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Cygańska M, Kludacz-Alessandri M, Pyke C. Healthcare Costs and Health Status: Insights from the SHARE Survey. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1418. [PMID: 36674169 PMCID: PMC9864144 DOI: 10.3390/ijerph20021418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 12/30/2022] [Accepted: 01/07/2023] [Indexed: 06/17/2023]
Abstract
The substantial rise in hospital costs over recent years is associated with the rapid increase in the older age population. This study addresses an empirical gap in the literature concerning the determinants of high hospital costs in a group of older patients in Europe. The objective of the study is to examine the association of patient health status with in-hospital costs among older people across European countries. We used the data from the Survey of Health, Ageing and Retirement in Europe (SHARE) database. The analysis included 9671 patients from 18 European countries. We considered socio-demographic, lifestyle and clinical variables as possible factors influencing in-hospital costs. Univariate and multivariable logistic regression analyses were used to determine the determinants of in-hospital costs. To benchmark the hospital costs across European countries, we used the cost-outlier methodology. Rates of hospital cost outliers among older people varies from 5.80 to 12.65% across Europe. Factors associated with extremely high in-patient costs differ among European countries. In most countries, they include the length of stay in the hospital, comorbidities, functional mobility and physical activity. The treatment of older people reporting heart attack, diabetes, chronic lung disease and cancer are more often connected with cost outliers. The risk of being a cost outlier increased by 20% with each day spent in the hospital. We advocate that including patient characteristics in the reimbursement system could provide a relatively simple strategy for reducing hospitals' financial risk connected with exceptionally costly cases.
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Affiliation(s)
- Małgorzata Cygańska
- Department of Finance, Economics and Finance Institute, The Faculty of Economics University o Warmia and Mazury in Olsztyn, 10-719 Olsztyn, Poland
| | | | - Chris Pyke
- Lancashire School of Business and Enterprise, University of Central Lancashire, Preston PR1 2HE, UK
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2
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Smithman MA, Haggerty J, Gaboury I, Breton M. Improved access to and continuity of primary care after attachment to a family physician: longitudinal cohort study on centralized waiting lists for unattached patients in Quebec, Canada. BMC PRIMARY CARE 2022; 23:238. [PMID: 36114464 PMCID: PMC9482231 DOI: 10.1186/s12875-022-01850-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 09/08/2022] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Having a regular family physician is associated with many benefits. Formal attachment – an administrative patient-family physician agreement – is a popular feature in primary care, intended to improve access to and continuity of care with a family physician. However, little evidence exists about its effectiveness. In Quebec, Canada, where over 20% of the population is unattached, centralized waiting lists help attach patients. This provides a unique opportunity to observe the influence of attachment in previously unattached patients. The aim was to evaluate changes in access to and continuity of primary care associated with attachment to a family physician through Quebec’s centralized waiting lists for unattached patients.
Methods
We conducted an observational longitudinal population cohort study, using medical services billing data from public health insurance in the province of Québec, Canada. We included patients attached through centralized waiting lists for unattached patients between 2012 and 2014 (n = 410,140). Our study was informed by Aday and Andersen’s framework for the study of access to health services. We compared outcomes during four 12-month periods: two periods before and two periods after attachment, with T0–2 years as the reference period. Outcome measures were number of primary care visits and Bice-Boxerman Concentration of Care Index at the physician and practice level (for patients with ≥2 visits in a given period). We included age, sex, region remoteness, medical vulnerability, and Charlson Comorbidity Index as covariates in regression models fitted with generalized estimating equations.
Results
The number of primary care visits increased by 103% in the first post attachment year and 29% in the second year (p < 0.001). The odds of having all primary care visits concentrated with a single physician increased by 53% in the first year and 22% (p < 0.001) in the second year after attachment. At the practice level, the odds of perfect concentration of care increased by 19% (p < 0.001) and 15% (p < 0.001) respectively, in first and second year after attachment.
Conclusion
Our results show an increase in patients’ number of primary care visits and concentration of care at the family physician and practice level after attachment to a family physician. This suggests that attachment may help improve access to and continuity of primary care.
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Junek ML, Jones A, Heckman G, Demers C, Griffith LE, Costa AP. The predictive utility of functional status at discharge: a population-level cohort analysis. BMC Geriatr 2022; 22:8. [PMID: 34979946 PMCID: PMC8722185 DOI: 10.1186/s12877-021-02652-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 11/23/2021] [Indexed: 11/18/2022] Open
Abstract
Background Functional status is a patient-important, patient-centered measurement. The utility of functional status measures to inform post-discharge patient needs is unknown. We sought to examine the utility of routinely collected functional status measures gathered from older hospitalized patients to predict a panel of post-discharge outcomes. Methods In this population-based retrospective cohort study, Adults 65+ discharged from an acute hospitalization between 4 November 2008 and 18 March 2016 in Ontario, Canada and received an assessment of functional status at discharge using the Health Outcomes for Better Information and Care tool were included. Multivariable regression analysis was used to determine the relationship between functional status and emergency department (ED) re-presentation, hospital readmission, long term care facility (LTCF) admission or wait listing (‘LTCF readiness’), and death at 180 days from discharge. Results A total of 80 020 discharges were included. 38 928 (48.6%) re-presented to the ED, 24 222 (30.3%) were re-admitted, 5 037 (6.3%) were LTCF ready, and 9 047 (11.3%) died at 180 days. Beyond age, diminished functional status at discharge was the factor most associated with LTCF readiness (adjusted Odds Ratio [OR] 4.11 for those who are completely dependent for activities of daily living compared to those who are independent; 95% Confidence Interval [CI]: 3.70-4.57) and death (OR 3.99; 95% CI: 3.67-4.35). Functional status also had a graded relationship with each outcome and improved the discriminability of the models predicting death and LTCF readiness (p<0.01) but not ED re-presentation or hospital re-admission. Conclusion Routinely collected functional status at discharge meaningfully improves the prediction of long term care home readiness and death. The routine assessment of functional status can inform post-discharge care and planning for older adults. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02652-6.
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Affiliation(s)
- Mats L Junek
- Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada. .,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
| | - Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - George Heckman
- Schlegel Research Institute on Aging, Waterloo, Ontario, Canada.,University of Waterloo, School of Public Health and Health Systems, Waterloo, Ontario, Canada
| | - Catherine Demers
- Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Lauren E Griffith
- Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada.,McMaster Institute for Research on Aging, Hamilton, Ontario, Canada
| | - Andrew P Costa
- Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Schlegel Research Institute on Aging, Waterloo, Ontario, Canada.,McMaster Institute for Research on Aging, Hamilton, Ontario, Canada
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Pérez-Zepeda MU, Carrillo-Vega MF, Theou O, Jácome-Maldonado LD, García-Peña C. Hospital Complications and Frailty in Mexican Older Adults: An Emergency Care Cohort Analysis. Front Med (Lausanne) 2020; 7:505. [PMID: 33134303 PMCID: PMC7550456 DOI: 10.3389/fmed.2020.00505] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 07/22/2020] [Indexed: 11/30/2022] Open
Abstract
Objectives: To describe the association of frailty level on admittance to the Emergency Department (ED) with various hospital complications including delirium, low phase angle, and low handgrip strength. Design: Prospective cohort. Setting: ED rooms of two public general hospitals in Mexico City. Participants: A total of 548 persons 60 years or older who were admitted to the ED and who were alive during follow-up testing at home were included. Measurements: A 32-item frailty index (FI) was measured on admission to the ED. Outcome measures included delirium, phase angle, and hand grip strength measured during different stages of the hospitalization (i.e., from admission to the ED through to follow-up at home). Results: From this final sample, mean age was 76 years (± SD 7.2) and 58.4% (n = 320) were women. Mean waiting time in the ED was 5.1 h (± SD 6.2), the average stay in the ED was 99.9 (±68.2) h, and 274 subjects (50%) were admitted to a general ward after ED admission. FI was not associated with phase angle and was negatively associated with handgrip strength at admission to ED (β = −3.97, confidence interval [CI] 95% −5.56 −2.38, p < 0.001), discharge from ED (β = −3.94, CI 95% −5.97 −1.90, p < 0.001), and discharge from hospital (β = −4.93, CI 95% −7.68 −2.18, p = 0.01). FI was positively associated with delirium (β = 3.68, CI 95% 1.53–5.83, p < 0.01). Conclusion: Higher frailty at ED admission was associated with lower hand grip strength and delirium during hospitalization in Mexican older adults.
