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Liu S. Analysis of the factors influencing the effectiveness of local government's purchase of older adults care services - a grounded theory study based on typical cases. Front Public Health 2023; 11:1202472. [PMID: 37637803 PMCID: PMC10449363 DOI: 10.3389/fpubh.2023.1202472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 07/26/2023] [Indexed: 08/29/2023] Open
Abstract
Background Population aging is a basic national condition in China at present and for a long time to come, forcing the country to accelerate the pace of building its public older adults care system. The government's purchase of older adults care services has become an effective way to make up for the lack of the family's older adults care function, to which the Chinese government attaches particular importance. The article selects 11 typical cases from the excellent case base released by the Chinese Ministry of Civil Affairs officials in 2022 to study the influencing factors of the effect of local government purchase of older adults care service supply. Methods NVivo data analysis tools have significant advantages in retrieving, analyzing and coding data more efficiently and accurately, which helps to construct theoretical propositions and formulate hypotheses to be tested in qualitative research. The study intends to adopt the grounded theory approach to analyze the text with the help of NVivo12 software, to condense the practice mechanism of local governments' purchasing of older adults care services and to construct a relational model. Results Taking "the supply effect of local government purchasing older adults services" as the main logic line, the article summarizes the four main influencing factors of the supply effect of government purchasing older adults services: the real demand of the society, the government's power and responsibility system, the government's governance ability, and the society's acceptance ability. Conclusion The sense of gain, happiness and security of the older adults group is the starting point and landing point of the older adults service policy formulation and implementation. Policy guidance and decision-making have an important impact on the quality of the supply of older adults care services and the development of the older adults care services industry. Clarifying the direction of policy guidance, reflecting the comprehensive efficiency of government governance and utilizing the professional advantages of social forces, is the key to improving the effectiveness of the government's purchase of older adults care services.
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Affiliation(s)
- Sujun Liu
- School of Political Science and Public Administration, China University of Political Science and Law, Beijing, China
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Aranda MP, Kremer IN, Hinton L, Zissimopoulos J, Whitmer RA, Hummel CH, Trejo L, Fabius C. Impact of dementia: Health disparities, population trends, care interventions, and economic costs. J Am Geriatr Soc 2021; 69:1774-1783. [PMID: 34245588 PMCID: PMC8608182 DOI: 10.1111/jgs.17345] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/07/2021] [Accepted: 05/16/2021] [Indexed: 01/14/2023]
Abstract
INTRODUCTION The dementia experience is not a monolithic phenomenon-and while core elements of dementia are considered universal-people living with dementia experience the disorder differently. Understanding the patterning of Alzheimer's disease and related dementias (ADRD) in the population with regards to incidence, risk factors, impacts on dementia care, and economic costs associated with ADRD can provide clues to target risk and protective factors for all populations as well as addressing health disparities. METHODS We discuss information presented at the 2020 National Research Summit on Care, Services, and Supports for Persons with Dementia and Their Caregivers, Theme 1: Impact of Dementia. In this article, we describe select population trends, care interventions, and economic impacts, health disparities and implications for future research from the perspective of our diverse panel comprised of academic stakeholders, and persons living with dementia, and care partners. RESULTS Dementia incidence is decreasing yet the advances in population health are uneven. Studies examining the educational, geographic and race/ethnic distribution of ADRD have identified clear disparities. Disparities in health and healthcare may be amplified by significant gaps in the evidence base for pharmacological and non-pharmacological interventions. The economic costs for persons living with dementia and the value of family care partners' time are high, and may persist into future generations. CONCLUSIONS Significant research gaps remain. Ensuring that ADRD healthcare services and long-term care services and supports are accessible, affordable, and effective for all segments of our population is essential for health equity. Policy-level interventions are in short supply to redress broad unmet needs and systemic sources of disparities. Whole of society challenges demand research producing whole of society solutions. The urgency, complexity, and scale merit a "whole of government" approach involving collaboration across numerous federal agencies.
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Affiliation(s)
| | - Ian N. Kremer
- LEAD Coalition (Leaders Engaged on Alzheimer’s Disease)
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Hwang U, Dresden SM, Vargas-Torres C, Kang R, Garrido MM, Loo G, Sze J, Cruz D, Richardson LD, Adams J, Aldeen A, Baumlin KM, Courtney DM, Gravenor S, Grudzen CR, Nimo G, Zhu CW. Association of a Geriatric Emergency Department Innovation Program With Cost Outcomes Among Medicare Beneficiaries. JAMA Netw Open 2021; 4:e2037334. [PMID: 33646311 PMCID: PMC7921898 DOI: 10.1001/jamanetworkopen.2020.37334] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
IMPORTANCE There has been a significant increase in the implementation and dissemination of geriatric emergency department (GED) programs. Understanding the costs associated with patient care would yield insight into the direct financial value for patients, hospitals, health systems, and payers. OBJECTIVE To evaluate the association of GED programs with Medicare costs per beneficiary. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included data on Medicare fee-for-service beneficiaries at 2 hospitals implementing Geriatric Emergency Department Innovations in Care Through Workforce, Informatics, and Structural Enhancement (GEDI WISE) (Mount Sinai Medical Center [MSMC] and Northwestern Memorial Hospital [NMH]) from January 1, 2013, to November 30, 2016. Analyses were conducted and refined from August 28, 2018, to November 20, 2020, using entropy balance to account for observed differences between the treatment and comparison groups. INTERVENTIONS Treatment included consultation with a transitional care nurse (TCN) or a social worker (SW) trained for the GEDI WISE program at a beneficiary's first ED visit (index ED visit). The comparison group included beneficiaries who were never seen by either a TCN or an SW during the study period. MAIN OUTCOMES AND MEASURES The main outcome evaluated was prorated total Medicare payer expenditures per beneficiary over 30 and 60 days after the index ED visit encounter. RESULTS Of the total 24 839 unique Medicare beneficiaries, 4041 were seen across the 2 EDs; 1947 (17.4%) at MSMC and 2094 (15.4%) at the NMH received treatment from either a GED TCN and/or a GED SW. The mean (SD) age of beneficiaries at MSMC was 78.8 (8.5) years and at NMH was 76.4 (7.7) years. Most patients at both hospitals were female (6821 [60.8%] at MSMC and 8023 [58.9%] at NMH) and White (7729 [68.9%] at MSMC and 9984 [73.3%] at NMH). Treatment was associated with statistically significant mean savings per beneficiary of $2436 (95% CI, $1760-$3111; P < .001) at one ED and $2905 (95% CI, $2378-$3431; P < .001) at the other ED in the 30 days after the index ED visit. The association between treatment and mean cumulative savings at 60 days after the index ED visit per beneficiary was also significant: $1200 (95% CI, $231-$2169; P = .02) at one ED and $3202 (95% CI, $2452-$3951; P < .001) at the other ED. CONCLUSIONS AND RELEVANCE Among Medicare fee-for-service beneficiaries, receipt of ED-based geriatric treatment by a TCN and/or an SW was associated with lower Medicare expenditures. These estimated cost savings may be used when calculating or considering the bundled value and potential reimbursement per patient for GED care programs.
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Affiliation(s)
- Ula Hwang
- Department of Emergency Medicine, Yale University, New Haven, Connecticut
- Geriatric Research, Education Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Scott M. Dresden
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Carmen Vargas-Torres
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Raymond Kang
- Center for Healthcare Studies, Northwestern University, Chicago, Illinois
| | - Melissa M. Garrido
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts
- Partnered Evidence-Based Policy Resource Center, Boston VA Healthcare Systems, Boston, Massachusetts
| | - George Loo
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jeremy Sze
- Department of Emergency Medicine, New York University Grossman School of Medicine, New York
- Department of Population Health, New York University Grossman School of Medicine, New York
| | - Daniel Cruz
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lynne D. Richardson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - James Adams
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Kevin M. Baumlin
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - D. Mark Courtney
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas
| | | | - Corita R. Grudzen
- Department of Emergency Medicine, New York University Grossman School of Medicine, New York
| | - Gloria Nimo
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Carolyn W. Zhu
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Thanh NX, Patil T, Knudsen C, Hamlin SN, Lightfoot H, Hanson HM, Cleaver D, Chan K, Silvius J, Oddie S, Fielding S. Return on Investment of the Primary Health Care Integrated Geriatric Services Initiative Implementation. J Ment Health Policy Econ 2020; 23:101-109. [PMID: 32853159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/23/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Since June 2017, the Primary Health Care Integrated Geriatric Services Initiative (PHC IGSI) has been implemented in Alberta, Canada to, among other aims, reduce costs of unplanned health service utilization while maximizing the utilization of available community resources to support people living with dementia living in communities. AIM OF THE STUDY We performed an economic evaluation of this initiative to inform policy regarding sustainability, scale up and spread. METHODS We used a cohort design together with a difference-in-difference approach and a propensity score matching technique to calculate impacts of the intervention on patient's health service utilization, including inpatient, outpatient and physician services, as well as prescription drugs. We then used a decision tree to compare between benefits and costs of the intervention and reported net benefits (NB) and return on investment ratios (ROI). We used a health system perspective and a time horizon of 1 year. Both deterministic and probabilistic sensitivity analyses were performed for the uncertainty of parameters. We analyzed real-world data extracted from the Alberta Health Administrative Databases. All costs/savings were inflated to 2019 CAD (CAD 1 \sim = USD 0.75) using the Canadian Consumer Price Index. RESULTS The intervention reduced the use of hospital (inpatient, emergency, and outpatient) services by increasing the use of community services (physician and prescription drug). As hospital services are expensive, the PHC IGSI community intervention resulted in a NB from CAD 554 to 4,046 per patient-year for the health system, and a ROI from 1.3 to 3.1 meaning that every CAD invested in PHC IGSI would bring CAD 1.3 to 3.1 in return. The probability of PHC IGSI to be cost-saving was 56.4% to 69.3%. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE The PHC IGSI is cost-effective in Alberta. IMPLICATIONS FOR HEALTH POLICY The savings would be larger if the initiative is sustained, scaled up and spread because of not only a reduced cost of intervention in the sustainability phase, but also because of the increased number of patients that would be impacted. IMPLICATIONS FOR FURTHER RESEARCH Future studies taking a societal perspective to also include costs for families and health and social sectors at the community level, would be desirable. Additionally, future works to determine how wellbeing is impacted by the PHC IGSI as vertical and horizontal integration interventions are implemented at the community level, are essential to undertake. Finally, in addition to people living with dementia, the PHC IGSI also supports people living in the community with frailty and other geriatric syndromes, therefore, the cost-savings estimated in this study are likely underestimated.
