Factors impacting hospital avoidance program utilisation in the care of acutely unwell residential aged care facility residents

Uncommon Sociodemographic Factors Are Associated With Racial Disparities in Length of Stay Following Oncologic Elective Colectomy

INTRODUCTION

Although outcome disparities by race have been identified in colorectal cancer, these patterns are challenging to explain using variables that are commonly available in databases. In a single institution serving a diverse community, length of stay (LOS) varies by race following elective oncologic colectomy. We investigated previously unexplored variables that may explain the relationship between race and LOS following elective resection of colorectal neoplasms.

METHODS

Retrospective, single institution cohort study from January 2015 to December 2020 for adult patients undergoing elective colorectal cancer resections. Baseline demographic variables and intraoperative factors were analyzed for changes in LOS following elective colorectal resection. Additional retrospective chart review was carried out to determine household member composition and distance from home to hospital. Bivariate analysis was conducted to determine which variables should be included in multivariable analyses. All analyses were conducted using SAS Academic.

RESULTS

Most patients (n = 383) were Asian (40%), Black (12%), or Hispanic (26%). Race and LOS were associated with age (P = 0.001 and P < 0.001 for race and LOS, respectively), American Society of Anesthesiologists class (P = 0.004 and P < 0.001), enhanced recovery after surgery protocols (P = 0.006 and P < 0.001), household members (P = 0.009 and P = 0.002), and discharge disposition (P = 0.049 and P < 0.001). In multivariable analysis, household members (P = 0.021) independently remained associated with LOS after controlling for race (P = 0.008) and discharge disposition (P < 0.001).

CONCLUSIONS

Household member composition varies with LOS, suggesting that level of support at home may influence decisions regarding discharge disposition, which lead to differences in LOS.

Acute Appendicitis in the Epicenter of the COVID-19 Pandemic: A New York City Single-Center Experience

BACKGROUND

Appendectomy is the gold standard for simple appendicitis. During the coronavirus-19 pandemic, it was estimated that appendectomies in the United States decreased by 24%. We aimed to describe trends in acute appendicitis management at a center located in one of the largest epicenters of the pandemic.

METHODS

This is a retrospective cohort study in a single institution located in Queens, New York, of patients who presented with acute appendicitis. A pre-COVID time period, March-June 2019, was compared to peak-COVID, March-June 2020, and late-COVID, March-June 2021.

RESULTS

Of the 382 patients admitted with appendicitis during the time periods, 164 were admitted pre-COVID. Appendicitis presentations decreased by 44% during peak-COVID and 23% in late-COVID. Patients were younger during peak-COVID compared to pre-COVID (39 vs 34 years old, P = .036). Incidence of complicated appendicitis in pre-, peak-, and late-COVID was equivalent (41% vs 46% vs 45%) and operative management was similar (85% vs 76% vs 79%). Non-operative patients had shorter lengths of stay (pre- vs peak-COVID: 4.6 vs 2.9 days, P = .006). Readmission rates were similar between the cohorts across time periods.

CONCLUSIONS

During peak-COVID, there was a significant decrease in presentation of acute appendicitis but clinical presentation and outcomes remained similar between the cohorts. Patients who were managed non-operatively may be discharged earlier without increased rates of readmissions.

Factors influencing the implementation of early discharge hospital at home and admission avoidance hospital at home: a qualitative evidence synthesis

BACKGROUND

Worldwide there is an increasing demand for Hospital at Home as an alternative to hospital admission. Although there is a growing evidence base on the effectiveness and cost-effectiveness of Hospital at Home, health service managers, health professionals and policy makers require evidence on how to implement and sustain these services on a wider scale.

OBJECTIVES

(1) To identify, appraise and synthesise qualitative research evidence on the factors that influence the implementation of Admission Avoidance Hospital at Home and Early Discharge Hospital at Home, from the perspective of multiple stakeholders, including policy makers, health service managers, health professionals, patients and patients' caregivers. (2) To explore how our synthesis findings relate to, and help to explain, the findings of the Cochrane intervention reviews of Admission Avoidance Hospital at Home and Early Discharge Hospital at Home services.