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Affiliation(s)
- Mario Ulises Pérez-Zepeda
- Dirección de Investigación, Instituto Nacional de Geriatría, México City, México.,Department of Medicine, Dalhousie University, Halifax, NS, Canada.,Centro de Investigación en Ciencias de la Salud (CICSA), FCS, Universidad Anáhuac México Campus Norte, Huixquilucan de Degollado, Mexico
| | | | - Olga Theou
- Department of Medicine, Dalhousie University, Halifax, NS, Canada.,School of Physiotherapy, Dalhousie University, Halifax, NS, Canada
| | | | - Carmen García-Peña
- Dirección de Investigación, Instituto Nacional de Geriatría, México City, México
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Tavenier J, Rasmussen LJH, Houlind MB, Andersen AL, Panum I, Andersen O, Petersen J, Langkilde A, Nehlin JO. Alterations of monocyte NF-κB p65/RelA signaling in a cohort of older medical patients, age-matched controls, and healthy young adults. Immun Ageing 2020; 17:25. [PMID: 33685482 PMCID: PMC7938715 DOI: 10.1186/s12979-020-00197-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 08/12/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Altered monocyte NF-κB signaling is a possible cause of inflammaging and driver of aging, however, evidence from human aging studies is sparse. We assessed monocyte NF-κB signaling across different aging trajectories by comparing healthy older adults to older adults with a recent emergency department (ED) admission and to young adults. METHODS We used data from: 52 older (≥65 years) Patients collected upon ED admission and at follow-up 30-days after discharge; 52 age- and sex-matched Older Controls without recent hospitalization; and 60 healthy Young Controls (20-35 years). Using flow cytometry, we assessed basal NF-κB phosphorylation (pNF-κB p65/RelA; Ser529) and induction of pNF-κB following stimulation with LPS or TNF-α in monocytes. We assessed frailty (FI-OutRef), physical and cognitive function, and plasma levels of IL-6, IL-18, TNF-α, and soluble urokinase plasminogen activator receptor. RESULTS Patients at follow-up were frailer, had higher levels of inflammatory markers and decreased physical and cognitive function than Older Controls. Patients at follow-up had higher basal pNF-κB levels than Older Controls (median fluorescence intensity (MFI): 125, IQR: 105-153 vs. MFI: 80, IQR: 71-90, p < 0.0001), and reduced pNF-κB induction in response to LPS (mean pNF-κB MFI fold change calculated as the log10 ratio of LPS-stimulation to the PBS-control: 0.10, 95% CI: 0.08 to 0.12 vs. 0.13, 95% CI: 0.10 to 0.15, p = 0.05) and TNF-α stimulation (0.02, 95% CI: - 0.00 to 0.05 vs. 0.10, 95% CI: 0.08 to 0.12, p < 0.0001). Older Controls had higher levels of inflammatory markers than Young Controls, but basal pNF-κB MFI did not differ between Older and Young Controls (MFI: 81, IQR: 70-86; p = 0.72). Older Controls had reduced pNF-κB induction in response to LPS and TNF-α compared to Young Controls (LPS: 0.40, 95% CI: 0.35 to 0.44, p < 0.0001; and TNF-α: 0.33, 95% CI: 0.27 to 0.40, p < 0.0001). In Older Controls, basal pNF-κB MFI was associated with FI-OutRef (p = 0.02). CONCLUSIONS Increased basal pNF-κB activity in monocytes could be involved in the processes of frailty and accelerated aging. Furthermore, we show that monocyte NF-κB activation upon stimulation was impaired in frail older adults, which could result in reduced immune responses and vaccine effectiveness.
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Affiliation(s)
- Juliette Tavenier
- Department of Clinical Research, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark.
| | - Line Jee Hartmann Rasmussen
- Department of Clinical Research, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark
- Department of Psychology and Neuroscience, Duke University, Durham, NC, 27708, USA
| | - Morten Baltzer Houlind
- Department of Clinical Research, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark
- The Capital Region Pharmacy, 2730, Herlev, Denmark
- Department of Drug Design and Pharmacology, University of Copenhagen, 2100, Copenhagen, Denmark
| | - Aino Leegaard Andersen
- Department of Clinical Research, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark
| | - Inge Panum
- Department of Clinical Microbiology, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark
| | - Ove Andersen
- Department of Clinical Research, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark.
- Emergency Department, Copenhagen University Hospital Amager and Hvidovre, 2650, Hvidovre, Denmark.
- Department of Clinical Medicine, University of Copenhagen, 2200, Copenhagen, Denmark.
| | - Janne Petersen
- Department of Clinical Research, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark
- Center for Clinical Research and Prevention, Copenhagen University Hospital, 2000, Frederiksberg, Denmark
- Section of Biostatistics, Department of Public Health, University of Copenhagen, 1014, Copenhagen, Denmark
| | - Anne Langkilde
- Department of Clinical Research, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark
| | - Jan O Nehlin
- Department of Clinical Research, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark
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6
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Haraldseide LM, Sortland LS, Hunskaar S, Morken T. Contact characteristics and factors associated with the degree of urgency among older people in emergency primary health care: a cross-sectional study. BMC Health Serv Res 2020; 20:345. [PMID: 32321500 PMCID: PMC7178956 DOI: 10.1186/s12913-020-05219-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 04/13/2020] [Indexed: 01/06/2024] Open
Abstract
Background As the proportion of older people increases, so will the consumption of health services. The aim of this study was to describe the contact characteristics among older people and to identify factors associated with the degree of urgency at the Norwegian out-of-hours (OOH) emergency primary health care services. Methods Inhabitants aged ≥70 years who contacted the OOH service during 2014–2017 in seven OOH districts in Norway were included. We investigated the variables sex, age, time of contact, mode of contact, ICPC-2 based reason for encounter (RFE), priority degree and initial response. We also performed frequency analyses, rate calculations and a log-binomial regression. Results A total of 38,293 contacts were registered. The contact rate/1000 inhabitants/year was three times higher in the oldest age group (≥90 years) compared to the youngest age group (70–74 years). Direct attendance accounted for 8.4% of the contacts and 32.8% were telephone contacts from health professionals. The most frequent RFE chapter used was “A General and unspecified” (21.0%) which also showed an increasing rate with higher age. 6.0% of the contacts resulted in a home visit from a doctor. Variables significantly associated with urgent priority degree were RFEs regarding cardiovascular (Relative risk (RR) 1.85; CI 1.74–1.96), neurological (RR 1.55; CI 1.36–1.77), respiratory (RR 1.40; CI 1.30–1.51) and digestive (RR 1.22; CI 1.10–1.34) issues. In addition, telephone calls from health professionals (RR 1.21; CI 1.12–1.31), direct attendance (RR 1.13; CI 1.04–1.22), contacts on weekdays (RR 1.13; CI 1.06–1.20) and contacts from men (RR 1.13; CI 1.09–1.17) were significantly associated with urgent priority degree. Conclusions This study provides important information about the Norwegian older inhabitants’ contact with the OOH emergency primary health care services. There are a wide variety of RFEs, and the contact rate is high and increases with higher age. Telephone contact is most common. The OOH staff frequently identify older people as having “general and unspecified” reasons for encounters. OOH nursing staff would benefit from having screening tools and enhanced geriatric training to best support this vulnerable group when these individuals call the OOH service.
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Affiliation(s)
- Lisa Marie Haraldseide
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Kalfarveien 31, NO-5018, Bergen, Norway.
| | - Linn Solveig Sortland
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Kalfarveien 31, NO-5018, Bergen, Norway
| | - Steinar Hunskaar
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Kalfarveien 31, NO-5018, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Tone Morken
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Kalfarveien 31, NO-5018, Bergen, Norway
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Hamilton T, Johnson L, Quinn BT, Coppola J, Sachs D, Migliaccio J, Phipps C, Schwartz J, Capasso M, Carpenter M, Putrino D. Telehealth Intervention Programs for Seniors: An Observational Study of a Community-Embedded Health Monitoring Initiative. Telemed J E Health 2020; 26:438-445. [DOI: 10.1089/tmj.2018.0248] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Taya Hamilton
- Department of Telemedicine and Virtual Rehabilitation, Burke Medical Research Institute, White Plains, New York
| | - Liam Johnson
- Stroke Department, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia
| | - Brian T Quinn
- Department of Telemedicine and Virtual Rehabilitation, Burke Medical Research Institute, White Plains, New York
| | - Jean Coppola
- Westchester Public/Private Partnership for Aging Services, White Plains, New York
- Seidenberg School of Computer Science and Information Systems, Pace University, Pleasantville, New York
| | - David Sachs
- Westchester Public/Private Partnership for Aging Services, White Plains, New York
- Seidenberg School of Computer Science and Information Systems, Pace University, Pleasantville, New York
| | - John Migliaccio
- Westchester Public/Private Partnership for Aging Services, White Plains, New York
| | - Colette Phipps
- Westchester Public/Private Partnership for Aging Services, White Plains, New York
- Department of Senior Program and Services, The Westchester County Department of Senior Programs and Services, White Plains, New York
| | - Jennifer Schwartz
- Westchester Public/Private Partnership for Aging Services, White Plains, New York
- Department of Senior Program and Services, The Westchester County Department of Senior Programs and Services, White Plains, New York
| | - Marikay Capasso
- Westchester Public/Private Partnership for Aging Services, White Plains, New York
- Department of Senior Program and Services, The Westchester County Department of Senior Programs and Services, White Plains, New York
| | - Mae Carpenter
- Westchester Public/Private Partnership for Aging Services, White Plains, New York
- Department of Senior Program and Services, The Westchester County Department of Senior Programs and Services, White Plains, New York
| | - David Putrino
- Department of Telemedicine and Virtual Rehabilitation, Burke Medical Research Institute, White Plains, New York
- Westchester Public/Private Partnership for Aging Services, White Plains, New York
- Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, Manhattan, New York
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Brandão D, Ribeiro O, Teixeira L, Paúl C. Perceived risk of institutionalization, hospitalization, and death in oldest old primary care patients. Arch Gerontol Geriatr 2019; 87:103974. [PMID: 31786410 DOI: 10.1016/j.archger.2019.103974] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 10/05/2019] [Accepted: 11/06/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVES This study aims to analyze the accuracy and predictive ability of the Risk Instrument for Screening in the Community (RISC) scored by general practitioners (GPs) in a sample of primary care patients aged 80+ with perceived mental health concerns. METHOD GPs ranked the perceived risk of the three adverse outcomes (hospitalization, institutionalization and death) at 1 year in a five Likert scale (RISC score), where 1 is the lowest risk and 5 is the highest. Follow up contacts were conducted after 1 year of assessment in order to collect data on the three outcomes. RESULTS The 1-year proportion of institutionalization, hospitalization and death were 12.1 %, 25.2 % and 19.0 % respectively. Based upon the sensitivity and specificity from the Receiver Operating Characteristic (ROC) curves, we found an optimal cut-off point of ≥4 for the RISC. The RISC had fair accuracy for 1-year risk of institutionalization (Area Under the ROC curve (AUC) = 0.75, 95% CI 0.43-0.68) and hospitalization (AUC = 0.65, 95% CI 0.52-0.78), but not for death (AUC = 0.55, 95% CI 0.43-0.68). CONCLUSIONS The RISC as a short global subjective assessment is to be considered a reliable tool for use by GPs. Our results showed that RISC seems to be a good instrument to triage very old people at risk for institutionalization but with poor accuracy at predicting hospitalization and limited predictive ability for death, suggesting further research and caution on this instrument's use.
