Casemix, resource use and geriatric medicine in England and Wales

Resources and Costs Associated with Disabilities of Elderly People Living at Home and in Institutions

Cette étude a été réalisée auprès d'un échantillon représentatif de sujets âgées vivant à domicile (n = 300), dans des ressources de type familial (RTF) ou des pavilions (n = 271) et dans des institutions d'hébergement (n = 774) de zones métropolitaine, urbaines et rurales du Québec afin de: 1) déterminer le niveau d'incapacité et les ressources consacrés aux soins des personnes âgées vivant à domicile ou en institution; 2) estimer les coûts (publics, privés et bénévoles) de ces ressources; 3) comparer les coûts à autonomie égale; 4) prédire les coûts selon le niveau d'incapacité. Les principaux résultats montrent que les sujets des trois milieux de vie présentent des différences significatives quant au niveau d'incapacité, à l'état cognitif et aux soins requis et fournis, bien que des chevauchements importants étaient notables. Le score d'incapacité explique 85 pour cent de la variance du temps de soins ainsi que, respectivement, 55, 15 et 68 pour cent des coûts à domicile, en RTF et pavilions et en institutions. Les soins infirmiers et d'assistance sont responsables de la majorité des coûts dans tous les milieux de vie. Le coût social total des soins à domicile étaient plus élevé que ceux en RTF et pavilions pour les sujets avec un score d'incapacité de 7,4 et plus et même supérieur à ceux en institutions pour un score au-dessus de 38,7.

Early re-hospitalization of elderly people discharged from a geriatric ward

BACKGROUND AND AIMS

Hospitalized elderly patients generally have a high level of disability and comorbidity. In many cases, at hospital discharge, the achieved health status balance is poor, and consequently the risk of further disability and hospital readmission is great. Identifying factors leading to hospital readmission could be helpful in reducing such events. The aim of the study was to evaluate the incidence and predictive factors of hospital readmission.

METHODS

We conducted an observational cohort study of a group of patients discharged from the Geriatric Ward of the San Giovanni Battista Hospital, Torino (Italy). The study sample contained 839 patients aged 80.6 +/- 6.3 years. The average hospital stay was 17.5 +/- 18.9 days (range 1-274 days).

RESULTS

Follow-up lasted three months, at the end of which 107 patients (12.8%) had been readmitted, 83 (9.9%) had only one readmission and 24 (2.9%) one or more readmissions. The first readmission took place within 15 days of discharge for 24 patients (2.9%) and within 30 days of discharge for 27 (3.2%). A new hospital admission within 15 days of discharge increased the risk of mortality (RR=3) and also the probability of a second re-hospitalization. 10.1% patients died; 88.2% of the patients who died had at least one readmission, whereas only 4.2% of live patients had a new hospital admission.

CONCLUSIONS

Tumors, dementia, comorbidity, high education level, day hospital course and period of convalescence were all significantly and independently related to readmission.

Disability-based classification system for older people in integrated long-term care services: the Iso-SMAF profiles

This study was conducted to develop and evaluate a disability-based classification system for management of long-term care (LTC) needs in an integrated service delivery system. We collected cross-sectional data on 29 items of the Functional Autonomy Measurement System (SMAF) from a stratified multistage sampling of 1977 elderly people with disabilities living in different environments. Disability profiles were identified using statistical clustering techniques combined with advice form a panel of experts. Their clinical meaningfulness, stability, reproducibility, homogeneity, heterogeneity and predictive validity were evaluated. The Iso-SMAF classification consisted of 14 homogeneous disability profiles characterized by a gradual progression in the severity of disabilities in instrumental activities of daily living (IADL) and activities of daily living (ADL) accompanied by predominant limitations either in mobility or mental functions. The profiles achieved a Kappa reproducibility coefficient of 0.67 through cross validation. A stable cluster structure emerged when the items were analyzed using different methods. They explained 82% of the variance in nursing care time, 80% of the variance in cost of nursing care (skilled and unskilled) and 57% of the variance in total costs including both formal and informal sources of LTC services. The conclusion recommends their use for planning, managing and predicting LTC service needs in an integrated care system.

