Acute Care Use Research Articles

Defining user needs for an electronic tool to improve chemotherapy-related toxicity management.

157 Background: Cancer drugs are associated with toxicities which can negatively impact patients’ (pts) quality of life, outcomes and increase acute care use (ACU). There is increasing interest in leveraging technology to solve clinical problems in healthcare. We hypothesized that an electronic tool (toxicity module) targeting management of chemotherapy toxicities could decrease ACU by facilitating more effective symptom management. Methods: Participatory design methodology consisting of end user needs assessment through ethnographic field study (shadowing and in-depth interviews) and focus groups was used to inform design of an interactive prototype toxicity module. Oncology pts and their caregivers, and health care providers (HCPs) including oncologists, oncology nurses and primary care providers were included in all stages of development. Contemporaneous notes were taken during ethnography while focus groups were also audio recorded. Thematic analysis through ideation sessions and time-of-day exercises allowed identification of overarching issues. Results: Eight pts and 8 HCPs participated in the ethnographic field study. Two focus groups, one with 7 pts, one with 4 HCPs were held. Most themes were common to both pts and HCPs; gaps and barriers in the current system, need for decision aids, improved HCP communication and options in care delivery, and access to credible information delivered in a timely, secure manner and integrated into existing systems. Additionally, pts further identified missed opportunities, care not meeting their needs, feeling overwhelmed and anxious and wanting to be more empowered; HCPs identified accountability as an issue. These themes informed development of a prototype for a web-based toxicity management tool, which has served the purpose of defining user needs for symptom tracking, self-management advice, and timely communication with an oncology provider. Iterative evaluation over 2 rounds of usability testing is currently underway. Conclusions: An electronic tool that integrates just-in-time self-management advice and oncology provider support into routine care may address some of the gaps identified in the current system for managing chemotherapy toxicity.

Feasibility, acceptability, and efficacy of a proactive telephone intervention to improve toxicity management during chemotherapy.

105 Background: Chemotherapy (chemo) is associated with a significant risk of toxicity, which often peaks between ambulatory visits. Consequently, effective remote symptom management support is essential to optimize self-management and resource use, including emergency department visits and hospitalizations (ED+H) during chemo. The aim of this study was to examine the feasibility, acceptability and effects of a telephone management intervention on symptomatic toxicity and resource use during chemo for early stage breast cancer (EBC). Methods: A prospective study of telephone-based toxicity management among women receiving neo-adjuvant or adjuvant chemo for EBC was undertaken at one urban and one rural site in Ontario, Canada. The intervention consisted of two standardized calls by nurses assessing common toxicities after each chemo (call 1 within 3 days and call 2 within 8-10 days). Primary outcome measures were feasibility and acceptability based on patient (pt) and clinician feedback. Efficacy was evaluated by self-reported ED+H. Results: Between 09/2013 and 12/2014, 77 women with EBC were enrolled (mean age 55 years). Most commonly used regimens were AC-paclitaxel (58%) and FEC-docetaxel (16%). 78% of pts received primary GCSF prophylaxis. Adherence with calls was 82%; mean call duration was 9 minutes. The intervention was well received by both pts and clinicians. 97% of pts indicated they liked receiving the calls and 94% would recommend this protocol be offered to all pts receiving chemo. Clinicians and pts felt the calls reduced pt anxiety by providing just-in-time education and counselling. Twenty five (33%) pts reported at least one ED+H during chemo, lower than the historical rate of 44% for this population in Ontario. Challenges included introducing an intervention that involved both routine clinical personnel and research staff and incorporating the calls into existing work responsibilities. Conclusions: Telephone-based toxicity management during ESB chemo is feasible, perceived as valuable by clinicians and pts, and may be associated with lower rates of acute care use. Larger scale evaluations of this approach focusing on effectiveness are warranted.

Association of high rates of practice-level inpatient-intensity with end-of-life outcomes, readmission rates, and weekend hospitalizations among Medicare patients with cancer.

