Understanding Pathways into Care-homes using Data (UnPiCD study): a two-part model to estimate inpatient and care-home costs using national linked health and social care data

BACKGROUND

Pathways into care-homes have been under-researched. Individuals who move-in to a care-home from hospital are clinically distinct from those moving-in from the community. However, it remains unclear whether the source of care-home admission has any implications in term of costs. Our aim was to quantify hospital and care-home costs for individuals newly moving-in to care homes to compare those moving-in from hospital to those moving-in from the community.

METHODS

Using routinely-collected national social care and health data we constructed a cohort including people moving into care-homes from hospital and community settings between 01/04/2013-31/03/2015 based on records from the Scottish Care-Home Census (SCHC). Individual-level data were obtained from Scottish Morbidity Records (SMR01/04/50) and death records from National Records of Scotland (NRS). Unit costs were identified from NHS Scotland costs data and care-home costs from the SCHC. We used a two-part model to estimate costs conditional on having incurred positive costs. Additional analyses estimated differences in costs for the one-year period preceding and following care-home admission.

RESULTS

We included 14,877 individuals moving-in to a care-home, 8,472 (57%) from hospital, and 6,405 (43%) from the community. Individuals moving-in to care-homes from the community incurred higher costs at £27,117 (95% CI £ 26,641 to £ 27,594) than those moving-in from hospital with £24,426 (95% CI £ 24,037 to £ 24,814). Hospital costs incurred during the year preceding care-home admission were substantially higher (£8,323 (95% CI£8,168 to £8,477) compared to those incurred after moving-in to care-home (£1,670 (95% CI£1,591 to £1,750).

CONCLUSION

Individuals moving-in from hospital and community have different needs, and this is reflected in the difference in costs incurred. The reduction in hospital costs in the year after moving-in to a care-home indicates the positive contribution of care-home residency in supporting those with complex needs. These data provide an important contribution to inform capacity planning on care provision for adults with complex needs and the costs of care provision.

Evaluating the effect of inequalities in oral anti-coagulant prescribing on outcomes in people with atrial fibrillation

Aims

Whilst anti-coagulation is typically recommended for thromboprophylaxis in atrial fibrillation (AF), it is often never prescribed or prematurely discontinued. The aim of this study was to evaluate the effect of inequalities in anti-coagulant prescribing by assessing stroke/systemic embolism (SSE) and bleeding risk in people with AF who continue anti-coagulation compared with those who stop transiently, permanently, or never start.

Methods and results

This retrospective cohort study utilized linked Scottish healthcare data to identify adults diagnosed with AF between January 2010 and April 2016, with a CHA2DS2-VASC score of ≥2. They were sub-categorized based on anti-coagulant exposure: never started, continuous, discontinuous, and cessation. Inverse probability of treatment weighting-adjusted Cox regression and competing risk regression was utilized to compare SSE and bleeding risks between cohorts during 5-year follow-up. Of an overall cohort of 47 427 people, 26 277 (55.41%) were never anti-coagulated, 7934 (16.72%) received continuous anti-coagulation, 9107 (19.2%) temporarily discontinued, and 4109 (8.66%) permanently discontinued. Lower socio-economic status, elevated frailty score, and age ≥ 75 were associated with a reduced likelihood of initiation and continuation of anti-coagulation. Stroke/systemic embolism risk was significantly greater in those with discontinuous anti-coagulation, compared with continuous [subhazard ratio (SHR): 2.65; 2.39-2.94]. In the context of a major bleeding event, there was no significant difference in bleeding risk between the cessation and continuous cohorts (SHR 0.94; 0.42-2.14).

Conclusion

Our data suggest significant inequalities in anti-coagulation prescribing, with substantial opportunity to improve initiation and continuation. Decision-making should be patient-centred and must recognize that discontinuation or cessation is associated with considerable thromboembolic risk not offset by mitigated bleeding risk.

How Least Developed to Lower-Middle Income Countries Use Health Technology Assessment: A Scoping Review

Health Technology Assessment (HTA) is a multidisciplinary tool to inform healthcare decision-making. HTA has been implemented in high-income countries (HIC) for several decades but has only recently seen a growing investment in low- and middle-income countries. A scoping review was undertaken to define and compare the role of HTA in least developed and lower middle-income countries (LLMIC). MEDLINE and EMBASE databases were searched from January 2015 to August 2021. A matrix comprising categories on HTA objectives, methods, geographies, and partnerships was used for data extraction and synthesis to present our findings. The review identified 50 relevant articles. The matrix was populated and sub-divided into further categories as appropriate. We highlight topical aspects of HTA, including initiatives to overcome well-documented challenges around data and capacity development, and identify gaps in the research for consideration. Those areas we found to be under-studied or under-utilized included disinvestment, early HTA/implementation, system-level interventions, and cross-sectoral partnerships. We consider broad practical implications for decision-makers and researchers aiming to achieve greater interconnectedness between HTA and health systems and generate recommendations that LLMIC can use for HTA implementation. Whilst HIC may have led the way, LLMIC are increasingly beginning to develop HTA processes to assist in their healthcare decision-making. This review provides a forward-looking model that LLMIC can point to as a reference for their own implementation. We hope this can be seen as timely and useful contributions to optimize the impact of HTA in an era of investment and expansion and to encourage debate and implementation.