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Affiliation(s)
- Nguyen X Thanh
- Strategic Clinical Networks, Alberta Health Services, Alberta, Canada, 2-103 South Tower, Seventh Street Plaza, 10030 107 St. Edmonton, Alberta, Canada, T5J 3E4.,
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Lu J, He T, Wei G, Wu J, Wei C. Cumulative Prospect Theory: Performance Evaluation of Government Purchases of Home-Based Elderly-Care Services Using the Pythagorean 2-tuple Linguistic TODIM Method. Int J Environ Res Public Health 2020; 17:E1939. [PMID: 32188059 PMCID: PMC7212755 DOI: 10.3390/ijerph17061939] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/10/2020] [Accepted: 03/13/2020] [Indexed: 11/23/2022]
Abstract
The aging trend of China's population is increasing, and the pension problem is becoming increasingly prominent. The pension mode provided by the government alone can no longer meet the social demand, and the government's purchase of home-based care services from social organizations has become a new trend. In order to improve the efficiency and quality of pension services, a reasonable performance evaluation model needs to be established. Performance evaluations of home-based elderly-care services purchased by the government are problematic as a result of multiple-attribute group decision-making (MAGDM), as the problems are not single-attribute or single-expert issues. The extended TODIM not only integrates the advantages of cumulative prospect theory (CPT) into a consideration of the psychological factors of DMs, but also retains the superiority of the classical TODIM in relative dominance. The Pythagorean 2-tuple linguistic sets (P2TLSs) could easily depict qualitative assessment information related to the government's purchase of home-based care services. Thus, in this paper, we extend the TODIM method based on the cumulative prospect theory (CPT) to the Pythagorean 2-tuple linguistic sets (P2TLSs) and propose a Pythagorean 2-tuple linguistic CPT-TODIM (P2TL-CPT-TODIM) method for MAGDM. The P2TL-CPT-TODIM method was proven superior to the classical one through a case study that included a performance evaluation of a home-based elderly-care service purchased by the government. Meanwhile, a comparison with the P2TL-CPT-TODIM method was performed to demonstrate the stability and effectiveness of the designed method.
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Affiliation(s)
- Jianping Lu
- School of Business, Sichuan Normal University, Chengdu 610101, China;
| | - Tingting He
- School of Business, Sichuan Normal University, Chengdu 610101, China;
| | - Guiwu Wei
- School of Business, Sichuan Normal University, Chengdu 610101, China;
| | - Jiang Wu
- School of Statistics, Southwestern University of Finance and Economics, Chengdu 611130, China; (J.W.); (C.W.)
| | - Cun Wei
- School of Statistics, Southwestern University of Finance and Economics, Chengdu 611130, China; (J.W.); (C.W.)
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Yue M, Wang Y, Low CK, Yoong JSY, Cook AR. Optimal Design of Population-Level Financial Incentives of Influenza Vaccination for the Elderly. Value Health 2020; 23:200-208. [PMID: 32113625 DOI: 10.1016/j.jval.2019.08.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 08/13/2019] [Accepted: 08/20/2019] [Indexed: 05/26/2023]
Abstract
OBJECTIVES To identify how monetary incentives affect influenza vaccination uptake rate using a randomized control experiment and to subsequently design an optimal incentive program in Singapore, a high-income country with a market-based healthcare system. METHODS 4000 people aged ≥65 were randomly assigned to 4 treatment groups (1000 each) and were offered a monetary incentive (in shopping vouchers) if they chose to participate. The baseline group was invited to complete a questionnaire with incentives of 10 Singapore dollars (SGD; where 1 SGD ≈ 0.73 USD), whereas the other three groups were invited to complete the questionnaire and be vaccinated against influenza at their own cost of around 32 SGD, in return for incentives of 10, 20, or 30 SGD. RESULTS Increasing the total incentive for vaccination and reporting from 10 to 20 SGD increased participation in vaccination from 4.5% to 7.5% (P < .001). Increasing the total incentive from 20 to 30 SGD increased the participation rate to 9.2%, but this was not statistically significantly different from a 20-SGD incentive. The group of nonworking elderly were more sensitive to changes in incentives than those who worked. In addition to working status, the effects of increasing incentives on influenza vaccination rates differed by ethnicity, socio-economic status, household size, and a measure of social resilience. There were no significant differential effects by age group, gender, or education, however. The cost of the program per completed vaccination under a 20-SGD incentive is 36.80 SGD, which was the lowest among the three intervention arms. For a hypothetical population-level financial incentive program to promote influenza vaccination among the elderly, accounting for transmission dynamics, an incentive between 10 and 20 SGD minimizes the cost per completed vaccination from both governmental and health system perspectives. CONCLUSIONS Appropriate monetary incentives can boost influenza vaccination rates. Increasing monetary incentives for vaccination from 10 to 20 SGD can improve the influenza vaccination uptake rate, but further increasing the monetary incentive to 30 SGD results in no additional gains. A partial incentive may therefore be considered to improve vaccination coverage in this high-risk group.
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Affiliation(s)
- Mu Yue
- School of Mathematical Sciences, University of Electronic Science and Technology of China, Chengdu, Sichuan, China; Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Yi Wang
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Chng Kiat Low
- Department of Statistics and Applied Probability, National University of Singapore, Singapore
| | - Joanne Su-Yin Yoong
- Center for Economic and Social Research, University of Southern California, Los Angeles, CA, USA; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Alex R Cook
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore; Department of Statistics and Applied Probability, National University of Singapore, Singapore; Duke-NUS Medical School Singapore, Singapore.
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7
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Hu B, Li B, Wang J, Shi C. Home and community care for older people in urban China: Receipt of services and sources of payment. Health Soc Care Community 2020; 28:225-235. [PMID: 31508864 DOI: 10.1111/hsc.12856] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 07/19/2019] [Accepted: 08/25/2019] [Indexed: 06/10/2023]
Abstract
This study investigates the characteristics of Chinese older people receiving home and community care and the factors associated with the sources of payment for care services. The data come from the Social Survey of Older People in Urban China, which collected information from a random sample of 3,247 older people aged 60 and over in 10 large cities in different regions of China in 2017. Anderson's behavioural model of care utilisation is used to guide the analyses. The study identifies four striking features of the Chinese social care system. First, although disabilities are a significant predictor of receiving home and community care, a large proportion of care recipients do not have disabilities. Second, perceived proximity of care is the most important predictor, which implies high elasticity of demand for care services with regard to perceived distance and the great geographical inequality of care resources in the cities. Third, the government policies support the use of the internet to facilitate care access, but the enabling effect of the internet among older people is limited. Finally, sources of payment for care differ significantly according to people's age, living arrangements, disability and level of education. We argue that the government should consider shifting the focus of financial support from service providers to care recipients in the future.
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Affiliation(s)
- Bo Hu
- Department of Health Policy, Care Policy and Evaluation Centre (CPEC), London School of Economics and Political Science, London, UK
| | - Bingqin Li
- Social Policy Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Jing Wang
- Institute of Sociology, Chinese Academy of Social Sciences, Beijing, China
| | - Cheng Shi
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, China
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Ang YH, Ginting ML, Wong CH, Tew CW, Liu C, Sivapragasam NR, Matchar DB. From Hospital to Home: Impact of Transitional Care on Cost, Hospitalisation and Mortality. Ann Acad Med Singap 2019; 48:333-337. [PMID: 31875471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Yan Hoon Ang
- Department of Geriatric Medicine, Khoo Teck Puat Hospital, Singapore
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Chen Y, Wilson L, Kornak J, Dudley RA, Merrilees J, Bonasera SJ, Byrne CM, Lee K, Chiong W, Miller BL, Possin KL. The costs of dementia subtypes to California Medicare fee-for-service, 2015. Alzheimers Dement 2019; 15:899-906. [PMID: 31175026 PMCID: PMC7183386 DOI: 10.1016/j.jalz.2019.03.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 03/18/2019] [Accepted: 03/25/2019] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Dementia is among the costliest of medical conditions, but it is not known how these costs vary by dementia subtype. METHODS The effect of dementia diagnosis subtype on direct health care costs and utilization was estimated using 2015 California Medicare fee-for-service data. Potential drivers of increased costs in Lewy body dementia (LBD), in comparison to Alzheimer's disease, were tested. RESULTS 3,001,987 Medicare beneficiaries were identified, of which 8.2% had a dementia diagnosis. Unspecified dementia was the most common diagnostic category (59.6%), followed by Alzheimer's disease (23.2%). LBD was the costliest subtype to Medicare, on average, followed by vascular dementia. The higher costs in LBD were explained in part by falls, urinary incontinence or infection, depression, anxiety, dehydration, and delirium. DISCUSSION Dementia subtype is an important predictor of health care costs. Earlier identification and targeted treatment might mitigate the costs associated with co-occurring conditions in LBD.
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Affiliation(s)
- Yingjia Chen
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, San Francisco, CA, USA
| | - Leslie Wilson
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, CA, USA; Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - John Kornak
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - R Adams Dudley
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Jennifer Merrilees
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, San Francisco, CA, USA; Global Brain Health Institute, University of California, San Francisco, San Francisco, CA, USA
| | - Stephen J Bonasera
- Division of Geriatrics, Department of Internal Medicine, Home Instead Center for Successful Aging, University of Nebraska Medical Center, Omaha, NE, USA
| | - Christie M Byrne
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, San Francisco, CA, USA
| | - Kirby Lee
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, CA, USA
| | - Winston Chiong
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, San Francisco, CA, USA; Global Brain Health Institute, University of California, San Francisco, San Francisco, CA, USA
| | - Bruce L Miller
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, San Francisco, CA, USA
| | - Katherine L Possin
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, San Francisco, CA, USA; Global Brain Health Institute, University of California, San Francisco, San Francisco, CA, USA.
