The Association between Home Healthcare and Burdensome Transitions at the End-of-Life in People with Dementia: A 12-Year Nationwide Population-Based Cohort Study

Mortality rate and its determinants among people with dementia receiving home healthcare: a nationwide cohort study

People with dementia (PwD) who receive home healthcare (HHC) may have distressing symptoms, complex care needs and high mortality rates. However, there are few studies investigating the determinants of mortality in HHC recipients. To identify end-of-life care needs and tailor individualized care goals, we aim to explore the mortality rate and its determinants among PwD receiving HHC. We conducted a retrospective cohort study using a Taiwanese national population database. People with new dementia diagnosis in 2007-2016 who received HHC were included. We calculated the accumulative mortality rate and applied Poisson regression model to estimate the risk of mortality for each variable (adjusted risk ratios, aRR) with a 95% confidence interval (CI). We included 95,831 PwD and 57,036 (59.5%) of them died during the follow-up period (30.5% died in the first-year). Among comorbidities, cirrhosis was associated with the highest mortality risks (aRR 1.65, 95% CI 1.49-1.83). Among HHC-related factors, higher visit frequency of HHC (> 2 versus ≦1 times/month, aRR 3.52, 95% CI 3.39-3.66) and higher level of resource utilization group (RUG, RUG 4 versus 1, aRR = 1.38, 95% CI 1.25-1.51) were risk factor of mortality risk. Meanwhile, HHC provided by physician and nurse was related to reduced mortality risk (aRR 0.79, 95% CI 0.77-0.81) compared to those provided by nurse only. Anticipatory care planning and timely end-of life care should be integrated in light of the high mortality rate among PwD receiving HHC. Determinants associated with increased mortality risk facilitate the identification of high risk group and tailoring the appropriate care goals. Trial registration number: ClinicalTrials.gov Identifier is NCT04250103 which has been registered on 31st January 2020.

The effectiveness of telehealth interventions for people with multiple sclerosis: A systematic review and meta-analysis protocol

Objective

Multiple sclerosis (MS) is a chronic neurological condition that significantly impacts the quality of life of affected individuals. Telehealth interventions (TIs) have emerged as a promising avenue for providing healthcare services remotely, potentially improving outcomes and enhancing the quality of life for people with MS. This systematic review aims to assess the impact and efficacy of TIs on outcomes of people with MS by synthesizing and comparing outcomes from related randomized controlled trials.

Methods

The systematic review protocol will involve searching electronic databases (PubMed, Web of Science, Scopus, EMBASE, CENTRAL), gray literature resources, and key journals from 1997 to June 2023 for keywords related to Telehealth and MS. The collection of research-related articles will be followed by the removal of duplicates before they are included in the study. During the screening stage, the titles and abstracts of the articles will be reviewed, and irrelevant articles will be excluded. The full text of relevant articles will be independently evaluated by two researchers, and data will be extracted from the final articles. The findings will be classified and recorded in an extraction table. The risk of bias will be assessed using the Cochrane Collaboration tool. The data will be analyzed using STATA version 14.2. The PROSPERO ID for this study is CRD42023450081.

Discussion

This study aims to address the current knowledge gap by investigating the comparative effectiveness of TIs. The findings of this research will provide valuable insights and evidence regarding the effectiveness of these interventions, assess their feasibility and accessibility, examine patient outcomes, identify research gaps, and offer guidance for clinical practice and policy-making.

Primary care contacts, continuity, identification of palliative care needs, and hospital use: a population-based cohort study in people dying with dementia

BACKGROUND

Reducing hospital admissions among people dying with dementia is a policy priority.

AIM

To explore associations between primary care contacts, continuity of primary care, identification of palliative care needs, and unplanned hospital admissions among people dying with dementia.

DESIGN AND SETTING

This was a retrospective cohort study using the Clinical Practice Research Datalink linked with hospital records and Office for National Statistics data. Adults (>18 years) who died between 2009 and 2018 with a diagnosis of dementia were included in the study.

METHOD

The association between GP contacts, Herfindahl-Hirschman Index continuity of care score, palliative care needs identification before the last 90 days of life, and multiple unplanned hospital admissions in the last 90 days was evaluated using random-effects Poisson regression.

RESULTS

In total, 33 714 decedents with dementia were identified: 64.1% (n = 21 623) female, mean age 86.6 years (SD 8.1), mean comorbidities 2.2 (SD 1.6). Of these, 1894 (5.6%) had multiple hospital admissions in the last 90 days of life (increase from 4.9%, 95% confidence interval [CI] = 4.2 to 5.6 in 2009 to 7.1%, 95% CI = 5.7 to 8.4 in 2018). Participants with more GP contacts had higher risk of multiple hospital admissions (incidence risk ratio [IRR] 1.08, 95% CI = 1.05 to 1.11). Higher continuity of care scores (IRR 0.79, 95% CI = 0.68 to 0.92) and identification of palliative care needs (IRR 0.66, 95% CI = 0.56 to 0.78) were associated with lower frequency of these admissions.