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Affiliation(s)
- Daniela Brandão
- Center for Health Technology and Services Research (CINTESIS), Porto, Portugal; Faculty of Medicine, University of Porto (FMUP), Porto, Portugal.
| | - Oscar Ribeiro
- Center for Health Technology and Services Research (CINTESIS), Porto, Portugal; Department of Education and Psychology, University of Aveiro (DEP.UA), Aveiro, Portugal
| | - Laetitia Teixeira
- Center for Health Technology and Services Research (CINTESIS), Porto, Portugal; Institute of Biomedical Sciences Abel Salazar (ICBAS), University of Porto, Porto, Portugal; EPIUnit, Institute of Public Health, University of Porto, Porto, Portugal
| | - Constança Paúl
- Center for Health Technology and Services Research (CINTESIS), Porto, Portugal; Institute of Biomedical Sciences Abel Salazar (ICBAS), University of Porto, Porto, Portugal
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Kong D, Li M, Wong YLI, Wang J, Sun BC, Dong X. Correlates of Emergency Department Service Utilization Among U.S. Chinese Older Adults. J Immigr Minor Health 2019; 21:938-945. [PMID: 30302622 PMCID: PMC6639148 DOI: 10.1007/s10903-018-0828-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Older adults visit emergency departments (EDs) at a disproportionally higher rate than other age groups. Prior studies examining racial disparities in ED utilization focus on African Americans and Hispanics. There is a dearth of information on ED utilization patterns among older Asian Americans despite the evidence that ED expenditures in Asian Americans are comparable to that of Caucasians. To address this knowledge gap, we examined factors associated with ED service utilization in the largest Asian subgroup, U.S. Chinese older adults. Cross-sectional data from the Population Study of Chinese Elderly in Chicago (PINE) (N = 3,157) were used. Multivariate negative binomial regression analyses were conducted to examine significant factors associated with ED use. Higher education (rate ratio [RR] = 1.03, 95% confidence interval [CI] 1.00-1.05) and acculturation levels (RR = 1.02, CI 1.00-1.04), fewer people in the household (RR = 0.94, CI 0.88-0.99), health insurance coverage (RR = 1.34, CI 1.01-1.78), lower income (RR = 0.89, CI 0.80-0.99), poorer perceived health (RR = 0.67, CI 0.58-0.77), more functional limitations (RR = 1.09, CI 1.06-1.13) and depressive symptoms (RR = 1.04, CI 1.02-1.07), and a history of heart disease (RR = 2.28, CI 1.83-2.84), stroke (RR = 1.68, CI 1.20-2.35), cancer (RR = 1.86, CI 1.31-2.63), and hip fracture (RR = 1.42, CI 1.02-1.98) were associated with higher rates of ED visits. Our findings highlight several significant correlates of ED use in U.S. Chinese older adults. Culturally-appropriate interventions modifying these factors have the potential to decrease ED visits and improve care outcomes in this population.
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Affiliation(s)
- Dexia Kong
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, 112 Paterson Street, New Brunswick, NJ, 08901, USA.
| | - Mengting Li
- Rush University Medical Center, Chicago, IL, USA
| | - Yin-Ling Irene Wong
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, PA, USA
| | - Jinjiao Wang
- School of Nursing, University of Rochester Medical Center, Rochester, NY, USA
| | - Benjamin C Sun
- Center for Policy Research-Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Xinqi Dong
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, 112 Paterson Street, New Brunswick, NJ, 08901, USA
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10
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Pandey KR, Yang F, Cagney KA, Smieliauskas F, Meltzer DO, Ruhnke GW. The impact of marital status on health care utilization among Medicare beneficiaries. Medicine (Baltimore) 2019; 98:e14871. [PMID: 30896632 PMCID: PMC6709281 DOI: 10.1097/md.0000000000014871] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To explain prior literature showing that married Medicare beneficiaries achieve better health outcomes at half the per person cost of single beneficiaries, we examined different patterns of healthcare utilization as a potential driver.Using the Medicare Current Beneficiary Survey (MCBS) data, we sought to understand utilization patterns in married versus currently-not-married Medicare beneficiaries. We analyzed the relationship between marital status and healthcare utilization (classified based on setting of care utilization into outpatient, inpatient, and skilled nursing facility (SNF) use) using logistic regression modeling. We specified models to control for possible confounders based on the Andersen model of healthcare utilization.Based on 13,942 respondents in the MCBS dataset, 12,929 had complete data, thus forming the analytic sample, of whom 6473 (50.3%) were married. Of these, 58% (vs. 36% of those currently-not-married) were male, 45% (vs. 47%) were age >75, 24% (vs. 70%) had a household income below $25,000, 18% (vs. 14%) had excellent self-reported general health, and 56% (vs. 36%) had private insurance. Compared to unmarried respondents, married respondents had a trend toward higher odds of having a recent outpatient visit (unadjusted odds ratio (OR) 1.11, 95% confidence interval (CI) 1.04-1.19, adjusted odds ratio (AOR) 1.10, (CI) 0.99-1.22), and lower odds in the year prior to have had an inpatient stay (AOR 0.84, CI 0.72-0.99) or a SNF stay (AOR 0.55, CI 0.40-0.75).Based on MCBS data, odds of self-reported inpatient and SNF use were lower among married respondents, while unadjusted odds of outpatient use were higher, compared to currently-not-married beneficiaries.
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Affiliation(s)
- Kiran Raj Pandey
- The Center for Health and the Social Sciences, University of Chicago, IL
| | - Fan Yang
- Department of Biostatistics and Informatics, University of Colorado Denver, Aurora, CO
| | | | | | - David O. Meltzer
- The Center for Health and the Social Sciences, University of Chicago, IL
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Gregory W. Ruhnke
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL 60637, USA
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Factors for Self-Managing Care Following Older Adults’ Discharge from the Emergency Department: A Qualitative Study. Can J Aging 2018; 38:76-89. [DOI: 10.1017/s071498081800034x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
RÉSUMÉCette étude avait pour but d’identifier les facteurs qui influent sur la capacité des personnes âgées à prendre en charge leur santé après une consultation au service des urgences (SU). Les questionnaires de l’enquête (n = 380) ont été remplis en SU par des personnes âgées et leurs aidants et visaient à évaluer leur perception de la compréhension de l’information qui leur était fournie. Des entrevues (n = 51) ont été réalisées avec un sous-échantillon de participants au cours des quatre semaines suivant leur consultation au SU et ont examiné les facteurs ayant une incidence sur l’autogestion des problèmes de santé. La perception de la compréhension de l’information reçue en SU (« oui, certainement ») était meilleure lors de la consultation au SU (91 %) que lors du suivi (71 %), lorsque 20 % des participants ne comprenaient pas ou n’étaient pas certains qu’ils avaient compris ce qui leur avait été communiqué en SU. Les patients ont rapporté que l’autogestion de leurs problèmes de santé était influencée par: la communication avec le personnel du SU, la compréhension des attentes suivant le congé de l’hôpital, l’état de santé, la disponibilité des aidants et divers facteurs externes. De plus, les soignants ont aussi mentionné l’appui aux soignants et la résistance des patients aux recommandations. L’utilisation de stratégies adaptées aux aînés en SU (p. ex. recommandations écrites, confirmation de la compréhension des recommandations), particulièrement celles liées à l’identification des personnes à risque et de celles nécessitant davantage de soutiens transitoires ou un meilleur accès ou intégration aux ressources disponibles dans la communauté amélioreraient l’autogestion des problèmes de santé suivant les consultations en SU.