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Gyurmey T, Kwiatkowski J. Program of All-Inclusive Care for the Elderly (PACE): Integrating Health and Social Care Since 1973. R I Med J (2013) 2019; 102:30-32. [PMID: 31167525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
According to the Centers for Medicare & Medicaid Services (CMS), the future of older adult care in the United States has arrived in a provider-sponsored health plan model that integrates medical, behavioral, and social care for frail elders. This approach gives the provider complete control over patient outcomes and total cost of care and enables participants to live safely in the community - rather than a nursing home - for an extra four years, on average. This article reviews the Program of All-inclusive Care for the Elderly (PACE) model, whose roots go back to the 1970s in California, and offers case studies on two PACE-RI participants with chronic healthcare needs. In both examples, the patients reduced hospitalizations and increased mental and physical health, all while alleviating caregiver stress. With the older population slated to double by 2060, the time has come to expand PACE to more people. A few years ago, the acting administrator of the Centers for Medicare & Medicaid Services (CMS) said he was "glimpsing into our future" when he visited a provider-sponsored health plan that integrated medical, behavioral, and social care for frail elders, allowing them to remain in the community rather than live in a nursing home.[1] This approach to aging services successfully braided Medicare and Medicaid funding and gave the provider complete control over patient outcomes and total cost of care over a significant period - the key elements to delivering "value-based care." What is noteworthy is that this program of the "future" has been in Rhode Island since 2005 and in other parts of the country since 1973! It helps its medically complex participants live at home for an extra four years on average and retain a much higher quality of life, all while controlling associated costs for the government through capitated payment arrangements.[5] The program is called PACE - short for Program of All-inclusive Care for the Elderly - and it is a comprehensive and community-based model of care that coordinates medical, behavioral, and social services for individuals ages fifty-five and older who have high care needs but can remain safely in the community. PACE is currently offered in 31 states.[2] The model is backed by the National PACE Association and serves 50,000 seniors in 126 sponsoring organizations at 260 PACE centers across the country. While PACE has already had some success at scaling its integrated services, emerging demographics and heightened outreach poise the program for significant growth.
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Affiliation(s)
- Tsewang Gyurmey
- Chief Medical Officer of the PACE Organization of Rhode Island
| | - Joan Kwiatkowski
- Chief Executive Officer of the PACE Organization of Rhode Island. From 2013-2016, she served as the Chair of the Board of the National PACE Association
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Burn AM, Bunn F, Fleming J, Turner D, Fox C, Malyon A, Brayne C. Case finding for dementia during acute hospital admissions: a mixed-methods study exploring the impacts on patient care after discharge and costs for the English National Health Service. BMJ Open 2019; 9:e026927. [PMID: 31164367 PMCID: PMC6561413 DOI: 10.1136/bmjopen-2018-026927] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE Between 2012 and 2017 dementia case finding was routinely carried out on people aged 75 years and over with unplanned admissions to acute hospitals across England. The assumption was that this would lead to better planning of care and treatment for patients with dementia following discharge from hospital. However, little is known about the experiences of patients and carers or the impacts on other health services. This study explored the impact of dementia case finding on older people and their families and on their use of services. DESIGN Thematic content analysis was conducted on qualitative interview data and costs associated with service use were estimated. Measures included the Mini-Mental State Examination, the EuroQol quality of life scale and a modified Client Service Receipt Inventory. SETTING Four counties in the East of England. PARTICIPANTS People aged ≥75 years who had been identified by case finding during an unplanned hospital admission as warranting further investigation of possible dementia and their family carers. RESULTS We carried out 28 interviews, including 19 joint patient-carer(s), 5 patient only and 4 family carer interviews. Most patients and carers were unaware that memory assessments had taken place, with many families not being informed or involved in the process. Participants had a variety of views on memory testing in hospital and had concerns about how hospitals carried out assessments and communicated results. Overall, case finding did not lead to general practitioner (GP) follow-up after discharge home or lead to referral for further investigation. Few services were initiated because of dementia case finding in hospital. CONCLUSIONS This study shows that dementia case finding may not lead to increased GP follow-up or service provision for patients after discharge from hospital. There is a need for a more evidence-based approach to the initiation of mandatory initiatives such as case finding that inevitably consume stretched human and financial resources.
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Affiliation(s)
- Anne-Marie Burn
- Cambridge Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, Cambridgeshire, UK
| | - Frances Bunn
- Centre for Research in Public Health and Community Care, University of Hertfordshire, Hatfield, Hertfordshire, UK
| | - Jane Fleming
- Cambridge Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, Cambridgeshire, UK
| | - David Turner
- Norwich Medical School, University of East Anglia Faculty of Medicine and Health Sciences, Norwich, Norfolk, UK
| | - Chris Fox
- Norwich Medical School, University of East Anglia Faculty of Medicine and Health Sciences, Norwich, Norfolk, UK
| | - Alexandra Malyon
- Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, UK
| | - Carol Brayne
- Cambridge Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, Cambridgeshire, UK
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Ratcliffe J, Cameron I, Lancsar E, Walker R, Milte R, Hutchinson CL, Swaffer K, Parker S. Developing a new quality of life instrument with older people for economic evaluation in aged care: study protocol. BMJ Open 2019; 9:e028647. [PMID: 31129602 PMCID: PMC6538028 DOI: 10.1136/bmjopen-2018-028647] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION The ageing of the population represents a significant challenge for aged care in Australia and in many other countries internationally. In an environment of increasing resource constraints, new methods, techniques and evaluative frameworks are needed to support resource allocation decisions that maximise the quality of life and well-being of older people. Economic evaluation offers a rigorous, systematical and transparent framework for measuring quality and efficiency, but there is currently no composite mechanism for incorporating older people's values into the measurement and valuation of quality of life for quality assessment and economic evaluation. In addition, to date relatively few economic evaluations have been conducted in aged care despite the large potential benefits associated with their application in this sector. This study will generate a new preference based older person-specific quality of life instrument designed for application in economic evaluation and co-created from its inception with older people. METHODS AND ANALYSIS A candidate descriptive system for the new instrument will be developed by synthesising the findings from a series of in-depth qualitative interviews with 40 older people currently in receipt of aged care services about the salient factors which make up their quality of life. The candidate descriptive system will be tested for construct validity, practicality and reliability with a new independent sample of older people (n=100). Quality of life state valuation tasks using best worst scaling (a form of discrete choice experiment) will then be undertaken with a representative sample of older people currently receiving aged care services across five Australian states (n=500). A multinomial (conditional) logistical framework will be used to analyse responses and generate a scoring algorithm for the new preference-based instrument. ETHICS AND DISSEMINATION The new quality of life instrument will have wide potential applicability in assessing the cost effectiveness of new service innovations and for quality assessment across the spectrum of ageing and aged care. Results will be disseminated in ageing, quality of life research and health economics journals and through professional conferences and policy forums. This study has been reviewed by the Human Research Ethics Committee of the University of South Australia and has ethics approval (Application ID: 201644).
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Affiliation(s)
- Julie Ratcliffe
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Ian Cameron
- Rehabilitation Studies Unit, University of Sydney, Sydney, New South Wales, Australia
| | - Emily Lancsar
- College of Health and Medicine, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Ruth Walker
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Rachel Milte
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Claire Louise Hutchinson
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Kate Swaffer
- Dementia Alliance International, Adelaide, South Australia, Australia
| | - Stuart Parker
- Institute of Health and Society/Newcastle University Institute for Ageing, Newcastle University, Newcastle upon Tyne, UK
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Tsiachristas A, Ellis G, Buchanan S, Langhorne P, Stott DJ, Shepperd S. Should I stay or should I go? A retrospective propensity score-matched analysis using administrative data of hospital-at-home for older people in Scotland. BMJ Open 2019; 9:e023350. [PMID: 31072849 PMCID: PMC6527981 DOI: 10.1136/bmjopen-2018-023350] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES To compare the characteristics of populations admitted to hospital-at-home services with the population admitted to hospital and assess the association of these services with healthcare costs and mortality. DESIGN In a retrospective observational cohort study of linked patient level data, we used propensity score matching in combination with regression analysis. PARTICIPANTS Patients aged 65 years and older admitted to hospital-at-home or hospital. INTERVENTIONS Three geriatrician-led admission avoidance hospital-at-home services in Scotland. OUTCOME MEASURES Healthcare costs and mortality. RESULTS Patients in hospital-at-home were older and more socioeconomically disadvantaged, had higher rates of previous hospitalisation and there was a greater proportion of women and people with several chronic conditions compared with the population admitted to hospital. The cost of providing hospital-at-home varied between the three sites from £628 to £2928 per admission. Hospital-at-home was associated with 18% lower costs during the follow-up period in site 1 (ratio of means 0.82; 95% CI: 0.76 to 0.89). Limiting the analysis to costs during the 6 months following index discharge, patients in the hospital-at-home cohorts had 27% higher costs (ratio of means 1.27; 95% CI: 1.14 to 1.41) in site 1, 9% (ratio of means 1.09; 95% CI: 0.95 to 1.24) in site 2 and 70% in site 3 (ratio of means 1.70; 95% CI: 1.40 to 2.07) compared with patients in the control cohorts. Admission to hospital-at-home was associated with an increased risk of death during the follow-up period in all three sites (1.09, 95% CI: 1.00 to 1.19 site 1; 1.29, 95% CI: 1.15 to 1.44 site 2; 1.27, 95% CI: 1.06 to 1.54 site 3). CONCLUSIONS Our findings indicate that in these three cohorts, the populations admitted to hospital-at-home and hospital differ. We cannot rule out the risk of residual confounding, as our analysis relied on an administrative data set and we lacked data on disease severity and type of hospitalised care received in the control cohorts.