5 Background: Substantial practice-level variation exists in use of acute hospital care for patients receiving anti-cancer therapy. The aim of this study was to determine whether patient outcomes were associated with greater inpatient-intensity at the treating practices. Methods: Retrospective analysis of 397,646 Medicare beneficiaries receiving anti-cancer therapy in 2012. Each beneficiary was associated with a practice and practices were ranked based on average payments for inpatient admissions (inpatient intensity). Outcomes included 30-day readmission, weekend admissions, intensive-care unit (ICU) stays in the last month of life, and hospice stay of at least 7 days. Outcomes were measured for each quartile of practice inpatient-intensity. We fit multivariable logistic regression models to calculate adjusted odds ratios for each outcome for each quartile of inpatient-intensity. Results: Total and unplanned 30-day readmissions increased from 22.8% to 31.9% (adjusted odds ratio and 95% confidence interval: 1.45 [1.39-1.50]) and 19.8% to 27.1% (1.36 [1.31-1.41]), respectively, for patients in practices in the lowest and highest quartiles of inpatient-intensity. The proportion of admissions occurring on the weekend was similar across quartiles. The proportion of decedents with an ICU stay in the last month of life increased from 18.0% to 25.5% (1.33, 1.19–1.49) while the proportion with a hospice stay of > = 7 days decreased from 50.9% to 42.5% (0.79, 0.74–0.86) between those in practices in the lowest and highest quartiles of inpatient intensity. Conclusions: Participants in oncology practice delivery reform may find significant opportunity to improve quality and reduce costs by initially focusing on processes related to improving end-of-life care and reducing readmissions.

Geriatric Conditions in a Population-Based Sample of Older Homeless Adults.

Older homeless adults living in shelters have high rates of geriatric conditions, which may increase their risk for acute care use and nursing home placement. However, a minority of homeless adults stay in shelters and the prevalence of geriatric conditions among homeless adults living in other environments is unknown. We determined the prevalence of common geriatric conditions in a cohort of older homeless adults, and whether the prevalence of these conditions differs across living environments. We interviewed 350 homeless adults, aged 50 and older, recruited via population-based sampling in Oakland, CA. We evaluated participants for common geriatric conditions. We assessed living environment using a 6-month follow-back residential calendar, and used cluster analysis to identify participants' primary living environment over the prior 6 months. Participants stayed in 4 primary environments: unsheltered locations (n = 162), multiple locations including shelters and hotels (n = 88), intermittently with family/friends (n = 57), and, in a recently homeless group, rental housing (n = 43). Overall, 38.9% of participants reported difficulty performing 1 or more activities of daily living, 33.7% reported any falls in the past 6 months, 25.8% had cognitive impairment, 45.1% had vision impairment, and 48.0% screened positive for urinary incontinence. The prevalence of geriatric conditions did not differ significantly across living environments. Geriatric conditions were common among older homeless adults living in diverse environments, and the prevalence of these conditions was higher than that seen in housed adults 20 years older. Services that address geriatric conditions are needed for older homeless adults living across varied environments.

Detained and Distressed: Persistent Distressing Symptoms in a Population of Older Jail Inmates (TH360B)

•Describe the prevalence of symptomatic distress in a population of older jail inmates, including physical, psychological, existential, and social suffering.•Identify sociodemographic and health factors associated with physically distressing symptoms in this population.•Understand the high prevalence of overlap among physical distress and other forms of distress (psychological, social, and existential) in older jail inmates and its implications for jail-based treatment paradigms. Among older adults, distressing symptoms are associated with decreased function, acute care use, and mortality. However, little is known about distressing symptomatology in the rapidly growing population of older jail inmates. This study describes the prevalence of and factors associated with distressing symptoms in older jail inmates, and examines the overlap between different forms of symptom distress. This descriptive cross-sectional study of 125 jail inmates age 55 or older in the San Francisco County jail examined the following forms of symptom distress: physical (Memorial Symptom Assessment Scale, defined as severe, frequent, and distressing), psychological (anxiety [GAD-2] or depression [PHQ-2]), existential (Patient Dignity Inventory), and social (Three Item Loneliness Scale). Participant sociodemographics, health conditions, functional ability, and behavioral health risk factors were collected using self-report and chart review. We identified factors associated with physical distress using Chi-squared tests, and determined overlap between forms of distress using set theory analysis. Participants had a mean age of 60 (range 55-87 yrs.) and were predominantly black (63%) and of low-income (86% <$15,000/yr). Overall, 100 (80%) participants reported one or more distressing symptoms, including physical (44%), psychological (56%), existential (71%), and social (45%). Factors associated with physical distress included low income, multimorbidity, serious mental illness (SMI), and functional impairment. Many participants experienced multiple forms of distress; of the 100 participants with any distressing symptom, 51% reported 3 or more forms of distress. Nearly all participants with physical distress also reported existential distress (93%). Among older inmates, physical distress was associated with poor health (multimorbidity, functional impairment, SMI) and low income. Overlap between forms of distress was common, particularly physical and existential distress.