A system of patient classification in long-term psychiatric inpatients: Resource Utilization Groups T-18 (RUG T-18)

This paper shows the application of a 'case mix' system (Resources Utilization Groups T18 or RUG-T18) to a Spanish long-term inpatient psychiatric sample.

OBJECTIVE

To examine the capacity of RUG-T18 to predict patient resource use (spent time of care) in a long-term psychiatric sample.

SUBJECTS AND RESEARCH DESIGN

Data included an assessment of 163 patients' characteristics, corresponding to groups of the RUG-T18, and detailed measurement of nursing staff care over a 24-h period.

RESULTS

'Severe behavioural problems' was the most frequent RUG-T18 category. There were significant differences in the spent time of care in the different groups and high variability in the distribution of time of care within groups and in the total sample.

CONCLUSIONS

The RUG T-18 system should be improved to become a useful case mix system in long-term psychiatric inpatients. The high variance intragroups could be minimized improving the psychopathological aspects of the system.

Les soins de longue durée aux personnes âgées: Choix d'un système clinico-administratif dans le contexte d'un réseau de soins intégrés

For the past 10 years, in long-term care systems, we have witnessed the accelerated deployment of casemix management systems. A casemix is formed by clusters, defined by individual characteristics that explain similar resource use. However, certain questions regarding the development of these systems must be raised. Moreover, none of these systems was developed in the context of an integrated care organization that can track the progress of a dependent elderly person through every kind of care arrangement available—from own home, through intermediate facility, to long-term care institution. This article emphasizes the necessity of being well informed about the features of existing systems, in order to choose or develop the system that best answers the goals of a particular health care system. Finally, it underlines important elements that should be considered in each step of the development of a casemix system in this context.

Characteristics of geriatric patients related to early and late readmissions to hospital

The aim of the study was to evaluate which characteristics of geriatric patients account for readmission to hospital, 6 months after discharge. All patients (203 females, 176 males) consecutively admitted over a two-month period to four acute geriatric care units, located in the cities of Chieti, Perugia, Pescara and Prato, participated in the study. Data that could potentially explain early and late readmissions were collected for each patient. Prevalence of diseases and comorbidity were assessed with the Cumulative Illness Rating Scale (CIRS); physical function by self-report (ADL, IADL) and objective (Stand and Walking Speed) measures; cognitive level by MMSE; and depressive symptoms by the Geriatric Depression Scale (GDS). Information on family and social support were also obtained. After discharge, data on hospital readmissions were collected for six months. For each readmitted patient (cases), medical records were reviewed, and supplementary information was obtained from families and general practitioners. Readmissions were classified as "early" (within the first three months), "late" (within the third and sixth month), and "multiple" (2 or more readmissions irrespective of the period). Patients not readmitted (alive at home) were considered as controls. Systematic differences between centers and between periods of readmissions were evaluated using one-way analyses of variance, and Pearson's chi 2 test. Factors related to early, late, and multiple readmission were identified in multivariate logistic regression models. On univariate analysis, patients readmitted over the first three-month period were sicker than controls (CIRS classes 3-4: 52.1% vs 34.1%), had more social problems or behavioral symptoms, and were more functionally impaired (ADL dependencies 3.3 +/- 0.4 vs 2.1 +/- 0.2). Patients who were readmitted between the third and the sixth month after discharge had a significantly higher CIRS total score (p = 0.006). Patients with multiple readmissions had more severe diseases, and more social problems. On multivariate analysis, early readmission was associated with unsatisfactory social conditions, living alone, severity of diseases and cognitive impairment, while late readmission was associated with comorbidity only. Multiple readmissions were related only to social factors, and to hospital admission before the baseline evaluation. The findings of this study suggest that interventions aimed at improving unfavorable social conditions may reduce the rate of rehospitalization in geriatric patients.