.62).

CONCLUSION

Oregon's Medicaid cutbacks were followed by increases in ED use and hospitalizations by the uninsured. Recent federal legislation facilitating similar Medicaid changes in other states may lead to replication of these events elsewhere.

Continuity of primary care and emergency department utilization among elderly people

BACKGROUND

People aged 65 years or more represent a growing group of emergency department users. We investigated whether characteristics of primary care (accessibility and continuity) are associated with emergency department use by elderly people in both urban and rural areas.

METHODS

We conducted a cross-sectional study using information for a random sample of 95,173 people aged 65 years or more drawn from provincial administrative databases in Quebec for 2000 and 2001. We obtained data on the patients' age, sex, comorbidity, rate of emergency department use (number of days on which a visit was made to an emergency department per 1000 days at risk [i.e., alive and not in hospital] during the 2-year study period), use of hospital and ambulatory physician services, residence (urban v. rural), socioeconomic status, access (physician: population ratio, presence of primary physician) and continuity of primary care.

RESULTS

After adjusting for age, sex and comorbidity, we found that an increased rate of emergency department use was associated with lack of a primary physician (adjusted rate ratio [RR] 1.45, 95% confidence interval [CI] 1.41-1.49) and low or medium (v. high) levels of continuity of care with a primary physician (adjusted RR 1.46, 95% CI 1.44-1.48, and 1.27, 95% CI 1.25-1.29, respectively). Other significant predictors of increased use of emergency department services were residence in a rural area, low socioeconomic status and residence in a region with a higher physician:population ratio. Among the patients who had a primary physician, continuity of care had a stronger protective effect in urban than in rural areas.

INTERPRETATION

Having a primary physician and greater continuity of care with this physician are factors associated with decreased emergency department use by elderly people, particularly those living in urban areas.

Continuity of care for acutely unwell older adults from nursing homes

BACKGROUND

Continuity of care (COC) for acutely unwell older adults, particularly those who are nursing home residents, who present to hospital, is complicated by the presence of co-morbid conditions, long waiting times, both for the ambulance and in the department, and poor after-hours general practitioner access.

AIM

To present a critical review of the literature on COC for older adults from nursing homes who present to hospital and who are acutely unwell. The review will answer the following questions: (i) What is the contemporary meaning of the construct continuity of care? (ii) What is the relevance of continuity of care to the population of older adults who reside in nursing homes and present to hospital? and (iii) What models exist for promoting continuity of care to older adults who present to hospital?

METHOD

Guided by the conceptual analysis process a database search of CINAHL and MEDLINE was carried out utilizing the search terms 'continuity of care', 'older adults', 'nursing homes', 'emergency department' and 'acute illness'. A hand-search of additional references was also conducted. Retrieved articles were critically reviewed if they focused on older adult patients, the acute care/community settings and COC.

FINDINGS

The contemporary meaning of the COC is that it incorporates care of an individual patient over time by bridging discrete elements in the care pathway. Four distinct models of COC were identified. These were Primary Health Care; General Practice and Primary Medical Care; Consumers; and Health Policy and Systems. All are based on the proviso that the individual is sufficiently independent to be able to coordinate their own care and to take overall responsibility.

CONCLUSIONS

The connection between COC and acutely unwell older adults who present to hospital is a prolific area for further research. In particular, the effectiveness of programmes aimed at enhancing the advanced nursing practice role and the COC process for older adults, needs investigation.