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Affiliation(s)
- Apostolos Tsiachristas
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Graham Ellis
- Monklands Hospital, NHS Lanarkshire, Airdrie, UK
| | - Scott Buchanan
- Information Services Division, National Services Scotland, Edinburgh, UK
| | - Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - David J Stott
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Sasha Shepperd
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Seamer P, Brake S, Moore P, Mohammed MA, Wyatt S. Did government spending cuts to social care for older people lead to an increase in emergency hospital admissions? An ecological study, England 2005-2016. BMJ Open 2019; 9:e024577. [PMID: 31028036 PMCID: PMC6501965 DOI: 10.1136/bmjopen-2018-024577] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Government spending on social care in England reduced substantially in real terms following the economic crisis in 2008, meanwhile emergency admissions to hospitals have increased. We aimed to assess the extent to which reductions in social care spend on older people have led to increases in emergency hospital admissions. DESIGN We used negative binomial regression for panel data to assess the relationship between emergency hospital admissions and government spend on social care for older people. We adjusted for population size and for levels of deprivation and health. SETTING Hospitals and adult social care services in England between April 2005 and March 2016. PARTICIPANTS People aged 65 years and over resident in 132 local councils. OUTCOME MEASURES Primary outcome variable-emergency hospital admissions of adults aged 65 years and over. Secondary outcome measure-emergency hospital admissions for ambulatory care sensitive conditions (ACSCs) of adults aged 65 years and over. RESULTS We found no significant relationship between the changes in the rate of government spend (£'000 s) on social care for older people within councils and our primary outcome variable, emergency hospital admissions (Incidence rate ratio (IRR) 1.009, 95% CI 0.965 to 1.056) or our secondary outcome measure, admissions for ACSCs (IRR 0.975, 95% CI 0.917 to 1.038). CONCLUSIONS We found no evidence to support the view that reductions in government spend on social care since 2008 have led to increases in emergency hospital admissions in older people. Policy makers may wish to review schemes, such as the Better Care Fund, which are predicated on a relationship between social care provision and emergency hospital admissions of older people.
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Affiliation(s)
- Paul Seamer
- The Strategy Unit, NHS Midlands and Lancashire Commissioning Support Unit, West Bromwich, UK
| | - Simon Brake
- Warwick Medical School, University of Warwick, Coventry, UK
- Head Office, NHS Walsall Clinical Commissioning Group, Walsall, UK
| | - Patrick Moore
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Mohammed A Mohammed
- The Strategy Unit, NHS Midlands and Lancashire Commissioning Support Unit, West Bromwich, UK
- Faculty of Health Studies, University of Bradford, Bradford, UK
| | - Steven Wyatt
- The Strategy Unit, NHS Midlands and Lancashire Commissioning Support Unit, West Bromwich, UK
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Akdeniz M, Hahnel E, Ulrich C, Blume-Peytavi U, Kottner J. Prevalence and associated factors of skin cancer in aged nursing home residents: A multicenter prevalence study. PLoS One 2019; 14:e0215379. [PMID: 31009466 PMCID: PMC6476496 DOI: 10.1371/journal.pone.0215379] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 04/01/2019] [Indexed: 11/18/2022] Open
Abstract
Non-melanoma-skin cancer is an emerging clinical problem in the elderly, fair skinned population which predominantly affects patients aged older than 70 years. Its steady increase in incidence rates and morbidity is paralleled by related medical costs. Despite the fact that many elderly patients are in need of care and are living in nursing homes, specific data on the prevalence of skin cancer in home care and the institutional long-term care setting is currently lacking. A representative multicenter prevalence study was conducted in a random sample of ten institutional long-term care facilities in the federal state of Berlin, Germany. In total, n = 223 residents were included. Actinic keratoses, the precursor lesions of invasive cutaneous squamous cell carcinoma were the most common epithelial skin lesions (21.1%, 95% CI 16.2 to 26.9). Non-melanoma skin cancer was diagnosed in 16 residents (7.2%, 95% CI 4.5 to 11.3). None of the residents had a malignant melanoma. Only few bivariate associations were detected between non-melanoma skin cancer and demographic, biographic and functional characteristics. Male sex was significantly associated with actinic keratosis whereas female sex was associated with non-melanoma skin cancer. Smoking was associated with an increased occurrence of non-melanoma skin cancer. Regular dermatology check-ups in nursing homes would be needed but already now due to financial limitations, lack of time in daily clinical practice and limited number of practising dermatologists, it is not the current standard. With respect to the worldwide growing aging population new programs and decisions are required. Overall, primary health care professionals should play a more active role in early diagnosis of skin cancer in nursing home residents. Dermoscopy courses, web-based or smartphone-based applications and teledermatology may support health care professionals to provide elderly nursing home residents an early diagnosis of skin cancer.
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Affiliation(s)
- Merve Akdeniz
- Department of Dermatology and Allergy, Clinical Research Center for Hair and Skin Science, Charité-Universitätsmedizin Berlin, Germany
| | - Elisabeth Hahnel
- Department of Dermatology and Allergy, Clinical Research Center for Hair and Skin Science, Charité-Universitätsmedizin Berlin, Germany
| | - Claas Ulrich
- Department of Dermatology and Allergy, Skin Cancer Center, Charité-Universitätsmedizin, Berlin, Germany
| | - Ulrike Blume-Peytavi
- Department of Dermatology and Allergy, Clinical Research Center for Hair and Skin Science, Charité-Universitätsmedizin Berlin, Germany
| | - Jan Kottner
- Department of Dermatology and Allergy, Clinical Research Center for Hair and Skin Science, Charité-Universitätsmedizin Berlin, Germany
- * E-mail:
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Eckermann S, Phillipson L, Fleming R. Re-design of Aged Care Environments is Key to Improved Care Quality and Cost Effective Reform of Aged and Health System Care. Appl Health Econ Health Policy 2019; 17:127-130. [PMID: 30328015 DOI: 10.1007/s40258-018-0435-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Simon Eckermann
- Australian Health Services Research Institute, University of Wollongong, Wollongong, Australia.
| | - Lyn Phillipson
- School of Health and Society, Faculty of Social Sciences, University of Wollongong, Wollongong, Australia
| | - Richard Fleming
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
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Exley J, Abel GA, Fernandez JL, Pitchforth E, Mendonca S, Yang M, Roland M, McGuire A. Impact of the Southwark and Lambeth Integrated Care Older People's Programme on hospital utilisation and costs: controlled time series and cost-consequence analysis. BMJ Open 2019; 9:e024220. [PMID: 30833317 PMCID: PMC6443075 DOI: 10.1136/bmjopen-2018-024220] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES To estimate the impact on hospital utilisation and costs of a multi-faceted primary care intervention for older people identified as being at risk of avoidable hospitalisation. DESIGN Observational study: controlled time series analysis and estimation of costs and cost consequences of the Programme. General practitioner (GP)'s practice level data were analysed from 2009 to 2016 (intervention operated from 2012 to 2016). Mixed-effect Poisson regression models of hospital utilisation included comparisons with control practices and background trends in addition to within-practice comparisons. Cost estimation used standard tariff values. SETTING 94 practices in Southwark and Lambeth and 263 control practices from other parts of England. MAIN OUTCOME MEASURES Hospital utilisation: emergency department attendance, emergency admissions, emergency admissions for ambulatory sensitive conditions, outpatient attendance, elective admission and length of stay. RESULTS By the fourth year of the Programme, there were reductions in accident and emergency (A&E) attendance (rate ratio 0.944, 95% CI 0.913 to 0.976), outpatient attendances (rate ratio 0.938, 95% CI 0.902 to 0.975) and elective admissions (rate ratio 0.921, 95% CI 0.908 to 0.935) but there was no evidence of reduced emergency admissions. The costs of the Programme were £149 per resident aged 65 and above but savings in hospital costs were only £86 per resident aged 65 and above, equivalent to a net increase in health service expenditure of £64 per resident though the Programme was nearly cost neutral if set-up costs were excluded. Holistic assessments carried out by GPs and consequent Integrated Care Management (ICM) plans were associated with increases in elective activity and costs; £126 increase in outpatient attendance and £936 in elective admission costs per holistic assessment carried out, and £576 increase in outpatient and £5858 in elective admission costs per patient receiving ICM. CONCLUSIONS The Older People's Programme was not cost saving. Some aspects of the Programme were associated with increased costs of elective care, possibly through the identification of unmet need.
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Affiliation(s)
- Josephine Exley
- Cambridge Centre for Health Services Research, RAND Europe, Cambridge, Cambridgeshire, UK
| | - Gary A Abel
- University of Exeter Medical School, Exeter, UK
| | - José-Luis Fernandez
- Personal Social Services Research Unit, London School of Economics, London, UK
| | | | - Silvia Mendonca
- Cambridge Centre for Health Services Research, University of Cambridge, Cambridge, UK
| | - Miaoqing Yang
- Cambridge Centre for Health Services Research, RAND Europe, Cambridge, Cambridgeshire, UK
| | - Martin Roland
- Cambridge Centre for Health Services Research, University of Cambridge, Cambridge, UK
| | - Alistair McGuire
- Department of Health Policy, London School of Economics, London, UK
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Kinchin I, Jacups S, Mann J, Quigley R, Harvey D, Doran CM, Strivens E. Efficacy and cost-effectiveness of a community-based model of care for older patients with complex needs: a study protocol for a multicentre randomised controlled trial using a stepped wedge cluster design. Trials 2018; 19:668. [PMID: 30514378 PMCID: PMC6280415 DOI: 10.1186/s13063-018-3038-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 11/03/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Community-dwelling older persons with complex care needs may deteriorate rapidly and require hospitalisation if they receive inadequate support for their conditions in the community. INTERVENTION A comprehensive, multidimensional geriatric assessment with care coordination was performed in a community setting-Older Persons ENablement And Rehabilitation for Complex Health conditions (OPEN ARCH). OBJECTIVES This study will assess the acceptability and determine the impact of the OPEN ARCH intervention on the health and quality of life outcomes, health and social services utilisation of older people with multiple chronic conditions and emerging complex care needs. An economic evaluation will determine whether OPEN ARCH is cost-effective when compared to the standard care. METHODS/DESIGN This multicentre randomised controlled trial uses a stepped wedge cluster design with repeated cross-sectional samples. General practitioners (GPs; n ≥ 10) will be randomised as 'clusters' at baseline using simple randomisation. Each GP cluster will recruit 10-12 participants. Data will be collected on each participant at 3-month intervals (- 3, 0, 3, 6 and 9 months). The primary outcome is health and social service utilisation as measured by Emergency Department presentations, hospital admissions, in-patient bed days, allied health and community support services. Secondary outcomes include functional status, quality of life and participants' satisfaction. Cost-effectiveness of the intervention will be assessed as the change to cost outcomes, including the cost of implementing the intervention and subsequent use of services, and the change to health benefits represented by quality adjusted life years. DISCUSSION The results will have direct implications for the design and wider implementation of this new model of care for community-dwelling older persons with complex care needs. Additionally, it will contribute to the evidence base on acceptability, efficacy and cost-effectiveness of the intervention for this high-risk group of older people. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry, ACTRN12617000198325p . Registered on 6 February 2017.