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Park S, Kim B, Kwon E. The Role of Senior Housing in Hospitalizations Among Vulnerable Older Adults With Multiple Chronic Conditions: A Longitudinal Perspective. THE GERONTOLOGIST 2018; 58:932-941. [PMID: 28575200 DOI: 10.1093/geront/gnx046] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Indexed: 11/14/2022] Open
Abstract
Background and Objectives This study focuses on vulnerable elders (i.e., those with moderate or low incomes who live alone) and examines to what extent a senior housing environment moderates the effects of multiple chronic conditions (MCCs) on hospitalization over time. Research Design and Methods Data came from six waves (2002-2012) of the Health Retirement Study (N = 1,401 individuals, 3,705 observations). Mixed-effect multinomial logistic regression modeling estimated the effects of senior housing on changes in hospitalization. Results Vulnerable elders with MCCs were more likely to be hospitalized at both moderate and heavy levels at baseline. Consistent with the environment docility hypothesis, findings show that older individuals with MCCs who live in a senior housing environment have fewer hospitalizations over time. Discussions and Implications As one of the first efforts to build empirical knowledge on health care use among vulnerable elders in senior housing, our findings underscore the importance of continued research into these environments as a possible alternative to existing models.
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Affiliation(s)
- Sojung Park
- George Warren Brown School of Social Work at Washington University in One Brookings Drive, Saint Louis, Missouri
| | - BoRin Kim
- University of New Hampshire, Durham, UK
| | - Eunsun Kwon
- Center for Social Science, Seoul National University, Gwanak-gu, South Korea
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Coe AB, Moczygemba LR, Ogbonna KC, Parsons PL, Slattum PW, Mazmanian PE. Predictors of Emergent Emergency Department Visits and Costs in Community-Dwelling Older Adults. Health Serv Insights 2018; 11:1178632918790256. [PMID: 30150874 PMCID: PMC6108010 DOI: 10.1177/1178632918790256] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 06/15/2018] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND The number of yearly emergency department (ED) visits by older adults in the United States has been increasing. PURPOSE The objectives were to (1) describe the demographics, health-related variables, and ED visit characteristics for community-dwelling older adults using an urban, safety-net ED; (2) examine the association between demographics, health-related variables, and ED visit characteristics with emergent vs nonemergent ED visits; and (3) examine the association between demographics, health-related variables, ED visit characteristics, and ED visit costs. METHODS A cross-sectional, retrospective analysis of administrative electronic medical record and billing information from 2010 to 2013 ED visits (n = 7805) for community-dwelling older adults (⩾65 years old) from an academic medical center in central Virginia was conducted. RESULTS Most of the ED visits were by women (62%), African Americans (75%), and approximately 50% of ED visits were nonemergent (n = 3871). Men had 1.2 times the odds of an emergent ED visit (95% confidence interval [CI]: 1.02-1.37). The ED visits by white patients had 1.3 times the odds of an emergent ED visit (95% CI: 1.09-1.57) and 14% higher costs (white race: 95% CI: 1.07-1.21) compared with African American patients. Emergent ED visits were 60% more likely to have higher costs than nonemergent visits (95% CI: 1.52-1.69). White race and arrival by ambulance were associated with both emergent ED visits and higher total ED visit costs in this sample of ED visits by community-dwelling older adults. CONCLUSIONS Strategies to maximize opportunities for care in the primary care setting are warranted to potentially reduce nonemergent ED utilization in community-dwelling older adults.
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Affiliation(s)
| | | | - Kelechi C Ogbonna
- Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA
| | - Pamela L Parsons
- Virginia Commonwealth University School of Nursing, Richmond, VA, USA
| | | | - Paul E Mazmanian
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
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García-Peña C, Pérez-Zepeda MU, Robles-Jiménez LV, Sánchez-García S, Ramírez-Aldana R, Tella-Vega P. Mortality and associated risk factors for older adults admitted to the emergency department: a hospital cohort. BMC Geriatr 2018; 18:144. [PMID: 29914394 PMCID: PMC6006959 DOI: 10.1186/s12877-018-0833-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 06/10/2018] [Indexed: 11/18/2022] Open
Abstract
Background Older emergency department patients are more vulnerable than younger patients, yet many risk factors that contribute to the mortality of older patients remain unclear and under investigation. This study endeavored to determine mortality and factors associated with mortality in patients over 60 years of age who were admitted to the emergency departments of two general hospitals in Mexico City. Methods This is a hospital cohort study involving adults over 60 years of age admitted to the emergency department and who are beneficiaries of the Mexican Institute of Social Security and residents of Mexico City. All causes of mortality from the time of emergency department admission until a follow-up home visit after discharge were measured. Included risk factors were: socio-demographic, health-care related, mental and physical variables, and in-hospital care-related. Survival functions were estimated using Kaplan-Meier curves. Hazard ratios (HR) were derived from Cox regression models in a multivariate analysis. Results From the 1406 older adults who participated in this study, 306 (21.8%) did not survive. Independent mortality risk factors found in the last Cox model were age (HR = 1.02, 95% CI, 1.005–1.04; p = 0.01), length of stay in the ED (HR = 1.003, 95% CI = 0.99, 1.04; p = 0.006), geriatric care trained residents model in Hospital A (protective factor) (HR = 0.66, 95% CI = 0.46, 0.96; p = 0.031), and the FRAIL scale (HR of 1.34 95% CI, 1.02–1.76; p = 0.033). Conclusions Risk factors for mortality in patients treated at Mexican emergency departments are length of stay and variables related to frailty status.
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Affiliation(s)
- Carmen García-Peña
- Dirección de Investigación, Instituto Nacional de Geriatría, Periférico Sur No. 2767, Mexico City, Mexico.
| | - Mario Ulises Pérez-Zepeda
- Dirección de Investigación, Instituto Nacional de Geriatría, Periférico Sur No. 2767, Mexico City, Mexico
| | | | - Sergio Sánchez-García
- Unidad de Investigación en Epidemiología y Servicios de Salud, Área Envejecimiento, Mexico City, Mexico
| | | | - Pamela Tella-Vega
- Dirección de Investigación, Instituto Nacional de Geriatría, Periférico Sur No. 2767, Mexico City, Mexico
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Pimouguet C, Rizzuto D, Lagergren M, Fratiglioni L, Xu W. Living alone and unplanned hospitalizations among older adults: a population-based longitudinal study. Eur J Public Health 2017; 27:251-256. [PMID: 28339511 DOI: 10.1093/eurpub/ckw150] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Clément Pimouguet
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Debora Rizzuto
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Marten Lagergren
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden.,Stockholm Gerontology Research Center, Stockholm, Sweden
| | - Laura Fratiglioni
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden.,Stockholm Gerontology Research Center, Stockholm, Sweden
| | - Weili Xu
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
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Alhussain K, Meraya AM, Sambamoorthi U. Serious Psychological Distress and Emergency Room Use among Adults with Multimorbidity in the United States. PSYCHIATRY JOURNAL 2017; 2017:8565186. [PMID: 29085831 PMCID: PMC5612322 DOI: 10.1155/2017/8565186] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 07/28/2017] [Accepted: 08/09/2017] [Indexed: 01/10/2023]
Abstract
OBJECTIVES (1) To examine the association between serious psychological distress (SPD) and emergency room (ER) use in the past 12 months among adults with multimorbidity in the United States (US) and (2) to investigate the association between SPD and the reasons for ER use. METHODS The current study used a cross-sectional design with retrospective data from the 2015 National Health Interview Survey. Logistic regression models were used to assess the association between SPD and ER use among adults with multimorbidity. Among ER users, adjusted logistic regression models were conducted to examine the association between SPD and the reasons for the ER use. RESULTS After controlling for other variables, adults with multimorbidity and SPD were more likely to use ER than those with multimorbidity and no SPD (AOR = 1.61, 95% CI = 1.26, 2.04). Among ER users, there were no significant associations between SPD and the reasons for ER use after controlling for other variables. CONCLUSION Adults with multimorbidity and SPD were more likely to use ER as compared to those with multimorbidity and no SPD. Among adults with multimorbidity, routine screening for SPD may be needed to reduce the ER use.
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Affiliation(s)
- Khalid Alhussain
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, P.O. Box 9510, Morgantown, WV 26505, USA
| | - Abdulkarim M. Meraya
- Clinical Pharmacy Department, Faculty of Pharmacy, Jazan University, Jizan 45142, Saudi Arabia
| | - Usha Sambamoorthi
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, P.O. Box 9510, Morgantown, WV 26505, USA
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Hass Z, DePalma G, Craig BA, Xu H, Sands LP. Unmet Need for Help With Activities of Daily Living Disabilities and Emergency Department Admissions Among Older Medicare Recipients. THE GERONTOLOGIST 2017; 57:206-210. [PMID: 26603181 PMCID: PMC5881665 DOI: 10.1093/geront/gnv142] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 09/10/2015] [Indexed: 11/14/2022] Open
Abstract
Purpose of the Study This study determined whether self-reports of unmet need for help with activities of daily living (ADL) disabilities are prognostic of emergency department (ED) utilization. Design and Methods This prospective cohort study of 2,194 community-living, ADL-disabled subjects combined 2004 National Long-Term Care Survey responses with linked Medicare data through 2005. A negative binomial count model was computed to assess the association between unmet ADL need and number of subsequent ED admissions while statistically adjusting for predisposing, enabling, and need characteristics associated with ED admissions among older adults. Results The adjusted annual incidence rate (IR) for ED admissions was 19% higher for unmet versus met need (IR = 1.19; 95% confidence interval [CI] = 1.00-1.40; p = .047). The IR for ED admissions for falls and injuries was higher for those with unmet ADL versus met ADL need (IR = 1.43; 95% CI = 1.10-1.86), and trended toward significance for ED admissions for skin breakdown (IR = 2.02; 95% CI = 0.97-2.88), but was not significant for ED admissions for dehydration (IR = 1.13; 95% CI= 0.79-1.63). Implications Unmet ADL need is prognostic of ED admissions, especially for falls and injuries. Future research is needed to determine whether resolution of unmet ADL need reduces ED utilization.