1344 UNDERSTANDING PATHWAYS INTO CARE HOMES USING DATA (THE UNPICD STUDY)

Introduction

Moving into a care home is a significant, life-changing experience which occurs to address care needs which cannot be supported elsewhere. UK health policy recommends against moving into a care home from the acute hospital. However, this occurs in practice. Better understanding pathways into care homes could improve support for individuals and families, service planning and policymaking. Our aim was to characterise individuals who move-in to a care home from hospital and those moving-in from the community, identifying factors associated with moving-in from hospital.

Method

A retrospective observational cohort study was conducted involving adults moving into care homes in Scotland between 1/3/13-31/3/16 using the Scottish Care Home Census (SCHC), a national individual-level social care dataset. SCHC data were linked to routine data sources including hospital admissions, community prescribing and mortality. The data were split into those moving-in from hospital and those moving-in from the community. Descriptive statistics characterising the two groups were generated and multivariate regression undertaken to identify factors associated with moving-in from hospital.

Results

A total of 23,892 individuals were included in the analysis, of whom 13,564 (56.8%) moved-in from hospital. A third came directly from an acute hospital, with 57.7% from rehabilitation or community hospitals and 7.1% from inpatient psychiatry. Being male, receiving nursing care, high frailty risk, increasing numbers of hospital admissions and diagnoses of any fracture or stroke in the six months before moving-into the care home were all significant predictors of moving-in from hospital.

Conclusions

The population moving-in to care homes from hospital are clinical distinct from those moving-in from the community. National cross-sectoral data linkage of health and social care data is feasible, but the available data are dominated by health characteristics. There is an urgent need to operationalise other meaningful variables which shape care pathways to enhance understanding and evidence.

Understanding Pathways into Care homes using Data (UnPiCD study): a retrospective cohort study using national linked health and social care data

BACKGROUND

Pathways into care are poorly understood but important life events for individuals and their families. UK policy is to avoid moving-in to care homes from acute hospital settings. This assumes that moves from secondary care represent a system failure. However, those moving to care homes from community and hospital settings may be fundamentally different groups, each requiring differing care approaches.

OBJECTIVE

To characterise individuals who move-in to a care home from hospital and compare with those moving-in from the community.

DESIGN AND SETTING

A retrospective cohort study using cross-sectoral data linkage of care home data.

METHODS

We included adults moving-in to care homes between 1/4/13 and 31/3/16, recorded in the Scottish Care Home Census. Care home data were linked to general and psychiatric hospital admissions, community prescribing and mortality records to ascertain comorbidities, significant diagnoses, hospital resource use, polypharmacy and frailty. Multivariate logistic regression identified predictors of moving-in from hospital compared to from community.

RESULTS

We included 23,892 individuals moving-in to a care home, 13,564 (56.8%) from hospital and 10,328 (43.2%) from the community. High frailty risk adjusted Odds Ratio (aOR) 5.11 (95% Confidence Interval (CI): 4.60-5.68), hospital discharge with diagnosis of fracture aOR 3.91 (95%CI: 3.41-4.47) or stroke aOR 8.42 (95%CI: 6.90-10.29) were associated with moving-in from hospital. Discharge from in-patient psychiatry was also a highly significant predictor aOR 19.12 (95%CI: 16.26-22.48).

CONCLUSIONS

Individuals moving-in to care homes directly from hospital are clinically distinct from those from the community. Linkage of cross-sectoral data can allow exploration of pathways into care at scale.

Propensity score methods for comparative-effectiveness analysis: A case study of direct oral anticoagulants in the atrial fibrillation population

Objective

To explore methodological challenges when using real-world evidence (RWE) to estimate comparative-effectiveness in the context of Health Technology Assessment of direct oral anticoagulants (DOACs) in Scotland.

Methods

We used linkage data from the Prescribing Information System (PIS), Scottish Morbidity Records (SMR) and mortality records for newly anticoagulated patients to explore methodological challenges in the use of Propensity score (PS) matching, Inverse Probability Weighting (IPW) and covariate adjustment with PS. Model performance was assessed by standardised difference. Clinical outcomes (stroke and major bleeding) and mortality were compared for all DOACs (including apixaban, dabigatran and rivaroxaban) versus warfarin. Patients were followed for 2 years from first oral anticoagulant prescription to first clinical event or death. Censoring was applied for treatment switching or discontinuation.

Results

Overall, a good balance of patients’ covariates was obtained with every PS model tested. IPW was found to be the best performing method in assessing covariate balance when applied to subgroups with relatively large sample sizes (combined-DOACs versus warfarin).