SEARCH METHODS

We searched MEDLINE, CINAHL, Global Index Medicus and Scopus until 17 November 2022. We also applied reference checking and citation searching to identify additional studies. We searched for studies in any language.

SELECTION CRITERIA

We included qualitative studies and mixed-methods studies with qualitative data collection and analysis methods examining the implementation of new or existing Hospital at Home services from the perspective of different stakeholders.

DATA COLLECTION AND ANALYSIS

Two authors independently selected the studies, extracted study characteristics and intervention components, assessed the methodological limitations using the Critical Appraisal Skills Checklist (CASP) and assessed the confidence in the findings using GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research). We applied thematic synthesis to synthesise the data across studies and identify factors that may influence the implementation of Hospital at Home.

MAIN RESULTS

From 7535 records identified from database searches and one identified from citation tracking, we included 52 qualitative studies exploring the implementation of Hospital at Home services (31 Early Discharge, 16 Admission Avoidance, 5 combined services), across 13 countries and from the perspectives of 662 service-level staff (clinicians, managers), eight systems-level staff (commissioners, insurers), 900 patients and 417 caregivers. Overall, we judged 40 studies as having minor methodological concerns and we judged 12 studies as having major concerns. Main concerns included data collection methods (e.g. not reporting a topic guide), data analysis methods (e.g. insufficient data to support findings) and not reporting ethical approval. Following synthesis, we identified 12 findings graded as high (n = 10) and moderate (n = 2) confidence and classified them into four themes: (1) development of stakeholder relationships and systems prior to implementation, (2) processes, resources and skills required for safe and effective implementation, (3) acceptability and caregiver impacts, and (4) sustainability of services.

AUTHORS' CONCLUSIONS

Implementing Admission Avoidance and Early Discharge Hospital at Home services requires early development of policies, stakeholder engagement, efficient admission processes, effective communication and a skilled workforce to safely and effectively implement person-centred Hospital at Home, achieve acceptance by staff who refer patients to these services and ensure sustainability. Future research should focus on lower-income country and rural settings, and the perspectives of systems-level stakeholders, and explore the potential negative impact on caregivers, especially for Admission Avoidance Hospital at Home, as this service may become increasingly utilised to manage rising visits to emergency departments.

Economic and cost considerations of delivering and using mobile X-ray services in residential aged care facilities: A qualitative study

OBJECTIVE

To describe the economic and cost considerations of mobile X-ray services (MXS) in residential aged care facilities (RACFs), according to stakeholders (involved in residents' healthcare), residents living in RACFs and informal carers (ICs) of residents.

METHODS

Semistructured interviews were conducted with 20 residents and 27 ICs recruited from six RACFs across metropolitan Adelaide (South Australia, Australia), and 22 stakeholders, on their perspectives of using MXS in RACFs. Data relating to economic and cost considerations were extracted and analysed using thematic analysis.

RESULTS

Residents' mean age was 85 years, 60% were women and 40% had experienced an MXS in the last 12 months. Most ICs were daughters (70%) and wives (11%) and 30% had a family member who had experienced an MXS in the last 12 months. Stakeholders included RACF staff, GPs, a hospital avoidance program clinician, paramedics, emergency department clinicians, MXS radiographers and manager, and a radiologist. Four themes were presented: (1) business considerations, where private providers found it necessary to charge residents a co-payment to deliver MXS; (2) cost and payment process as a potential barrier to using MXS, with varied willingness and ability to pay for an MXS co-payment, and equity concerns; (3) overcoming cost and payment barriers, with staff and consumers sometimes using strategies to overcome cost barriers; and (4) perceived cost benefits of MXS to the healthcare system, residents and ICs.

CONCLUSIONS

Mobile X-ray services providers charge residents an upfront co-payment for business viability, which can be a barrier to some residents wishing to access MXS.