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Affiliation(s)
- Zach Hass
- Department of Statistics, Purdue University, West Lafayette, Indiana
| | - Glen DePalma
- Department of Statistics, Purdue University, West Lafayette, Indiana
| | - Bruce A Craig
- Department of Statistics, Purdue University, West Lafayette, Indiana
| | - Huiping Xu
- Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis
| | - Laura P Sands
- Department of Human Development, Virginia Tech, Blacksburg
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Improving the seniors' transition from hospital to the community: a case for intensive geriatric service workers. Int Psychogeriatr 2017; 29:149-163. [PMID: 27455883 DOI: 10.1017/s1041610216001058] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Limited continuity of care, poor communication between healthcare providers, and ineffective self-management are barriers to recovery as seniors transition back to the community following an Emergency Department (ED) visit or hospitalization. The intensive geriatric service worker (IGSW) role is a new service developed in southern Ontario, Canada to address gaps for seniors transitioning home from acute care to prevent rehospitalization and premature institutionalization through the provision of intensive support and follow-up to ensure adherence to care plans, facilitate communication with care providers, and promote self-management. This study describes the IGSW role and provides preliminary evidence of its impact on clients, caregivers and the broader health system. METHODS This mixed methods evaluation included a chart audit of all clients served, tracking of the achievement of goals for IGSW involvement, and interviews with clients and caregivers and other key informants. RESULTS During the study period, 632 clients were served. Rates of goal achievement ranged from 25%-87% and in cases where achieved, the extent of IGSW involvement mostly exceeded recommendations. IGSWs were credited with improving adherence with treatment recommendations, increasing awareness and use of community services, and improving self-management, which potentially reduced ED visits and hospitalizations and delayed institutionalization. CONCLUSIONS The IGSW role has the potential to improve supports for seniors and facilitate more appropriate use of health system resources, and represents a promising mechanism for improving the integration and coordination of care across health sectors.
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Walsh PG, Currier GW, Shah MN, Friedman B. Older Adults with Mental Disorders: What Factors Distinguish Those Who Present to Emergency Departments for Mental Health Reasons from Those Who Do Not? Am J Geriatr Psychiatry 2015; 23:1162-71. [PMID: 26238232 DOI: 10.1016/j.jagp.2015.05.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 05/17/2015] [Accepted: 05/21/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To identify among older adults with mental disorders factors associated with those who present to emergency departments (EDs) for mental health reasons versus those who do not. METHODS The authors conducted a secondary, cross-sectional analysis of the Medical Expenditure Panel Survey (MEPS), which comprises a representative sample of the U.S. civilian noninstitutionalized population. Of the MEPS participants ages 66 and older on December 31 of the survey years 2000-2005, the analysis sample (2,757) included the 177 persons with at least one mental health ED visit and the 2,580 persons with mental disorders without such a visit. The three categories of the Andersen behavioral model for healthcare services utilization-predisposing, enabling, and need factors-were used as the theoretical framework for the independent variables. RESULTS Logistic regression analysis indicated that four need factors (adjustment disorder [OR: 3.42], psychosis [OR: 2.68], fair perceived physical health status [OR: 2.24], and anxiety disorder [OR: 1.85]) and two predisposing characteristics (widowed and living alone [OR: 1.68] and female [OR: 1.56]) were significantly associated with older adults with mental disorders who present to an ED for mental health reasons. Good perceived mental health status (OR: 0.55) was protective against presenting to an ED. CONCLUSION EDs that serve populations with higher proportions of older persons that are women, widowed and living alone, with adjustment disorder, psychosis, anxiety disorders, or fair perceived physical health should expect to have a greater likelihood of older persons visiting the ED for mental health reasons.
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Affiliation(s)
- Patrick G Walsh
- Department of Psychiatry, University of Rochester, Rochester, NY; Department of Public Health Sciences, University of Rochester, Rochester, NY
| | - Glenn W Currier
- Department of Psychiatry, University of Rochester, Rochester, NY
| | - Manish N Shah
- Department of Public Health Sciences, University of Rochester, Rochester, NY; Department of Emergency Medicine, University of Rochester, Rochester, NY; Department of Medicine, University of Rochester, Rochester, NY
| | - Bruce Friedman
- Department of Psychiatry, University of Rochester, Rochester, NY; Department of Public Health Sciences, University of Rochester, Rochester, NY.
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He J, Hou XY, Toloo S, Patrick JR, Fitz Gerald G. Demand for hospital emergency departments: a conceptual understanding. World J Emerg Med 2014; 2:253-61. [PMID: 25215019 DOI: 10.5847/wjem.j.1920-8642.2011.04.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Accepted: 11/03/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Emergency departments (EDs) are critical to the management of acute illness and injury, and the provision of health system access. However, EDs have become increasingly congested due to increased demand, increased complexity of care and blocked access to ongoing care (access block). Congestion has clinical and organisational implications. This paper aims to describe the factors that appear to influence demand for ED services, and their interrelationships as the basis for further research into the role of private hospital EDs. DATA SOURCES Multiple databases (PubMed, ProQuest, Academic Search Elite and Science Direct) and relevant journals were searched using terms related to EDs and emergency health needs. Literature pertaining to emergency department utilisation worldwide was identified, and articles selected for further examination on the basis of their relevance and significance to ED demand. RESULTS Factors influencing ED demand can be categorized into those describing the health needs of the patients, those predisposing a patient to seeking help, and those relating to policy factors such as provision of services and insurance status. This paper describes the factors influencing ED presentations, and proposes a novel conceptual map of their interrelationship. CONCLUSION This review has explored the factors contributing to the growing demand for ED care, the influence these factors have on ED demand, and their interrelationships depicted in the conceptual model.
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Affiliation(s)
- Jun He
- School of Public Health, Queensland University of Technology, Queensland, Australia
| | - Xiang-Yu Hou
- School of Public Health, Queensland University of Technology, Queensland, Australia
| | - Sam Toloo
- School of Public Health, Queensland University of Technology, Queensland, Australia
| | - Jennifer R Patrick
- School of Public Health, Queensland University of Technology, Queensland, Australia
| | - Gerry Fitz Gerald
- School of Public Health, Queensland University of Technology, Queensland, Australia
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21
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Hunold KM, Richmond NL, Waller AE, Cutchin MP, Voss PR, Platts-Mills TF. Primary care availability and emergency department use by older adults: a population-based analysis. J Am Geriatr Soc 2014; 62:1699-706. [PMID: 25125087 DOI: 10.1111/jgs.12984] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To assess the relationship between the number of primary care providers (PCPs) in an area and emergency department (ED) visits by older adults. DESIGN Population-based cross-sectional observational study. SETTING Nonfederal EDs in North Carolina in 2010. PARTICIPANTS All older adults (n = 640,086) presenting to a nonfederal ED in North Carolina in 2010. MEASUREMENTS The primary outcome was the number of ED visits by older adults in each ZIP code per 100 adults aged 65 and older living in that ZIP code. A secondary outcome was the number of ED visits not resulting in hospital admission per 100 older adults. The primary predictor variable was the number of PCPs per 100 older residents for each ZIP code. Covariates included those representing healthcare need (Medicare hospitalizations, nursing home beds), predisposing factors for healthcare use (race, education, population density of older adults), and enabling factors (distance to the nearest ED). RESULTS In a multivariable regression model corrected for spatial clustering, ZIP code characteristics associated with ED visits included more hospitalizations by Medicare beneficiaries, more nursing home beds, and closer proximity to an ED. Number of PCPs per 100 older adult residents in each ZIP code was not associated with ED use, and the 95% confidence limit indicates at most a small effect of PCP availability on ED use. CONCLUSION These findings suggest that primary care availability has at most a limited effect on ED use by older adults in North Carolina.