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Affiliation(s)
- Irina Kinchin
- Centre for Indigenous Health Equity Research and School of Health, Medical and Applied Sciences, CQUniversity, Cairns, QLD Australia
- The Cairns Institute, James Cook University, Cairns, QLD Australia
| | - Susan Jacups
- Centre for Indigenous Health Equity Research and School of Health, Medical and Applied Sciences, CQUniversity, Cairns, QLD Australia
- The Cairns Institute, James Cook University, Cairns, QLD Australia
- Medical Services, Torres and Cape Hospital and Health Service, Cairns, QLD Australia
| | - Jennifer Mann
- Cairns and Hinterland Hospital and Health Service, Cairns, QLD Australia
| | - Rachel Quigley
- Cairns and Hinterland Hospital and Health Service, Cairns, QLD Australia
- College of Medicine and Dentistry, James Cook University, Cairns, QLD Australia
| | - Desley Harvey
- Cairns and Hinterland Hospital and Health Service, Cairns, QLD Australia
- Division of Tropical Health and Medicine, James Cook University, Cairns, QLD Australia
| | - Christopher M. Doran
- Centre for Indigenous Health Equity Research and School of Health, Medical and Applied Sciences, CQUniversity, Cairns, QLD Australia
| | - Edward Strivens
- Cairns and Hinterland Hospital and Health Service, Cairns, QLD Australia
- College of Medicine and Dentistry, James Cook University, Cairns, QLD Australia
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Scotti S. Preparing for Alzheimer's in America's 'Age Wave.'. NCSL Legisbrief 2018; 26:1-2. [PMID: 30501141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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20
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Glasper A. Strategies to alleviate shortages of nurses in adult social care. Br J Nurs 2018; 27:334-335. [PMID: 29561676 DOI: 10.12968/bjon.2018.27.6.334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
A lack of investment in adult social care has led to major staffing problems in care homes, according to a new report from the National Audit Office, as Emeritus Professor Alan Glasper, University of Southampton, explains.
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Affiliation(s)
- Adam J Zolotor
- president and CEO, North Carolina Institute of Medicine, Morrisville, North Carolina; associate professor, University of North Carolina Department of Family Medicine, Chapel Hill, North Carolina
| | - Rebecca Tippett
- founding director, Carolina Demography, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Soejono CH, Padmawati RS, Utarini A. Clinical Outcomes of Geriatric Care in Cipto Mangunkusumo Hospital, Before and After the Implementation of National Health Insurance Program. Acta Med Indones 2017; 49:336-342. [PMID: 29348384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND the National Health Insurance (NIH/JKN) has been enacted since January 2014. Various outcomes of geriatric patient care, such as improved functional status and quality of life have not been evaluated. Prolonged hospitalization and re-hospitalization are potentially affecting the efficiency care of this vulnarable group. This study aimed to identify the differences of functional status improvement, quality of life improvement, length of stay, and hospitalization of geriatric patients admitted to CMH between prior to and after NHI implementation. METHODS a cohort study with historical control was conducted among geriatric patients admitted to Acute Geriatric Ward CMH Hospital on two periods of time: January-December 2013 (pre-NHI implementation) and June 2014-May 2015 (after NHI implementation). Patients who died within 24 hours of hospital admission, those with APPACHE II score >24, advance stage cancer, transfer to other wards before they were discharged or have incomplete record were excluded from the study. Data on demographical and clinical characteristics, functional status, quality of life, length of stay, and re-hospitalization were taken from patient's medical record. The differences of studied outcomes were analyzed using t-test or Mann-Whitney test. RESULTS there were 102 subjects in pre-NHI and 135 subjects in NHI groups included in the study. Median lengths of stay were not different between two groups (12.5 days in pre-NHI and 10 days in NHI groups, p=0.087), although the proportion of patients with in-hospital stay less than 14 days was higher in NHI group. The difference of functional status of discharged patients in pre-NHI and NHI groups were 3 and 3 (p=0.149) respectively, whereas for health-related quality of life, although NHI group in the beginning showed a lower quality of life compared to the pre-NHI (0.163 [0.480] vs. 0.243 [0.550]; p=0.012). However, after incorporating comprehensive geriatric assessment (CGA) the quality of life improved significantly by the end of in-hospital care in both groups. Re-hospitalization incidence in NHI group was lower compared to pre-NHI (7 [5.2%] vs. 13 [12.7%]; p=0.038). CONCLUSION our study shows that there was no significant difference regarding length of stay, functional status, and health-related quality of life between prior to and after national health insurance implementation on admitted geriatric patients. Rehospitalization incidence showed better results in NHI group and hence NHI implementation is favored.
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Affiliation(s)
- Czeresna Heriawan Soejono
- Department of Internal Medicine, Faculty of Medicine Universitas Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia..
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Forma L, Jylhä M, Pulkki J, Aaltonen M, Raitanen J, Rissanen P. Trends in the use and costs of round-the-clock long-term care in the last two years of life among old people between 2002 and 2013 in Finland. BMC Health Serv Res 2017; 17:668. [PMID: 28927415 PMCID: PMC5606077 DOI: 10.1186/s12913-017-2615-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 09/12/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The structure of long-term care (LTC) for old people has changed: care has been shifted from institutions to the community, and death is being postponed to increasingly old age. The aim of the study was to analyze how the use and costs of LTC in the last two years of life among old people changed between 2002 and 2013. METHODS Data were derived from national registers. The study population contains all those who died at the age of 70 years or older in 2002-2013 in Finland (N = 427,078). The costs were calculated using national unit cost information. Binary logistic regression and Cox proportional hazard models were used to study the association of year of death with use and costs of LTC. RESULTS The proportion of those who used LTC and the sum of days in LTC in the last two years of life increased between 2002 and 2013. The mean number of days in institutional LTC decreased, while that for sheltered housing increased. The costs of LTC per user decreased. CONCLUSIONS Use of LTC in the last two years of life increased, which was explained by the postponement of death to increasingly old age. Costs of LTC decreased as sheltered housing replaced institutional LTC. However, an accurate comparison of costs of different types of LTC is difficult, and the societal costs of sheltered housing are not well known.
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Affiliation(s)
- Leena Forma
- Faculty of Social Sciences (health sciences) and Gerontology Research Center (GEREC), University of Tampere, 33014 Tampere, Finland
| | - Marja Jylhä
- Faculty of Social Sciences (health sciences) and Gerontology Research Center (GEREC), University of Tampere, 33014 Tampere, Finland
| | - Jutta Pulkki
- Faculty of Social Sciences (health sciences) and Gerontology Research Center (GEREC), University of Tampere, 33014 Tampere, Finland
| | - Mari Aaltonen
- Faculty of Social Sciences (health sciences) and Gerontology Research Center (GEREC), University of Tampere, 33014 Tampere, Finland
- Institute for Advanced Social Research, University of Tampere, Tampere, Finland
| | - Jani Raitanen
- Faculty of Social Sciences (health sciences) and Gerontology Research Center (GEREC), University of Tampere, 33014 Tampere, Finland
- UKK-Institute for Health Promotion, Tampere, Finland
| | - Pekka Rissanen
- Faculty of Social Sciences (health sciences) and Gerontology Research Center (GEREC), University of Tampere, 33014 Tampere, Finland
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Suijker JJ, MacNeil-Vroomen JL, van Rijn M, Buurman BM, de Rooij SE, Moll van Charante EP, Bosmans JE. Cost-effectiveness of nurse-led multifactorial care to prevent or postpone new disabilities in community-living older people: Results of a cluster randomized trial. PLoS One 2017; 12:e0175272. [PMID: 28414806 PMCID: PMC5393862 DOI: 10.1371/journal.pone.0175272] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 03/23/2017] [Indexed: 01/06/2023] Open
Abstract
Objective To evaluate the cost-effectiveness of nurse-led multifactorial care to prevent or postpone new disabilities in community-living older people in comparison with usual care. Methods We conducted cost-effectiveness and cost-utility analyses alongside a cluster randomized trial with one-year follow-up. Participants were aged ≥ 70 years and at increased risk of functional decline. Participants in the intervention group (n = 1209) received a comprehensive geriatric assessment and individually tailored multifactorial interventions coordinated by a community-care registered nurse with multiple follow-up visits. The control group (n = 1074) received usual care. Costs were assessed from a healthcare perspective. Outcome measures included disability (modified Katz-Activities of Daily Living (ADL) index score), and quality-adjusted life-years (QALYs). Statistical uncertainty surrounding Incremental Cost-Effectiveness Ratios (ICERs) was estimated using bootstrapped bivariate regression models while adjusting for confounders. Results There were no statistically significant differences in Katz-ADL index score and QALYs between the two groups. Total mean costs were significantly higher in the intervention group (EUR 6518 (SE 472) compared with usual care (EUR 5214 (SE 338); adjusted mean difference €1457 (95% CI: 572; 2537). Cost-effectiveness acceptability curves showed that the maximum probability of the intervention being cost-effective was 0.14 at a willingness to pay (WTP) of EUR 50,000 per one point improvement on the Katz-ADL index score and 0.04 at a WTP of EUR 50,000 per QALY gained. Conclusion The current intervention was not cost-effective compared to usual care to prevent or postpone new disabilities over a one-year period. Based on these findings, implementation of the evaluated multifactorial nurse-led care model is not to be recommended.