With the IPTW-IPCW approach, the treatment effect tends to be larger, but still in line with the treatment effect estimated using other PS methods. Covariate adjustment with PS in the outcome model performed well when applied to subgroups with smaller sample sizes (dabigatran versus warfarin), as this method does not require further reduction of sample size, and trimming or truncation of extreme weights.

Conclusion

The choice of adequate PS methods may vary according to the characteristics of the data. If assumptions of unobserved confounding hold, multiple approaches should be identified and tested. PS based methods can be implemented using routinely collected linked data, thus supporting Health Technology decision-making.

Atrial fibrillation and stroke outcomes in Scotland: real-world evidence from a contemporary, national dataset

Introduction

Atrial Fibrillation (AF) is an important cause of mortality and morbidity. The major risk of AF is stroke, which can be reduced through anticoagulation. The burden of stroke, and AF-related stroke, is particularly high in Scotland. It is often reported that AF-related stroke is associated with poorer outcomes than other stroke types, it is also thought to lead to an increased institutionalisation. Data supporting these observations are historic, but major advances in AF assessment and treatment could have changed outcome patterns. Real world evidence on outcomes, collected at scale, can give a useful measure of contemporary AF stroke outcomes.

Purpose

To assess whether stroke patients, with and without AF on admission, differ in terms of al-cause mortality, recurrence of stroke, and care home admission using contemporary large-scale observational data.

Methods

A retrospective cohort study linking national hospital, prescribing, care home and stroke audit data was conducted. The cohort, comprising patients ≥18 years of age with incident ischemic stroke between 2009 and 2017, was divided into three groups: AF-related stroke prescribed oral anticoagulant (OAC) pre-stroke event (AF-OAC Group); AF-related stroke not prescribed anticoagulant pre-stroke event (AF-noOAC Group); stroke with no prevalent or incident AF and no anticoagulation (comparator) (noAF-noOAC Group). Time-to-event analyses (adjusted for demographic and clinical characteristics) were conducted to estimate hazard ratios for recurrent stroke, all-cause mortality, and care-home admission with a follow-up time of two years.

Results

From a cohort of 64,159 incident ischemic strokes, 4,418 and 15,124 patients with AF were identified for groups AF-OAC and AF-noOAC, respectively. The remaining 44,617 patients belonged to group noAF-noOAC. An increasing number of incident strokes was observed with increasing age in each group up to 80–84 years. The risk of recurrent stroke was significantly greater in groups AF-OAC (HR 1.12 [95% CI 1.08,1.17]) and AF-noOAC (HR 1.05 [95% CI 1.03,1.08]) compared to noAF-noOAC group. An increased risk of all-cause mortality was observed in groups AF-OAC (HR 1.52 [95% CI 1.39,1.66]) and AF-noOAC (HR 1.59 [95% CI 1.51,1.68]) compared to the noAF-noOAC group. Patients in group AF-noOAC were more likely to be discharged to a care home following stroke (HR 1.37 [95% CI 1.23,1.52]) compared to patients in the other groups.

Conclusion

AF-related stroke is associated with poor outcomes, with significantly higher risks of recurrent stroke and all-cause mortality for patients with AF compared to non-AF stroke. Despite advances in AF care, our data suggest there is still potential to prevent a substantial proportion of disabling strokes through better identification and treatment of AF. These results must be interpreted with caution, as data take no account of treatment adherence, dosing or rationale for individual patient level prescribing decisions.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Bristol-Myers Squibb Research and Development

A two-part model to estimate inpatient, outpatient, prescribing and care home costs associated with atrial fibrillation in Scotland

OBJECTIVE

This study aimed to estimate global inpatient, outpatient, prescribing and care home costs for patients with atrial fibrillation using population-based, individual-level linked data.

DESIGN

A two-part model was employed to estimate the probability of resource utilisation and costs conditional on positive utilisation using individual-level linked data.

SETTINGS

Scotland, 5 years following first hospitalisation for AF between 1997 and 2015.

PARTICIPANTS

Patients hospitalised with a known diagnosis of AF or atrial flutter.

PRIMARY AND SECONDARY OUTCOME MEASURES

Inpatient, outpatient, prescribing and care home costs.

RESULTS

The mean annual cost for a patient with AF was estimated at £3785 (95% CI £3767 to £3804). Inpatient admissions and outpatient visits accounted for 79% and 8% of total costs, respectively; prescriptions and care home stay accounted for 7% and 6% of total costs. Inpatient cost was the main driver across all age groups. While inpatient cost contributions (~80%) were constant between 0 and 84 years, they decreased for patients over 85 years. This is offset by increasing care home cost contributions. Mean annual costs associated with AF increased significantly with increasing number of comorbidities.

CONCLUSION

This study used a contemporary and representative cohort, and a comprehensive approach to estimate global costs associated with AF, taking into account resource utilisation beyond hospital care. While overall costs, considerably affected by comorbidity, did not increase with increasing age, care home costs increased proportionally with age. Inpatient admission was the main contributor to the overall financial burden of AF, highlighting the need for improved mechanisms of early diagnosis to prevent hospitalisations.