Acute Health Care Utilization among Food-insecure Children in Primary Care Practices.

Building on prior research, this study tested two theories: (1) differences in child health care utilization can predict household food insecurity (FI), and (2) FI is associated with subsequent increased acute health care use. We conducted a prospective cohort study of 3,335 children screened for FI at three-year well-child visits in three urban practices, evaluating their acute care use one year before and after FI screening. Prior to screening, food-insecure participants had fewer acute primary care visits, but there were no differences in emergency department visits or hospitalizations. Overall, child demographic characteristics and health care use were no better than chance in predicting household FI. For those who screened positive, there were no differences in subsequent acute care use. This study suggests that the risk of FI among three-year olds cannot be reliably predicted based on acute health care use patterns, and FI may not be associated with subsequent acute health care use.

Palliative Care Consultations in Nursing Homes and Reductions in Acute Care Use and Potentially Burdensome End-of-Life Transitions

Palliative Care Consultations in Nursing Homes and Reductions in Acute Care Use and Potentially Burdensome End-of-Life Transitions

First incident hospitalisation for Australian women aged 70 and beyond: A 10 year examination using competing risks

There are increasing concerns regarding high hospital use among older adults and the capacity to manage the economic impact of the ageing population trend on healthcare systems. First hospitalisation in old age may act as a catalyst for ongoing intensification of health problems and acute care use. This study examined factors associated with first incident hospitalisation in women aged over 70, accounting for the health inequalities associated with geographic location. Survey data from 3780 women from the 1921 to 1926 cohort of the Australian Longitudinal Study on Women’s Health were matched with the Admitted Patients Data Collection and National Death Index. Days to first event (hospitalisation or death) were modelled using competing risks methods. A total of 3065 (80.3%) women had at least one hospital admission. More than half of the top 15 reasons for first hospitalisation were related to cardiovascular disease, with atrial fibrillation the most common. Proportional subdistribution hazards models showed that first hospital admission was driven by enabling and need factors including asthma/bronchitis diagnosis (HR=1.16; p=0.047), private health insurance (HR=1.16; p=0.004) more than two prescribed medications in previous month (HR=1.31; p=0.001), more than four general practitioner visits in previous year (HR=1.50; p=0.034), lower physical functioning (HR=0.99; p<0.001) and living in an inner regional area (HR=1.17; p=0.003). First overnight hospitalisation was primarily related with potentially preventable and treatable chronic diseases. Primary and secondary strategies aimed at chronic disease generally, and better chronic disease management particularly for cardiovascular and respiratory diseases, may play a vital role in disease prevention or delay in readmissions among this population.

Clinical Framework and Medical Countermeasure Use During an Anthrax Mass-Casualty Incident.