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Salam-White L, Hirdes JP, Poss JW, Blums J. Predictors of emergency room visits or acute hospital admissions prior to death among hospice palliative care clients in Ontario: a retrospective cohort study. BMC Palliat Care 2014; 13:35. [PMID: 25053920 PMCID: PMC4106206 DOI: 10.1186/1472-684x-13-35] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Accepted: 07/03/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hospice palliative care (HPC) is a philosophy of care that aims to relieve suffering and improve the quality of life for clients with life-threatening illnesses or end of life issues. The goals of HPC are not only to ameliorate clients' symptoms but also to reduce unneeded or unwanted medical interventions such as emergency room visits or hospitalizations (ERVH). Hospitals are considered a setting ill-prepared for end of life issues; therefore, use of such acute care services has to be considered an indicator of poor quality end of life care. This study examines predictors of ERVH prior to death among HPC home care clients. METHODS A retrospective cohort study of a sample of 764 HPC home care clients who received services from a community care access centre (CCAC) in southern Ontario, Canada. All clients were assessed using the Resident Assessment Instrument for Palliative Care (interRAI PC) as part of normal clinical practice between April 2008 and July 2010. The Andersen-Newman framework for health service utilization was used as a conceptual model for the basis of this study. Logistic regression and Cox regression analyses were carried out to identify predictors of ERVH. RESULTS Half of the HPC clients had at least one or more ERVH (n = 399, 52.2%). Wish to die at home (OR = 0.54) and advanced care directives (OR = 0.39) were protective against ERVH. Unstable health (OR = 0.70) was also associated with reduced probability, while infections such as prior urinary tract infections (OR = 2.54) increased the likelihood of ERVH. Clients with increased use of formal services had reduced probability of ERVH (OR = 0.55). CONCLUSIONS Findings of this study suggest that predisposing characteristics are nearly as important as need variables in determining ERVH among HPC clients, which challenges the assumption that need variables are the most important determinants of ERVH. Ongoing assessment of HPC clients is essential in reducing ERVH, as reassessments at specified intervals will allow care and service plans to be adjusted with clients' changing health needs and end of life preferences.
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Affiliation(s)
- Lialoma Salam-White
- School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Ontario N2L 3G1, Canada ; Hamilton Niagara Haldimand Brant Community Care Access Centre (HNHB CCAC), 211 Prichard Road, Unit 1, Hamilton, Ontario L8J 0G5, Canada
| | - John P Hirdes
- School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Ontario N2L 3G1, Canada
| | - Jeffrey W Poss
- School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Ontario N2L 3G1, Canada ; Hamilton Niagara Haldimand Brant Community Care Access Centre (HNHB CCAC), 211 Prichard Road, Unit 1, Hamilton, Ontario L8J 0G5, Canada
| | - Jane Blums
- Hamilton Niagara Haldimand Brant Community Care Access Centre (HNHB CCAC), 211 Prichard Road, Unit 1, Hamilton, Ontario L8J 0G5, Canada
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Ng S, Morgan RO, Walder A, Biswas J, Bass DM, Judge KS, Snow AL, Wilson N, Kunik ME. Functional Decline Predicts Emergency Department Use in Veterans With Dementia. Am J Alzheimers Dis Other Demen 2014; 29:362-71. [PMID: 24413540 PMCID: PMC10852555 DOI: 10.1177/1533317513518655] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2024]
Abstract
BACKGROUND We examined emergency room (ER) utilization by persons with dementia (PWDs) using caregiver and patient characteristics as predictors. METHODS A secondary analysis of 296 veteran-caregiver dyads. Caregivers recorded PWD baseline characteristics and noted ER visits over the next year. Two sets of regression models analyzed categorical ER use and repeat ER use. RESULTS In the univariate analysis, categorical use of the ER was predicted by patients' functional status (P ≤ .008) and Veterans Affairs priority grouping (P ≤ .02). Repeat ER admissions were predicted by functional status (P ≤ .04), number of chronic conditions (P ≤ .01), and caregiver-reported relationship strain (P ≤ .04). In multivariate analysis, categorical ER use was predicted by functional status (P ≤ .02), priority grouping (P ≤ .03), and number of chronic conditions (P ≤ .06). CONCLUSIONS Functional status most strongly predicted ER use, highlighting the promise of home-based interventions to improve activities of daily living. Number of chronic conditions and caregiver-reported relationship strain are potential targets of intervention during discharge process.
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Affiliation(s)
- Stephanie Ng
- Baylor College of Medicine, Houston, TX, USA Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, USA
| | - Robert O Morgan
- Management, Policy and Community Health, The University of Texas School of Public Health, Houston, TX, USA
| | - Annette Walder
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, USA Baylor College of Medicine, Houston, TX, USA
| | - Jonmenjoy Biswas
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA Baylor College of Medicine, Houston, TX, USA
| | - David M Bass
- Margaret Blenkner Research Institute, Benjamin Rose Institute, Cleveland, OH, USA
| | - Katherine S Judge
- Department of Psychology, Cleveland State University, Cleveland, OH, USA
| | - A Lynn Snow
- Center for Mental Health and Aging, University of Alabama, Tuscaloosa Veterans Affairs Medical Center, Tuscaloosa, AL, USA
| | - Nancy Wilson
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, USA Baylor College of Medicine, Houston, TX, USA
| | - Mark E Kunik
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, USA Baylor College of Medicine, Houston, TX, USA Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA VA South Central Mental Illness Research, Education and Clinical Center, USA
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Terndrup TE, Ali S, Hulse S, Shaffer M, Lloyd T. Multimedia education increases elder knowledge of emergency department care. West J Emerg Med 2013; 14:132-6. [PMID: 23599848 PMCID: PMC3628460 DOI: 10.5811/westjem.2012.11.12224] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Revised: 09/17/2012] [Accepted: 11/21/2012] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Elders who utilize the emergency department (ED) may have little prospective knowledge of appropriate expectations during an ED encounter. Improving elder orientation to ED expectations is important for satisfaction and health education. The purpose of this study was to evaluate a multi-media education intervention as a method for informing independently living elders about ED care. The program delivered messages categorically as, the number of tests, providers, decisions and disposition decision making. METHODS Interventional trial of representative elders over 59 years of age comparing pre and post multimedia program exposure. A brief (0.3 hour) video that chronicled the key events after a hypothetical 911 call for chest pain was shown. The video used a clinical narrator, 15 ED health care providers, and 2 professional actors for the patient and spouse. Pre- and post-video tests results were obtained with audience response technology (ART) assessed learning using a 4 point Likert scale. RESULTS Valid data from 142 participants were analyzed pre to post rankings (Wilcoxon signed-rank tests). The following four learning objectives showed significant improvements: number of tests expected [median differences on a 4-point Likert scale with 95% confidence intervals: 0.50 (0.00, 1.00)]; number of providers expected 1.0 (1.00, 1.50); communications 1.0 (1.00, 1.50); and pre-hospital medical treatment 0.50 (0.00, 1.00). Elders (96%) judged the intervention as improving their ability to cope with an ED encounter. CONCLUSION A short video with graphic side-bar information is an effective educational strategy to improve elder understanding of expectations during a hypothetical ED encounter following calling 911.
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Affiliation(s)
- Thomas E Terndrup
- Penn State College of Medicine, Department of Emergency Medicine, Hershey, Pennsylvania
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Salanitro AH, Hovater M, Hearld KR, Roth DL, Sawyer P, Locher JL, Bodner E, Brown CJ, Allman RM, Ritchie CS. Symptom burden predicts hospitalization independent of comorbidity in community-dwelling older adults. J Am Geriatr Soc 2012; 60:1632-7. [PMID: 22985139 DOI: 10.1111/j.1532-5415.2012.04121.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine whether cumulative symptom burden predicts hospitalization or emergency department (ED) visits in a cohort of older adults. DESIGN Prospective, observational study with a baseline in-home assessment of symptom burden. SETTING Central Alabama. PARTICIPANTS Nine hundred eighty community-dwelling adults aged 65 and older (mean 75.3 ± 6.7) recruited from a random sample of Medicare beneficiaries stratified according to sex, race, and urban/rural residence. MEASUREMENTS Symptom burden score (range 0-10). One point was given for each symptom reported: shortness of breath, tiredness or fatigue, problems with balance or dizziness, leg weakness, poor appetite, pain, stiffness, constipation, anxiety, and loss of interest in activities. Dependent variables were hospitalizations and ED visits, assessed every 6 months during the 8.5-year follow-up period. Using Cox proportional hazards models, time from the baseline in-home assessment to the first hospitalization and first hospitalization or ED visit was determined. RESULTS During the 8.5-year follow-up period, 545 (55.6%) participants were hospitalized or had an ED visit. Participants with greater symptom burden had higher risk of hospitalization (hazard ratio (HR) = 1.09, 95% confidence interval (CI) = 1.05-1.14) and hospitalization or ED visit (HR = 1.10, 95% CI = 1.06-1.14) than those with lower scores. Participants living in rural areas had significantly lower risk of hospitalization (HR = 0.83, 95% CI = 0.69-0.99) and hospitalization or ED visit (HR = 0.80, 95% CI = 0.70-0.95) than individuals in urban areas, independent of symptom burden and comorbidity. CONCLUSION Greater symptom burden was associated with higher risk of hospitalization and ED visits in community-dwelling older adults. Healthcare providers treating older adults should consider symptom burden to be an additional risk factor for subsequent hospital utilization.
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Affiliation(s)
- Amanda H Salanitro
- Geriatric Research, Education and Clinical Center Veterans Affairs Tennessee Valley Healthcare, Nashville, Tennessee 37212, USA.