A Model to Compare International Hospital Bed Numbers, including a Case Study on the Role of Indigenous People on Acute 'Occupied' Bed Demand in Australian States

Comparing international or regional hospital bed numbers is not an easy matter, and a pragmatic method has been proposed that plots the number of beds per 1000 deaths versus the log of deaths per 1000 population. This method relies on the fact that 55% of a person's lifetime hospital bed utilization occurs in the last year of life-irrespective of the age at death. This is called the nearness to death effect. The slope and intercept of the logarithmic relationship between the two are highly correlated. This study demonstrates how lines of equivalent bed provision can be constructed based on the value of the intercept. Sweden looks to be the most bed-efficient country due to long-term investment in integrated care. The potential limitations of the method are illustrated using data from English Clinical Commissioning Groups. The main limitation is that maternity, paediatric, and mental health care do not conform to the nearness to death effect, and hence, the method mainly applies to adult acute care, especially medical and critical care bed numbers. It is also suggested that sensible comparison can only be made by comparing levels of occupied beds rather than available beds. Occupied beds measure the expressed bed demand (although often constrained by access to care issues), while available beds measure supply. The issue of bed supply is made complex by the role of hospital size on the average occupancy margin. Smaller hospitals are forced to operate at a lower average occupancy; hence, countries with many smaller hospitals such as Germany and the USA appear to have very high numbers of available beds. The so-called 85% occupancy rule is an "urban myth" and has no fundamental basis whatsoever. The very high number of "hospital" beds in Japan is simply an artefact arising from "nursing home" beds being counted as a "hospital" bed in this country. Finally, the new method is applied to the expressed demand for occupied acute beds in Australian states. Using data specific to acute care, i.e., excluding mental health and maternity, a long-standing deficit of beds was identified in Tasmania, while an unusually high level of occupied beds in the Northern Territory (NT) was revealed. The high level of demand for beds in the NT appears due to an exceptionally large population of indigenous people in this state, who are recognized to have elevated health care needs relative to non-indigenous Australians. In this respect, indigenous Australians use 3.5 times more occupied bed days per 1000 deaths (1509 versus 429 beds per 1000 deaths) and 6 times more occupied bed days per 1000 population (90 versus 15 beds per 1000 population) than their non-indigenous counterparts. The figure of 1509 beds per 1000 deaths (or 4.13 occupied beds per 1000 deaths) for indigenous Australians is indicative of a high level of "acute" nursing care in the last months of life, probably because nursing home care is not readily available due to remoteness. A lack of acute beds in the NT then results in an extremely high average bed occupancy rate with contingent efficiency and delayed access implications.

Residents' perspectives of mobile X-ray services in support of healthcare-in-place in residential aged care facilities: a qualitative study

Background

Mobile X-ray services (MXS) could be used to investigate clinical issues in aged care residents within familiar surroundings, reducing transfers to and from emergency departments and enabling healthcare to be delivered in residential aged care facilities. There is however little research exploring consumer perspectives about such services. The objective of this research was to explore the perspectives and preferences of residents about the provision of MXS in residential aged care facilities, including their knowledge about the service, perceived benefits, and factors that require consideration for effective implementation.

Methods

A qualitative study design was used. The setting for the study included four residential aged care facilities of different sizes from different parts of a South Australian city. Purposive sampling was used to recruit participants. 16 residents participated in semi-structured interviews that were audio-recorded and transcribed verbatim. Data were inductively derived using thematic analysis.

Results

Participants had a mean age of 85 years, 56% were female, 25% had dementia and 25% had had a mobile X-ray in the last 12 months. Four themes were developed. Participants preferred mobile X-rays, provided as healthcare-in-place, to improve accessibility to them and minimize physical and psychological discomfort. Participants had expectations about the processes for receiving mobile X-rays. Costs of X-rays to people, family and society were a consideration. Decision making required residents be informed about mobile X-rays.

Conclusions

Residents have positive views of MXS as they can receive healthcare-in-place, with familiar people and surroundings. They emphasised that MXS delivered in residential aged care facilities need to be of equivalent quality to those found in other settings. Increased awareness of mobile X-ray services is required.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03212-2.