CONCLUSION

Multiple hospital admissions among people dying with dementia are increasing. Higher continuity of care and identification of palliative care needs are associated with a lower risk of multiple hospital admissions in this population, and might help prevent these admissions at the end of life.

Impact of home healthcare on end-of-life outcomes for people with dementia: a systematic review

BACKGROUND

Home healthcare (HHC) comprises clinical services provided by medical professionals for people living at home with various levels of care needs and health conditions. HHC may reduce care transitions from home to acute hospitals, but its long-term impact on homebound people living with dementia (PLWD) towards end-of-life remains unclear. We aim to describe the impact of HHC on acute healthcare utilization and end-of-life outcomes in PLWD.

METHODS

Design: Systematic review of quantitative and qualitative original studies which examine the association between HHC and targeted outcomes.

INTERVENTIONS

HHC.

PARTICIPANTS

At least 80% of study participants had dementia and lived at home.

MEASUREMENTS

Primary outcome was acute healthcare utilization in the last year of life. Secondary outcomes included hospice palliative care, advance care planning, continuity of care, and place of death. We briefly reviewed selected national policy to provide contextual information regarding these outcomes.

RESULTS

From 6831 articles initially identified, we included five studies comprising data on 4493 participants from USA, Japan, and Italy. No included studies received a "high" quality rating. We synthesised core properties related to HHC at three implementational levels. Micro-level: HHC may be associated with a lower risk of acute healthcare utilization in the early period (e.g., last 90 days before death) and a higher risk in the late period (e.g. last 15 days) of the disease trajectory toward end-of-life in PLWD. HHC may increase palliative care referrals. Advance care planning was an important factor influencing end-of-life outcomes. Meso-level: challenges for HHC providers in medical decision-making and initiating palliative care for PLWD at the end-of-life may require further training and external support. Coordination between HHC and social care is highlighted but not well examined. Macro-level: reforms of national policy or financial schemes are found in some countries but the effects are not clearly understood.

CONCLUSIONS

This review highlights the dearth of dementia-specific research regarding the impact of HHC on end-of-life outcomes. Effects of advance care planning during HHC, the integration between health and social care, and coordination between primary HHC and specialist geriatric/ palliative care services require further investigation.

Can we determine burdensome transitions in the last year of life based on time of occurrence and frequency? An explanatory mixed-methods study

Objective

Burdensome transitions are typically defined as having a transition in the last three days or multiple hospitalizations in the last three months of life, which is seldom verified with qualitative accounts from persons concerned. This study analyses types and frequencies of transitions in the last year of life and indicators of burdensome transitions from the perspective of bereaved relatives.

Method

Cross-sectional explanatory mixed-methods study with 351 surveyed and 41 interviewed bereaved relatives in a German urban area. Frequencies, t-tests, and Spearman correlations were computed for quantitative data. Qualitative data were analyzed using content analysis with provisional and descriptive coding/subcoding.

Results

Transitions rise sharply during the last year of life. 8.2% of patients experience a transition in the last three days and 7.8% three or more hospitalizations in the last three months of life. An empathetic way of telling patients about the prospect of death is associated with fewer transitions in the last month of life (r = 0.185, p = 0.046). Professionals being aware of the preferred place of death corresponds to fewer hospitalizations in the last three months of life (1.28 vs. 0.97, p = 0.021). Qualitative data do not confirm that burden in transitions is linked to having transitions in the last three days or multiple hospitalizations in the last three months of life. Burden is associated with (1) late and non-empathetic communication about the prospect of death, (2) not coordinating care across settings, and (3) not considering patients’ preferences.

Significance of results

Time of occurrence and frequency appear to be imperfect proxies for burdensome transitions. The subjective burden seems to be associated rather with insufficient information, preparation, and management of transitions.

Healthcare Utilization in Different Stages among Patients with Dementia: A Nationwide Population-Based Study

To evaluate the trend of healthcare utilization among patients with dementia (PwD) in different post-diagnosis periods, Taiwan's nationwide population database was used in this study. PwD were identified on the basis of dementia diagnoses during 2002-2011. We further subdivided the cases into 10 groups from the index year to the 10th year after diagnosis. The frequency of emergency department visits and hospitalizations, the length of stay, outpatient and department visits, and the number of medications used were retrieved. The Joinpoint regression approach was used to estimate the annual percent change (APC) of healthcare utilization. The overall trend of healthcare utilization increased with the progression of dementia, with a significant APC during the first to second year after diagnosis (p < 0.01), except that the frequency of outpatient visits showed a decreasing trend with a significant APC from the first to fifth year. All sex- and age-stratified analyses revealed that male gender and old age contributed to greater use of healthcare services but did not change the overall trend. This study provides a better understanding of medical resource utilization across the full spectrum of dementia, which can allow policymakers, physicians, and caregivers to devise better care plans for PwD.

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

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