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Lehnert T, König HH. [Effects of multimorbidity on health care utilization and costs]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2012; 55:685-92. [PMID: 22526857 DOI: 10.1007/s00103-012-1475-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Multiple chronic conditions (multimorbidity) are common among elderly patients; however, little is known about the specific effects of multimorbidity on health care utilization and health care costs. This article reviews empirical studies from the international literature that investigated the relationship between multiple chronic conditions and health care utilization (e.g. ambulatory care, stationary care, pharmacotherapy) and/or health care costs in elderly general populations. Although synthesis of studies was complicated, especially because of ambiguous definitions and measurements of multimorbidity, almost all studies observed a positive association of multimorbidity and utilization and costs. Many studies found that utilization and costs significantly increased with each additional chronic condition. In light of these findings coupled with the fear that current care arrangements may be inappropriate for many multimorbid patients, important implications for research and policy are presented and discussed.
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Affiliation(s)
- T Lehnert
- Institut für Medizinische Soziologie, Sozialmedizin und Gesundheitsökonomie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
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Lehnert T, Heider D, Leicht H, Heinrich S, Corrieri S, Luppa M, Riedel-Heller S, König HH. Review: Health Care Utilization and Costs of Elderly Persons With Multiple Chronic Conditions. Med Care Res Rev 2011; 68:387-420. [PMID: 21813576 DOI: 10.1177/1077558711399580] [Citation(s) in RCA: 486] [Impact Index Per Article: 37.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
This systematic literature review identified and summarized 35 studies that investigated the relationship between multiple chronic conditions (MCCs) and health care utilization outcomes (i.e. physician use, hospital use, medication use) and health care cost outcomes (medication costs, out-of-pocket costs, total health care costs) for elderly general populations. Although synthesis of studies was complicated because of ambiguous definitions and measurements of MCCs, and because of the multitude of outcomes investigated, almost all studies observed a positive association of MCCs and use/costs, many of which found that use/costs significantly increased with each additional condition. Several studies indicate a curvilinear, near exponential relationship between MCCs and costs. The rising prevalence, substantial costs, and the fear that current care arrangements may be inappropriate for many patients with MCCs, bring about a multitude of implications for research and policy, of which the most important are presented and discussed.
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Affiliation(s)
- Thomas Lehnert
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Hanna Leicht
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sven Heinrich
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Fan L, Shah MN, Veazie PJ, Friedman B. Factors associated with emergency department use among the rural elderly. J Rural Health 2011; 27:39-49. [PMID: 21204971 DOI: 10.1111/j.1748-0361.2010.00313.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Lin Fan
- Department of Community and Preventive Medicine, University of Rochester, Rochester, New York 14642, USA
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Claver ML. Deciding to use the emergency room: a qualitative survey of older veterans. JOURNAL OF GERONTOLOGICAL SOCIAL WORK 2011; 54:292-308. [PMID: 21462060 DOI: 10.1080/01634372.2011.552938] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Increasing use in the past decade has created pressure for hospital emergency rooms (ERs). Healthcare provided through an ER is expensive and is not designed to meet the complex needs of an older, chronically-ill population. ER visits are presented as the outcome of a decision-making process. Thirty veterans who had visited the ER in the previous year were asked about their decisions to use the ER. Their responses reflected four distinct approaches to ER use, which are characterized by frequency (frequent/infrequent) and risk for social isolation (low/high). Appropriate interventions by social work personnel might reduce inappropriate use of the ER and enhance the care of this vulnerable population.
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Affiliation(s)
- Maria L Claver
- Gerontology Program, California State University, Long Beach, California, USA.
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Kaskie B, Obrizan M, Cook EA, Jones MP, Liu L, Bentler S, Wallace RB, Geweke JF, Wright KB, Chrischilles EA, Pavlik CE, Ohsfeldt RL, Rosenthal GE, Wolinsky FD. Defining emergency department episodes by severity and intensity: A 15-year study of Medicare beneficiaries. BMC Health Serv Res 2010; 10:173. [PMID: 20565949 PMCID: PMC2903585 DOI: 10.1186/1472-6963-10-173] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2009] [Accepted: 06/21/2010] [Indexed: 11/12/2022] Open
Abstract
Background Episodes of Emergency Department (ED) service use among older adults previously have not been constructed, or evaluated as multi-dimensional phenomena. In this study, we constructed episodes of ED service use among a cohort of older adults over a 15-year observation period, measured the episodes by severity and intensity, and compared these measures in predicting subsequent hospitalization. Methods We conducted a secondary analysis of the prospective cohort study entitled the Survey on Assets and Health Dynamics among the Oldest Old (AHEAD). Baseline (1993) data on 5,511 self-respondents ≥70 years old were linked to their Medicare claims for 1991-2005. Claims then were organized into episodes of ED care according to Medicare guidelines. The severity of ED episodes was measured with a modified-NYU algorithm using ICD9-CM diagnoses, and the intensity of the episodes was measured using CPT codes. Measures were evaluated against subsequent hospitalization to estimate comparative predictive validity. Results Over 15 years, three-fourths (4,171) of the 5,511 AHEAD participants had at least 1 ED episode, with a mean of 4.5 episodes. Cross-classification indicated the modified-NYU severity measure and the CPT-based intensity measure captured different aspects of ED episodes (kappa = 0.18). While both measures were significant independent predictors of hospital admission from ED episodes, the CPT measure had substantially higher predictive validity than the modified-NYU measure (AORs 5.70 vs. 3.31; p < .001). Conclusions We demonstrated an innovative approach for how claims data can be used to construct episodes of ED care among a sample of older adults. We also determined that the modified-NYU measure of severity and the CPT measure of intensity tap different aspects of ED episodes, and that both measures were predictive of subsequent hospitalization.
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Affiliation(s)
- Brian Kaskie
- Department of Health Management and Policy, College of Public Health, the University of Iowa, Iowa City, Iowa, USA.
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McCusker J, Verdon J, Veillette N, Berg K, Emond T, Belzile E. Standardized Screening and Assessment of Older Emergency Department Patients: A Survey of Implementation in Quebec. Can J Aging 2010; 26:49-57. [PMID: 17430804 DOI: 10.3138/g236-p856-815w-3863] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
ABSTRACTCost-effective methods have been developed to help busy emergency department (ED) staff cope with the growing number of older patients, including quick screening and assessment tools to identify those at high risk and note their specific needs. This survey, from a sample of key informants from all EDs (n=111) in the province of Quebec (participation rate of 88.2%), investigated the implementation of these tools and barriers to implementation. Questionnaires (administered either by telephone or by self-completion) included characteristics of the ED, characteristics of the respondent, use of tools, and method of implementation. Barriers to the implementation of these tools included lack of resources for screening and follow-up, misunderstandings of the difference between screening and assessment tools, and need for adaptation of the tools to the local context. Education of staff and pre-implementation adaptation and testing are needed for successful implementation.
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Affiliation(s)
- Jane McCusker
- Department of Clinical Epidemiology and Community Studies, St. Mary's Hospital Centre, Montreal, QC.
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Claver ML, Levy-Storms L. The revolving door: high ER use among older veterans. QUALITATIVE HEALTH RESEARCH 2010; 20:365-374. [PMID: 19826079 DOI: 10.1177/1049732309350682] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Why do some older veterans visit the emergency room (ER) frequently? This study expands an existing decision-making model that describes how ER users recognize symptoms of a health problem, decide to seek medical care for the health problem, and decide to visit the ER specifically for the medical care. The focus of this inquiry is the role of older veterans' social support networks in decisions to visit the ER. Data were collected through in-depth, semistructured, in-person interviews with 30 community-dwelling, high-functioning veterans aged 65 years and older who had visited the ER frequently (3 or more times) in the previous year. We found that the older veteran study participants, regardless of the availability of social support, preferred to make decisions independently, relied heavily on formal social support network members, and received various types of assistance to visit the ER from informal social support networks.
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Affiliation(s)
- Maria L Claver
- California State University-Long Beach, Long Beach, California 90840, USA.
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Chi MJ, Wu SC, Chan DC, Lee CC. Social determinants of emergency utilization associated with patterns of care. Health Policy 2009; 93:137-42. [PMID: 19665250 DOI: 10.1016/j.healthpol.2009.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2008] [Revised: 07/07/2009] [Accepted: 07/13/2009] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Mei-Ju Chi
- Department of Health Care Administration, Chang Jung Christian University, No. 396, Sec. 1, Changrong Rd., Tainan, Taiwan.