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Affiliation(s)
- Jacqueline J. Suijker
- Department of General Practice, Academic Medical Center, Amsterdam, The Netherlands
- * E-mail:
| | - Janet L. MacNeil-Vroomen
- Department of Internal Medicine, Section of Geriatric Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Marjon van Rijn
- Department of Internal Medicine, Section of Geriatric Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Bianca M. Buurman
- Department of Internal Medicine, Section of Geriatric Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Sophia E. de Rooij
- Department of Internal Medicine, Section of Geriatric Medicine, Academic Medical Center, Amsterdam, The Netherlands
- University Center for Geriatric Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Judith E. Bosmans
- Department of Health Sciences and EMGO Institute for Health and Care Research, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Bae B, Choi BR, Song I. The impact of change from copayment to coinsurance on medical care usage and expenditure in outpatient setting in older Koreans. Int J Health Plann Manage 2017; 33:235-245. [PMID: 28370318 DOI: 10.1002/hpm.2416] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 03/02/2017] [Indexed: 11/07/2022] Open
Abstract
Patient cost-sharing change was implemented on August 1, 2007, for outpatient care in the clinic setting in Korea from copayment to coinsurance. This study aims to estimate the effect of the policy change on medical care usage and expenditure in older Koreans. By using national health insurance claims data from the Health Insurance Reimbursement Assessment Service, this study analyzed the entire 137 million claims for a total of approximately 4.1 million patients aged 60 to 69 years who had been diagnosed and/or treated for outpatient care in clinics from January 1, 2007, to December 31, 2008. Medical care usage was defined as the proportion of all beneficiaries in each group who visited clinics and the mean number of visit days per beneficiary. Medical care expenditure per visit day was expressed as total costs, reimbursed amount, and patient's out-of-pocket payment. Data on January through June of 2008 were analyzed as compared with the same months of 2007. Raw difference-in-difference and multiple regression analyses were performed. The interaction coefficients, which measured the impact of cost-sharing change, was -0.078 in model 1 and -0.039 in model 2 (P < .0001). In conclusion, a cost-sharing change from copayment to coinsurance reduced medical care usage and expenditure.
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Affiliation(s)
- Byoungjun Bae
- Bureau of Health Policy, Ministry of Health and Welfare, Sejong, South Korea
| | - Bo Ram Choi
- Department of Nursing, Yong-In Songdam College, Yongin-si, Gyeonggi-do, South Korea
| | - Inmyung Song
- Division of Risk Assessment and International Cooperation, Korea Centers for Disease Control and Prevention, Cheongju, South Korea
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Busetto L, Kiselev J, Luijkx KG, Steinhagen-Thiessen E, Vrijhoef HJM. Implementation of integrated geriatric care at a German hospital: a case study to understand when and why beneficial outcomes can be achieved. BMC Health Serv Res 2017; 17:180. [PMID: 28270122 PMCID: PMC5341181 DOI: 10.1186/s12913-017-2105-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Accepted: 02/21/2017] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Many health systems have implemented integrated care as an alternative approach to health care delivery that is more appropriate for patients with complex, long-term needs. The objective of this article was to analyse the implementation of integrated care at a German geriatric hospital and explore whether the use of a "context-mechanisms-outcomes"-based model provides insights into when and why beneficial outcomes can be achieved. METHODS We conducted 15 semi-structured interviews with health professionals employed at the hospital. The data were qualitatively analysed using a "context-mechanisms-outcomes"-based model. Specifically, mechanisms were defined as the different components of the integrated care intervention and categorised according to Wagner's Chronic Care Model (CCM). Context was understood as the setting in which the mechanisms are brought into practice and described by the barriers and facilitators encountered in the implementation process. These were categorised according to the six levels of Grol and Wensing's Implementation Model (IM): innovation, individual professional, patient, social context, organisational context and economic and political context. Outcomes were defined as the effects triggered by mechanisms and context, and categorised according to the six dimensions of quality of care as defined by the World Health Organization, namely effectiveness, efficiency, accessibility, patient-centeredness, equity and safety. RESULTS The integrated care intervention consisted of three main components: a specific reimbursement system ("early complex geriatric rehabilitation"), multidisciplinary cooperation, and comprehensive geriatric assessments. The inflexibility of the reimbursement system regarding the obligatory number of treatment sessions contributed to over-, under- and misuse of services. Multidisciplinary cooperation was impeded by a high workload, which contributed to waste in workflows. The comprehensive geriatric assessments were complemented with information provided by family members, which contributed to decreased likelihood of adverse events. CONCLUSIONS We recommend an increased focus on trying to understand how intervention components interact with context factors and, combined, lead to positive and/or negative outcomes.
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Affiliation(s)
- Loraine Busetto
- Tranzo Scientific Center for Care and Welfare, Tilburg University, Warandelaan 2, 5037 AB Tilburg, The Netherlands
| | - Jörn Kiselev
- Geriatrics Research Group, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Katrien Ger Luijkx
- Tranzo Scientific Center for Care and Welfare, Tilburg University, Warandelaan 2, 5037 AB Tilburg, The Netherlands
| | | | - Hubertus Johannes Maria Vrijhoef
- Tranzo Scientific Center for Care and Welfare, Tilburg University, Warandelaan 2, 5037 AB Tilburg, The Netherlands
- Panaxea B.V., Amsterdam, The Netherlands
- Department of Patient & Care, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussels, Belgium
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Burnham Mace B. Setting The Stage For 2017. Provider 2017; 43:30-34. [PMID: 29601703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Seniors Housing, Skilled Nursing, And The Economy.
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Affiliation(s)
- Alison While
- Emeritus Professor of Community Nursing, King's College London, Florence Nightingale Faculty of Nursing and Midwifery and Fellow of the QNI
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Slocum S, Lynn J. Organizing Eldercare for Geographic Communities. Perspect Biol Med 2017; 60:519-529. [PMID: 29576561 DOI: 10.1353/pbm.2017.0040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The dramatically increasing prevalence of elderly persons disabled by conditions associated with aging could motivate reexamination of service delivery and financing for this population, seeking quality, reliability, and efficiency. Research and innovation have established many components of effective reforms, such as patient-directed care planning, encouragement of volunteer networks and family caregiving, mobilizing services to the home, adhering to patient goals and priorities, limiting poly-pharmacy, reducing the risk of falls, and providing adequate support services for people with disabilities. However, none have become widespread and rarely, if ever, are all of the evidence-based improvements available to a particular disabled elder. This essay argues that reform for disabled elders should be anchored in geographic communities, with a new organizational entity having responsibility for measuring performance and implementing improvements. This entity would use data and public input to set priorities, test improvement strategies, and take steps to assure adequate workforce and service supply. In this MediCaring Community, sustaining finances could come from local taxes or capturing the savings in Medicare that arise with optimal comprehensive services. Generating a new structure to monitor and manage eldercare services for a geographic community would be readily accomplished in some communities and would be worth testing.
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Kruger TM, Gilland S, Frank JB, Murphy BC, English C, Meade J, Morrow K, Rush E. Cross-cultural comparison of long-term care in the United States and Finland: Research done through a short-term study-abroad experience. Gerontol Geriatr Educ 2017; 38:104-118. [PMID: 27635462 DOI: 10.1080/02701960.2016.1232591] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
In May 2014, a short-term study-abroad experience was conducted in Finland through a course offered at Indiana State University (ISU). Students and faculty from ISU and Eastern Illinois University participated in the experience, which was created to facilitate a cross-cultural comparison of long-term-care settings in the United States and Finland. With its outstanding system of caring for the health and social needs of its aging populace, Finland is a logical model to examine when considering ways to improve the quality of life for older adults who require care in the United States . Those participating in the course visited a series of long-term-care facilities in the region surrounding Terre Haute, Indiana, then travelled to Lappeenranta, Finland to visit parallel sites. Through limited-participation observation and semistructured interviews, similarities and differences in experiences, educations, and policies affecting long-term care workers in the United States and Finland were identified and are described here.
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Affiliation(s)
- Tina M Kruger
- a Department of Applied Health Sciences , Indiana State University , Terre Haute , Indiana , USA
| | - Sarah Gilland
- a Department of Applied Health Sciences , Indiana State University , Terre Haute , Indiana , USA
| | - Jacquelyn B Frank
- b School of Family and Consumer Sciences , Eastern Illinois University , Charleston , Illinois , USA
| | - Bridget C Murphy
- b School of Family and Consumer Sciences , Eastern Illinois University , Charleston , Illinois , USA
| | - Courtney English
- a Department of Applied Health Sciences , Indiana State University , Terre Haute , Indiana , USA
| | - Jana Meade
- c School of Nursing , Indiana State University , Terre Haute , Indiana , USA
| | - Kaylee Morrow
- d Early Learning Indiana , Indianapolis , Indiana , USA
| | - Evan Rush
- e Chemistry Department , Indiana State University , Terre Haute , Indiana , USA
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Gillick MR. Merchants of Health: Shaping the Experience of Illness Among Older People. Perspect Biol Med 2017; 60:530-548. [PMID: 29576562 DOI: 10.1353/pbm.2017.0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Despite nearly universal health-care coverage for older Americans, the quality of care for the sickest and frailest remains sub-optimal. Understanding why requires analysis of the medical ecosystem. This paper considers the role of four of the principal actors in this system: physicians, hospitals, drug companies, and Medicare. Physicians spend more time in the office addressing diabetes and hypertension than they do evaluating falls and impaired cognition because of their training and their interests. Hospital administrators affect the hospital experience by investing in procedural specialties at the expense of low-tech, high-touch care. Pharmaceutical companies affect the medications older patients take by direct-to-consumer advertising and marketing to physicians. Medicare affects the patient's experience by prospective payment for hospitals, resulting in the burgeoning of post-acute care to accommodate early hospital discharges. Determining how to improve the quality of care for older people requires identifying a lever that affects the entire system. Medicare is uniquely positioned to serve this role. Reforming Medicare by introducing cost-effectiveness criteria for reimbursement of expensive devices, by instituting requirements that medical resident training programs include exposure to multidisciplinary team care, and by introducing a new benefit package for the frail elderly could improve American geriatric care.
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Abbing HR. Health, Healthcare and Ageing Populations in Europe, a Human Rights Challenge for European Health Systems. Eur J Health Law 2016; 23:435-52. [PMID: 29210245 DOI: 10.1163/15718093-12341427] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Demographic changes (ageing populations) are a challenge for European health systems. Innovative solutions must ensure elderly patients equitable access to good quality, affordable healthcare. De-centralisation and de-institutionalisation in healthcare for the elderly have become policy priorities for European countries. Local governments must have sufficient experience for the necessary integration of health and social services. New ways of looking at health care systems are necessary for reasons of quality, accessibility, and costs-effectiveness. The implementation and co-ordinated monitoring of the health- and care rights of the aged in Europe should be given full attention. There needs to be a handbook on elderly as well as an ombudsman. The exchange of experiences and best practices, oversight of the quality and effectiveness of the health- and care services and the system as such are indispensable.