In 2014, CDC published updated guidelines for the prevention and treatment of anthrax (Hendricks KA, Wright ME, Shadomy SV, et al. Centers for Disease Control and Prevention expert panel meetings on prevention and treatment of anthrax in adults. Emerg Infect Dis 2014;20[2]. Available at http://wwwnc.cdc.gov/eid/article/20/2/13-0687_article.htm). These guidelines provided recommended best practices for the diagnosis and treatment of persons with naturally occurring or bioterrorism-related anthrax in conventional medical settings. An aerosolized release of Bacillus anthracis spores over densely populated areas could become a mass-casualty incident. To prepare for this possibility, the U.S. government has stockpiled equipment and therapeutics (known as medical countermeasures [MCMs]) for anthrax prevention and treatment. However, previously developed, publicly available clinical recommendations have not addressed the use of MCMs or clinical management during an anthrax mass-casualty incident, when the number of patients is likely to exceed the ability of the health care infrastructure to provide conventional standards of care and supplies of MCMs might be inadequate to meet the demand required. To address this gap, in 2013, CDC conducted a series of systematic reviews of the scientific literature on anthrax to identify evidence that could help clinicians and public health authorities set guidelines for intravenous antimicrobial and antitoxin use, diagnosis of anthrax meningitis, and management of common anthrax-specific complications in the setting of a mass-casualty incident. Evidence from these reviews was presented to professionals with expertise in anthrax, critical care, and disaster medicine during a series of workgroup meetings that were held from August 2013 through March 2014. In March 2014, a meeting was held at which 102 subject matter experts discussed the evidence and adapted the existing best practices guidance to a clinical use framework for the judicious, efficient, and rational use of stockpiled MCMs for the treatment of anthrax during a mass-casualty incident, which is described in this report. This report addresses elements of hospital-based acute care, specifically antitoxins and intravenous antimicrobial use, and the diagnosis and management of common anthrax-specific complications during a mass-casualty incident. The recommendations in this report should be implemented only after predefined triggers have been met for shifting from conventional to contingency or crisis standards of care, such as when the magnitude of cases might lead to impending shortages of intravenous antimicrobials, antitoxins, critical care resources (e.g., chest tubes and chest drainage systems), or diagnostic capability. This guidance does not address primary triage decisions, anthrax postexposure prophylaxis, hospital bed or workforce surge capacity, or the logistics of dispensing MCMs. Clinicians, hospital administrators, state and local health officials, and planners can use these recommendations to assist in the development of crisis protocols that will ensure national preparedness for an anthrax mass-casualty incident.

Intensity of Medical Interventions between Diagnosis and Death in Patients with Advanced Lung and Colorectal Cancer: A CanCORS Analysis.

Medical interventions are an important component of the illness experience in advanced cancer. To describe the use of medical interventions between diagnosis and death in decedents with metastatic lung and colorectal cancer. Retrospective analysis of a prospective cohort study. We studied 1,840 decedents from the Cancer Care Outcomes Research and Surveillance (CanCORS) study. Subjects had been diagnosed with stage IV lung or colorectal cancer between 2003 and 2005. Hospitalizations, surgeries, radiation therapy treatments, chemotherapy treatments, and end-of-life care, reported by tertile of overall survival time. Median survival in the bottom, middle, and top tertiles of survival was 1.2, 5.3, and 15.3 months for lung cancer, and 3.0, 18.0, and 44.4 months for colorectal cancer. Hospitalizations, chemotherapy receipt, and hospice enrollment increased with increasing survival. The median duration of chemotherapy in the top survival tertile was 149 days for lung cancer and 498 days for colorectal cancer. A minority of decedents used any hospice services, and the median duration of hospice enrollment exceeded 30 days only for enrollees in the top survival tertile (lung cancer, 35 days; colorectal cancer, 66 days). For patients with metastatic lung and colorectal cancer, longer survival is associated with increased intensity of medical care, characterized by greater use of chemotherapy and acute hospital care. Hospice utilization was uniformly low, and most hospice enrollees were referred to hospice in the last 30 days of life.