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Abstract
BACKGROUND Emergency department (ED) utilization by older patients has major implications for morbidity, mortality, and health costs, yet its behavioral determinants remain poorly understood. Powerfully tied to health in older adults, the "Big Five" personality traits of neuroticism, extroversion, openness to experience, agreeableness, and conscientiousness may predict ED use. OBJECTIVES Investigate the role of personality in prospective ED use among older patients. RESEARCH DESIGN Prospective cohort. SUBJECTS Adults aged 65 and older. MEASURES Participants completed the NEO Five Factor Inventory of personality at baseline, and interviewers administered the Cornell Services Index assessing ED use at baseline and 3 yearly follow-ups. RESULTS Controlling for income, education, gender, age, physician-assessed medical burden and physical functioning, and interviewer-assessed impairments in basic activities of daily living and physical self-maintenance, and depression, lower agreeableness and higher extroversion were each associated with increased odds of an ED visit over the follow-up period. A 1 sample deviation (SD) increase in extroversion (i.e., 50th versus 83rd population percentile) increased the odds of ED use by 51% (adjusted odds ratio [AOR] [95% CI] = 1.51 [1.03-2.21], z = 2.12, N = 923, p = 0.034). A 1-SD decrease in agreeableness (i.e., 50th versus 17th population percentile) increased odds of ED use by 54% (AOR [95% CI] = 1.54 [1.05-2.22], z = -2.25, N = 923, p = 0.034). CONCLUSION The greater assertiveness and social confidence signified by lower agreeableness and higher extroversion may help older adults overcome potential barriers to the ED. Overly introverted and agreeable older adults may require special encouragement to access the ED--particularly for time--sensitive conditions--to reduce morbidity and mortality.
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Parke B, McCusker J. Consensus-based policy recommendations for geriatric emergency care. Int J Health Care Qual Assur 2008; 21:385-95. [PMID: 18785465 DOI: 10.1108/09526860810880199] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this paper is to establish policy recommendations to address service and care delivery challenges facing hospital emergency departments (EDs) responding to the needs of increasing numbers of older adults. DESIGN/METHODOLOGY/APPROACH The consensus development process used an international expert interdisciplinary panel, convened at an international conference. Following a round table discussion and think-tank session, a nominal group method with constant comparative analysis and coding techniques was used to identify policy recommendations. Two rounds of electronic input followed the face-to-face meeting to reach consensus on priority ranking of the policy recommendations. Findings underwent an external review by four independent experts. FINDINGS A total of seven categories of policy recommendations were developed: education, integration and coordination of care, resources, ED physical environment, evidence-based practice, research and evaluation, and advocacy. RESEARCH LIMITATIONS/IMPLICATIONS The consensus development process did not include a systematic literature review on the topic. However, participants included experts in their disciplines. PRACTICAL IMPLICATIONS The recommendations may assist administrators, policy makers, clinicians, and researchers on future directions for improving emergency care and service delivery for older adults. ORIGINALITY/VALUE The paper describes the process and results of a consensus development activity for ED care and services of older adults.
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Hastings SN, George LK, Fillenbaum GG, Park RS, Burchett BM, Schmader KE. Does lack of social support lead to more ED visits for older adults? Am J Emerg Med 2008; 26:454-61. [DOI: 10.1016/j.ajem.2007.07.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2007] [Revised: 07/30/2007] [Accepted: 07/31/2007] [Indexed: 11/24/2022] Open
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McCusker J, Ionescu-Ittu R, Ciampi A, Vadeboncoeur A, Roberge D, Larouche D, Verdon J, Pineault R. Hospital Characteristics and Emergency Department Care of Older Patients Are Associated with Return Visits. Acad Emerg Med 2007. [DOI: 10.1111/j.1553-2712.2007.tb01802.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Affiliation(s)
- H. Asuman Kiyak
- Department of Oral & Maxillofacial Surgery; Department of Psychology; Institute on Aging at the University of Washington
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Emergency medicine management of the geriatric patient: an educational program for medical students. J Am Geriatr Soc 2005; 53:141-5. [PMID: 15667391 DOI: 10.1111/j.1532-5415.2005.53024.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This article describes the experience of fourth-year medical students participating in a geriatric education program integrated into a 4-week emergency medicine student clerkship. Between July 2002 and April 2003, all students in this required clerkship participated in a geriatric educational program consisting of a small group discussion of medical and psychosocial issues of older adult emergency department (ED) patients. Students used learned skills to evaluate older adult ED patients for medical and psychosocial issues and later followed up with these patients by telephoning them at their homes or visiting them in the hospital. Students tracked their evaluations of the medical problems, functional abilities, and social supports of patients in the ED. Students also noted when their assessments resulted in the acquisition of new skills or knowledge and when their evaluation of geriatric syndromes resulted in a change of the patient care plan. Seventy-seven students evaluated 217 patients in the ED, of whom 167 (77%) received a follow-up visit or phone call. Students documented learning new skills while caring for 80 (48%) of the older adult patients. Qualitative survey responses from students indicated that students had increased understanding of the importance of assessing functional status and social supports and providing interdisciplinary care. Integrating geriatric education modules into existing emergency medicine clerkships is an effective method to expand the geriatric curriculum in medical schools and to emphasize the importance of geriatric assessment and syndromes in emergency care.
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Abstract
Review of emergency department pain management practices demonstrates pain treatment inconsistency and inadequacy that extends across all demographic groups. This inconsistency and inadequacy appears to stem from a multitude of potentially remediable practical and attitudinal barriers that include (1) a lack of educational emphasis on pain management practices in nursing and medical school curricula and postgraduate training programs; (2) inadequate or nonexistent clinical quality management programs that evaluate pain management; (3) a paucity of rigorous studies of populations with special needs that improve pain management in the emergency department, particularly in geriatric and pediatric patients; (4) clinicians' attitudes toward opioid analgesics that result in inappropriate diagnosis of drug-seeking behavior and inappropriate concern about addiction, even in patients who have obvious acutely painful conditions and request pain relief; (5) inappropriate concerns about the safety of opioids compared with nonsteroidal anti-inflammatory drugs that result in their underuse (opiophobia); (6) unappreciated cultural and sex differences in pain reporting by patients and interpretation of pain reporting by providers; and (7) bias and disbelief of pain reporting according to racial and ethnic stereotyping. This article reviews the literature that describes the prevalence and roots of oligoanalgesia in emergency medicine. It also discusses the regulatory efforts to address the problem and their effect on attitudes within the legal community.
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Affiliation(s)
- Timothy Rupp
- Department of Surgery, Division of Emergency Medicine, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA.
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Thind A, Andersen R. Respiratory illness in the Dominican Republic: what are the predictors for health services utilization of young children? Soc Sci Med 2003; 56:1173-82. [PMID: 12600356 DOI: 10.1016/s0277-9536(02)00116-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Respiratory illness and diarrhoea continue to be the leading causes of paediatric morbidity and mortality in the Dominican Republic. An important first step in alleviating this disease burden is to understand patterns and predictors of health services utilization for these conditions. This study examines the predictors of (a) health services utilization, and (b) public versus private sector use, for respiratory illness in the under-five population in the Dominican Republic. The DHS-2 dataset (1991) was utilized for analysis. Logistic regression models for predicting use and non-use, and for predicting private versus public sector use, were constructed using the Andersen Behavioural Model as the conceptual framework. Our findings indicate that sex, location and possession index quartile are factors that influence the decision to seek care or not for respiratory illness in under-fives. In contrast, the choice between the public and private sector is determined by location and insurance status. From the policy perspective, if the Dominican Republic were to undertake steps to increase private insurance coverage, our results indicate that this would lead to increased utilization of private sector providers for respiratory illness by children having private insurance, but would not have an impact on overall utilization (i.e. use vs. non-use). On the other hand, one of the ways to deliver cost-effective interventions by the publicly financed system would be to improve facilities in the rural areas.
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Affiliation(s)
- Amardeep Thind
- Department of Health Services, UCLA School of Public Health, Room 31-299 CHS, Box 951772, Los Angeles, CA 90095-1772, USA.
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Mion LC, Palmer RM, Meldon SW, Bass DM, Singer ME, Payne SMC, Lewicki LJ, Drew BL, Connor JT, Campbell JW, Emerman C. Case finding and referral model for emergency department elders: a randomized clinical trial. Ann Emerg Med 2003; 41:57-68. [PMID: 12514683 DOI: 10.1067/mem.2003.3] [Citation(s) in RCA: 130] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE Elderly emergency department patients have complex medical needs and limited social support. A transitional model of care adapted from hospitals was tested for its effectiveness in the ED in reducing subsequent service use. METHODS A randomized clinical trial was conducted at 2 urban, academically affiliated hospitals. Participants were 650 community-residing individuals 65 years or older who were discharged home after an ED visit. Main outcomes were service use rates, defined as repeat ED visits, hospitalizations, or nursing home admissions, and health care costs at 30 and 120 days. Intervention consisted of comprehensive geriatric assessment in the ED by an advanced practice nurse and subsequent referral to a community or social agency, primary care provider, and/or geriatric clinic for unmet health, social, and medical needs. Control group participants received usual and customary ED care. RESULTS The intervention had no effect on overall service use rates at 30 or 120 days. However, the intervention was effective in lowering nursing home admissions at 30 days (0.7% versus 3%; odds ratio 0.21; 95% confidence interval [CI] 0.05 to 0.99) and in increasing patient satisfaction with ED discharge care (3.41 versus 3.03; mean difference 0.37; 95% CI 0.13 to 0.62). The intervention was more effective for high-risk than low-risk elders. CONCLUSION An ED-based transitional model of care reduced subsequent nursing home admissions but did not decrease overall service use for older ED patients. Further studies are needed to determine the best models of care for this setting and for at-risk patients.
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Affiliation(s)
- Lorraine C Mion
- Geriatric Nursing Program, Division of Nursing, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
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