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Funding cuts are leaving older and disabled people 'outside the system'. Nurs Older People 2016; 28:7. [PMID: 27682372 DOI: 10.7748/nop.28.8.7.s6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Older people are bearing the brunt of cuts to social care and increasing numbers of care homes could go out of business, a new report warns.
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O'Dowd A. Cuts to social care funding represent urgent threat to the NHS, warn experts. BMJ 2016; 354:i5021. [PMID: 27645258 DOI: 10.1136/bmj.i5021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Arsenijevic J, Groot W, Tambor M, Golinowska S, Sowada C, Pavlova M. A review of health promotion funding for older adults in Europe: a cross-country comparison. BMC Health Serv Res 2016; 16 Suppl 5:288. [PMID: 27608766 PMCID: PMC5016727 DOI: 10.1186/s12913-016-1515-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Health promotion interventions for older adults are important as they can decrease the onset and evolution of diseases and thus can reduce the medical costs related to those diseases. However, there is no comparative evidence on how those interventions are funded in European countries. The aim of this study is to explore the funding of health promotion interventions in general and health promotion interventions for older adults in particular in European countries. METHOD We use desk research to identify relevant sources of information such as official national documents, international databases and scientific articles. Fora descriptive overview on how health promotion is funded, we focus on three dimensions: who is funding health promotion, what are the contribution mechanisms and who are the collecting agents. In addition to general information on funding of health promotion, we explore how programs on health promotion for older population groups are funded. RESULTS There is a great diversity in funding of health promotion in European countries. Although public sources (tax and social health insurance revenues) are still most often used, other mechanisms of funding such as private donations or European funds are also common. Furthermore, there is no clear pattern in the funding of health promotion for different population groups. This is of particular importance for health promotion for older adults where information is limited across European countries. CONCLUSIONS This study provides an overview of funding of health promotion interventions in European countries. The main obstacles for funding health promotion interventions are lack of information and the fragmentation in the funding of health promotion interventions for older adults.
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Affiliation(s)
- Jelena Arsenijevic
- Department of Health Services Research; CAPHRI, Maastricht University Medical Center, Maastricht, The Netherlands
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Wim Groot
- Department of Health Services Research; CAPHRI, Maastricht University Medical Center, Maastricht, The Netherlands
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Top Institute Evidence-Based Education Research (TIER), Maastricht University, Maastricht, The Netherlands
| | - Marzena Tambor
- Faculty of Health Sciences, Department of Health Economics and Social Security, Institute of Public Health, Jagiellonian University Collegium Medicum, Krakow, Poland
| | - Stanislawa Golinowska
- Faculty of Health Sciences, Department of Health Economics and Social Security, Institute of Public Health, Jagiellonian University Collegium Medicum, Krakow, Poland
| | - Christoph Sowada
- Faculty of Health Sciences, Department of Health Economics and Social Security, Institute of Public Health, Jagiellonian University Collegium Medicum, Krakow, Poland
| | - Milena Pavlova
- Department of Health Services Research; CAPHRI, Maastricht University Medical Center, Maastricht, The Netherlands
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Huter K, Kocot E, Kissimova-Skarbek K, Dubas-Jakóbczyk K, Rothgang H. Economic evaluation of health promotion for older people-methodological problems and challenges. BMC Health Serv Res 2016; 16 Suppl 5:328. [PMID: 27609155 PMCID: PMC5016726 DOI: 10.1186/s12913-016-1519-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The support of health promotion activities for older people gains societal relevance in terms of enhancing the health and well-being of older people with a view to the efficient use of financial resources in the healthcare sector. Health economic evaluations have become an important instrument to support decision-making processes in many countries. Sound evidence on the cost-effectiveness of health promotion activities would encourage support for the implementation of health promotion activities for older people. This debate article discusses to what extent economic evaluation techniques are appropriate to support decision makers in the allocation of resources regarding health promotion activities for older people. We address the problem that the economic evaluation of these interventions is hampered by methodological obstacles that limit comparability, e.g. with economic evaluations of curative measures. Our central objective is to describe and discuss the specific problems and challenges entailed in the economic evaluation of health promotion activities especially for older people with regard to their usefulness for informing decision making processes. DISCUSSION Beyond general problems concerning the economic evaluation of health promotion, our discussion focusses on problems that pertain to the analysis of cost and outcomes of health promotion interventions for older people. With regard to costs these are general problems of economic evaluations, namely the actual implementation of a societal perspective, the appropriate measurement and valuation of informal caregiver time, the measurement and valuation of productivity costs and costs incurred in added years of life. The main problems concerning the identification and measurement of outcomes are related to the identification of outcome parameters that, firstly, adequately reflect the broad effects of health promotion interventions, especially social benefits that gain importance for older people, and secondly, ensure a comparability of effects across different age groups. In particular, the limitations of the widely used QALY for older people are discussed and recently developed alternatives are presented. CONCLUSIONS The key conclusion of the article is that a comparison of the effects of different health promotion initiatives between different age groups by means of economic evaluation is not recommendable. Taking into account the complex outcomes of health promotion interventions it has to be accepted that the outcomes of these interventions will often not be comparable with clinical interventions and have to be assessed differently.
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Affiliation(s)
- Kai Huter
- SOCIUM - Research Center on Inequality and Social Policy, University of Bremen, Mary-Somerville-Straße 5, 28359 Bremen, Germany
- High-profile area Health Sciences, University of Bremen, Bremen, Germany
| | - Ewa Kocot
- Health Economics and Social Security Department, Institute of Public Health, Jagiellonian University Medical College, Grzegórzecka 20 St., 30-351 Crakow, Poland
| | - Katarzyna Kissimova-Skarbek
- Health Economics and Social Security Department, Institute of Public Health, Jagiellonian University Medical College, Grzegórzecka 20 St., 30-351 Crakow, Poland
| | - Katarzyna Dubas-Jakóbczyk
- Health Economics and Social Security Department, Institute of Public Health, Jagiellonian University Medical College, Grzegórzecka 20 St., 30-351 Crakow, Poland
| | - Heinz Rothgang
- SOCIUM - Research Center on Inequality and Social Policy, University of Bremen, Mary-Somerville-Straße 5, 28359 Bremen, Germany
- High-profile area Health Sciences, University of Bremen, Bremen, Germany
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Aspinal F, Glasby J, Rostgaard T, Tuntland H, Westendorp RGJ. New horizons: Reablement - supporting older people towards independence. Age Ageing 2016; 45:572-6. [PMID: 27209329 DOI: 10.1093/ageing/afw094] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 04/13/2016] [Indexed: 11/13/2022] Open
Abstract
As the overwhelming majority of older people prefer to remain in their own homes and communities, innovative service provision aims to promote independence of older people despite incremental age associated frailty. Reablement is one such service intervention that is rapidly being adopted across high-income countries and projected to result in significant cost-savings in public health expenditure by decreasing premature admission to acute care settings and long-term institutionalisation. It is an intensive, time-limited intervention provided in people's homes or in community settings, often multi-disciplinary in nature, focussing on supporting people to regain skills around daily activities. It is goal-orientated, holistic and person-centred irrespective of diagnosis, age and individual capacities. Reablement is an inclusive approach that seeks to work with all kinds of frail people but requires skilled professionals who are willing to adapt their practise, as well as receptive older people, families and care staff. Although reablement may just seem the right thing to do, studies on the outcomes of this knowledge-based practice are inconsistent-yet there is an emerging evidence and practice base that suggests that reablement improves performance in daily activities. This innovative service however may lead to hidden side effects such as social isolation and a paradoxical increase in hospital admissions. Some of the necessary evaluative research is already underway, the results of which will help fill some of the evidence gaps outlined here.
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Affiliation(s)
- Fiona Aspinal
- Social Policy Research Unit, University of York, Heslington, York YO10 5DD, UK
| | - Jon Glasby
- School of Social Policy, Muirhead Tower, Room 829, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Tine Rostgaard
- KORA - Danish Institute for Local and Regional Government Research, 1150 København K, Denmark
| | - Hanne Tuntland
- Centre for Care Research Western Norway and Department of Occupational Therapy, Physiotherapy and Radiography, Bergen University College, 5020 Bergen, Norway
| | - Rudi G J Westendorp
- Department of Public Health and Center for Healthy Aging, University of Copenhagen, 1123 Copenhagen K, Denmark
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Bergman MA, Johansson P, Lundberg S, Spagnolo G. Privatization and quality: Evidence from elderly care in Sweden. J Health Econ 2016; 49:109-19. [PMID: 27394007 DOI: 10.1016/j.jhealeco.2016.06.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 06/04/2016] [Accepted: 06/22/2016] [Indexed: 05/16/2023]
Abstract
Non-contractible quality dimensions are at risk of degradation when the provision of public services is privatized. However, privatization may increase quality by fostering performance-improving innovation, particularly if combined with increased competition. We assemble a large data set on elderly care services in Sweden between 1990 and 2009 and estimate how opening to private provision affected mortality rates - an important and not easily contractible quality dimension - using a difference-in-difference-in-difference approach. The results indicate that privatization and the associated increase in competition significantly improved non-contractible quality as measured by mortality rates.
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Affiliation(s)
| | - Per Johansson
- Department of Statistics, IFAU - Institute for Labour Market and Education Policy Evaluation, Institute for the Study of Labor (IZA), Uppsala University, Sweden
| | - Sofia Lundberg
- Department of Economics, Umeå School of Business and Economics, Umeå University, Sweden.
| | - Giancarlo Spagnolo
- Stockholm School of Economics (SITE), EIEF, Centre for Economic Policy Research (CEPR), University of Rome 'Tor Vergata', Italy
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[Geriatric care will get more support starting in July]. MMW Fortschr Med 2016; 158 Spec No 1:16. [PMID: 27090668 DOI: 10.1007/s15006-016-8091-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Aged Care Senate Inquiry: The need to prioritise resident care over profits. Qld Nurse 2016; 35:18. [PMID: 27468438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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Comans TA, Peel NM, Hubbard RE, Mulligan AD, Gray LC, Scuffham PA. The increase in healthcare costs associated with frailty in older people discharged to a post-acute transition care program. Age Ageing 2016; 45:317-20. [PMID: 26769469 DOI: 10.1093/ageing/afv196] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 12/02/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND older people are high users of healthcare resources. The frailty index can predict negative health outcomes; however, the amount of extra resources required has not been quantified. OBJECTIVE to quantify the impact of frailty on healthcare expenditure and resource utilisation in a patient cohort who entered a community-based post-acute program and compare this to a cohort entering residential care. METHODS the interRAI home care assessment was used to construct a frailty index in three frailty levels. Costs and resource use were collected alongside a prospective observational cohort study of patients. A generalized linear model was constructed to estimate the additional cost of frailty and the cost of alternative residential care for those with high frailty. RESULTS participants (n = 272) had an average age of 79, frailty levels were low in 20%, intermediate in 50% and high in 30% of the cohort. Having an intermediate or high level of frailty increased the likelihood of re-hospitalisation and was associated with 22 and 43% higher healthcare costs over 6 months compared with low frailty. It was less costly to remain living at home than enter residential care unless >62% of subsequent hospitalisations in 6 months could be prevented. CONCLUSIONS the frailty index can potentially be used as a tool to estimate the increase in healthcare resources required for different levels of frailty. This information may be useful for quantifying the amount to invest in programs to reduce frailty in the community.
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Affiliation(s)
- Tracy A Comans
- Menzies Health Institute Queensland, Griffith University, University Drive Meadowbrook, Brisbane, Queensland 4131, Australia Metro North Hospital and Health Service District-Allied Health, The Prince Charles Hospital Rode Road Chermside, Brisbane, Queensland 4032, Australia
| | - Nancye M Peel
- Centre for Research in Geriatric Medicine, University of Queensland, Brisbane, Queensland 4102, Australia
| | - Ruth E Hubbard
- Centre for Research in Geriatric Medicine, University of Queensland, Brisbane, Queensland 4102, Australia The University of Queensland School of Medicine-Geriatric Medicine, Woolloongabba, Queensland, Australia
| | - Andrew D Mulligan
- Centre for Research in Geriatric Medicine, University of Queensland, Brisbane, Queensland 4102, Australia
| | - Leonard C Gray
- Centre for Research in Geriatric Medicine, University of Queensland, Woolloongabba, Queensland, Australia
| | - Paul A Scuffham
- Menzies Health Institute Queensland, Griffith University, University Drive Meadowbrook, Brisbane, Queensland 4131, Australia
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44
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Hawkes N. Policy layers delay funding of innovative care deal for elderly people, conference hears. BMJ 2016; 352:i868. [PMID: 26867557 DOI: 10.1136/bmj.i868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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45
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Pasco B. Impact of financial difficulty on health and aged care choices. Aust Nurs Midwifery J 2016; 23:30. [PMID: 27032137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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46
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Blom J, den Elzen W, van Houwelingen AH, Heijmans M, Stijnen T, Van den Hout W, Gussekloo J. Effectiveness and cost-effectiveness of a proactive, goal-oriented, integrated care model in general practice for older people. A cluster randomised controlled trial: Integrated Systematic Care for older People--the ISCOPE study. Age Ageing 2016; 45:30-41. [PMID: 26764392 PMCID: PMC4711660 DOI: 10.1093/ageing/afv174] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background: older people often experience complex problems. Because of multiple problems, care for older people in general practice needs to shift from a ‘problem-based, disease-oriented’ care aiming at improvement of outcomes per disease to a ‘goal-oriented care’, aiming at improvement of functioning and personal quality of life, integrating all healthcare providers. Feasibility and cost-effectiveness of this proactive and integrated way of working are not yet established. Design: cluster randomised trial. Participants: all persons aged ≥75 in 59 general practices (30 intervention, 29 control), with a combination of problems, as identified with a structured postal questionnaire with 21 questions on four health domains. Intervention: for participants with problems on ≥3 domains, general practitioners (GPs) made an integrated care plan using a functional geriatric approach. Control practices: care as usual. Outcome measures: (i) quality of life (QoL), (ii) activities of daily living, (iii) satisfaction with delivered health care and (iv) cost-effectiveness of the intervention at 1-year follow-up. Trial registration: Netherlands trial register, NTR1946. Results: of the 11,476 registered eligible older persons, 7,285 (63%) participated in the screening. One thousand nine hundred and twenty-one (26%) had problems on ≥3 health domains. For 225 randomly chosen persons, a care plan was made. No beneficial effects were found on QoL, patients' functioning or healthcare use/costs. GPs experienced better overview of the care and stability, e.g. less unexpected demands, in the care. Conclusions: GPs prefer proactive integrated care. ‘Horizontal’ care using care plans for older people with complex problems can be a valuable tool in general practice. However, no direct beneficial effect was found for older persons.
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Affiliation(s)
- Jeanet Blom
- Public Health and Primary Care, Leiden University Medical Center, Leiden2300 RC, The Netherlands
| | - Wendy den Elzen
- Public Health and Primary Care, Leiden University Medical Center, Leiden2300 RC, The Netherlands
| | - Anne H van Houwelingen
- Public Health and Primary Care, Leiden University Medical Center, Leiden2300 RC, The Netherlands
| | - Margot Heijmans
- Public Health and Primary Care, Leiden University Medical Center, Leiden2300 RC, The Netherlands
| | - Theo Stijnen
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
| | - Wilbert Van den Hout
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Jacobijn Gussekloo
- Public Health and Primary Care, Leiden University Medical Center, Leiden2300 RC, The Netherlands
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47
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Volobuev AN, Zaharova NO, Romanchuk NP, Romanov DV, Romanchuk PI, Adyshirin-Zade KA. [Modern principles of the geriatric analysis in medicine]. Adv Gerontol 2016; 29:461-470. [PMID: 28525694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The offered methodological principles of the geriatric analysis in medicine enables to plan economic parameters of social protection of the population, necessary amount of medical help financing, to define a structure of the qualified medical personnel training. It is shown that personal health and cognitive longevity of the person depend on the adequate system geriatric analysis and use of biological parameters monitoring in time. That allows estimate efficiency of the combined individual treatment. The geriatric analysis and in particular its genetic-mathematical component aimed at reliability and objectivity of an estimation of the person life expectancy in the country and in region due to the account of influence of mutagen factors as on a gene of the person during his live, and on a population as a whole.
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Affiliation(s)
- A N Volobuev
- Samara state medical university, Samara, 443099, Russian Federation;
| | - N O Zaharova
- Samara state medical university, Samara, 443099, Russian Federation;
| | - N P Romanchuk
- Samara state medical university, Samara, 443099, Russian Federation;
| | - D V Romanov
- Samara state medical university, Samara, 443099, Russian Federation;
| | - P I Romanchuk
- Samara state medical university, Samara, 443099, Russian Federation;
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48
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Tanajewski L, Franklin M, Gkountouras G, Berdunov V, Harwood RH, Goldberg SE, Bradshaw LE, Gladman JRF, Elliott RA. Economic Evaluation of a General Hospital Unit for Older People with Delirium and Dementia (TEAM Randomised Controlled Trial). PLoS One 2015; 10:e0140662. [PMID: 26684872 PMCID: PMC4687694 DOI: 10.1371/journal.pone.0140662] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 09/28/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND One in three hospital acute medical admissions is of an older person with cognitive impairment. Their outcomes are poor and the quality of their care in hospital has been criticised. A specialist unit to care for older people with delirium and dementia (the Medical and Mental Health Unit, MMHU) was developed and then tested in a randomised controlled trial where it delivered significantly higher quality of, and satisfaction with, care, but no significant benefits in terms of health status outcomes at three months. OBJECTIVE To examine the cost-effectiveness of the MMHU for older people with delirium and dementia in general hospitals, compared with standard care. METHODS Six hundred participants aged over 65 admitted for acute medical care, identified on admission as cognitively impaired, were randomised to the MMHU or to standard care on acute geriatric or general medical wards. Cost per quality adjusted life year (QALY) gained, at 3-month follow-up, was assessed in trial-based economic evaluation (599/600 participants, intervention: 309). Multiple imputation and complete-case sample analyses were employed to deal with missing QALY data (55%). RESULTS The total adjusted health and social care costs, including direct costs of the intervention, at 3 months was £7714 and £7862 for MMHU and standard care groups, respectively (difference -£149 (95% confidence interval [CI]: -298, 4)). The difference in QALYs gained was 0.001 (95% CI: -0.006, 0.008). The probability that the intervention was dominant was 58%, and the probability that it was cost-saving with QALY loss was 39%. At £20,000/QALY threshold, the probability of cost-effectiveness was 94%, falling to 59% when cost-saving QALY loss cases were excluded. CONCLUSIONS The MMHU was strongly cost-effective using usual criteria, although considerably less so when the less acceptable situation with QALY loss and cost savings were excluded. Nevertheless, this model of care is worthy of further evaluation. TRIAL REGISTRATION ClinicalTrials.gov NCT01136148.
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Affiliation(s)
- Lukasz Tanajewski
- School of Pharmacy, University of Nottingham, Nottingham, United Kingdom
| | - Matthew Franklin
- School of Pharmacy, University of Nottingham, Nottingham, United Kingdom
| | | | - Vladislav Berdunov
- School of Pharmacy, University of Nottingham, Nottingham, United Kingdom
| | - Rowan H. Harwood
- Health Care of Older People, Nottingham University Hospitals NHS Trust, Queens Medical Centre, Nottingham, United Kingdom
| | - Sarah E. Goldberg
- School of Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Lucy E. Bradshaw
- Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, United Kingdom
| | - John R. F. Gladman
- Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, United Kingdom
| | - Rachel A. Elliott
- School of Pharmacy, University of Nottingham, Nottingham, United Kingdom
- * E-mail:
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49
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Iacobucci G. Flagship £800m contract collapses after just eight months. BMJ 2015; 351:h6626. [PMID: 26637349 DOI: 10.1136/bmj.h6626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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50
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Aged care: Proposed deal reached; two ratified. Nurs N Z 2015; 21:37. [PMID: 26719880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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