Does Increasing Home Care Nursing Reduce Emergency Department Visits at the End of Life? A Population-Based Cohort Study of Cancer Decedents

ContextDespite being commonplace in health care systems, little research has described home care nursing's effectiveness to reduce acute care use at the end of life. ObjectivesTo examine the temporal association between home care nursing rate on emergency department (ED) visit rate in the subsequent week during the last six months of life. MethodsWe conducted a retrospective cohort study of end-of-life cancer decedents in Ontario, Canada, from 2004 to 2009 by linking administrative databases. We examined the association between home care nursing rate of one week with the ED rate in the subsequent week closer to death, controlling for covariates and repeated measures among decedents. Nursing was dichotomized into standard and end-of-life care intent. ResultsOur cohort included 54,576 decedents who used home care nursing services in the last six months before death, where 85% had an ED visit and 68% received end-of-life home care nursing. Patients receiving end-of-life nursing at any week had a significantly reduced ED rate in the subsequent week of 31% (relative rate [RR] 0.69; 95% confidence interval [CI] 0.68, 0.71) compared with standard nursing. In the last month of life, receiving end-of-life nursing and standard nursing rate of more than five hours/week was associated with a decreased ED rate of 41% (RR 0.59, 95% CI 0.58, 0.61) and 32% (RR 0.68, 95% CI 0.66, 0.70), respectively, compared with standard nursing of one hour/week. ConclusionOur study showed a temporal association between receiving end-of-life nursing in a given week during the last six months of life, and of more standard nursing in the last month of life, with a reduced ED rate in the subsequent week.

The Effect of Community-Based Specialist Palliative Care Teams on Place of Care

Prior research on community-based specialist palliative care teams used outcome measures of place of death and/or dichotomous outcome measures of acute care use in the last two weeks of life. However, existing research seldom measured the diverse places of care used and their timing prior to death. The study objective was to examine the place of care in the last 30 days of life. In this retrospective cohort study, patients who received care from a specialist palliative care team (exposed) were matched by propensity score to patients who received usual care in the community (unexposed) in Ontario, Canada. Measured was the percentage of patients in each place of care in the last month of life as a proportion of the total cohort. After matching, 3109 patients were identified in each group, where 79% had cancer and 77% received end-of-life home care. At 30 days compared to 7 days before death, the exposed group's proportions rose from 33% to 41% receiving home care and 14% to 15% in hospital, whereas the unexposed group's proportions rose from 28% to 32% receiving home care and 16% to 22% in hospital. Linear trend analysis (proportion over time) showed that the exposed group used significantly more home care services and fewer hospital days (p < 0.001) than the unexposed group. On the last day of life (place of death), the exposed group had 18% die in an in-patient hospital bed compared to 29% in usual care. Examining place of care in the last month can effectively illustrate the service use trajectory over time.

Adherence to Infliximab Treatment in a Pediatric Inflammatory Bowel Disease Cohort.

The aims of the study were to describe infliximab adherence in a pediatric inflammatory bowel disease cohort, to identify demographic and disease factors associated with adherence, and to examine differences in acute care use among adherent and nonadherent patients. Charts of patients who received infliximab at the Children's Hospital of Wisconsin (CHW) between October 2010 and October 2012 were retrospectively reviewed. A total of 151 patients met the inclusion criteria; 91.4% of the patients were adherent. Nonadherent patients had more emergency room visits and hospitalizations than adherent patients. The study is the first to show high adherence rates to infliximab in a pediatric cohort.

Association of Early Patient-Physician Care Planning Discussions and End-of-Life Care Intensity in Advanced Cancer.

Early patient-physician care planning discussions may influence the intensity of end-of-life (EOL) care received by veterans with advanced cancer. The study objective was to evaluate the association between medical record documentation of patient-physician care planning discussions and intensity of EOL care among veterans with advanced cancer. This was a retrospective cohort study. Subjects were 665 veteran decedents diagnosed with stage IV colorectal, lung, or pancreatic cancer in 2008, and followed till death or the end of the study period in 2011. We estimated the effect of patient-physician care planning discussions documented within one month of metastatic diagnosis on the intensity of EOL care measured by receipt of acute care, intensive interventions, chemotherapy, and hospice care, using multivariate logistic regression models. Veterans in our study were predominantly male (97.1%), white (74.7%), with an average age at diagnosis of 66.4 years. Approximately 31% received some acute care, 9.3% received some intensive intervention, and 6.5% had a new chemotherapy regimen initiated in the last month of life. Approximately 41% of decedents received no hospice or were admitted within three days of death. Almost half (46.8%) had documentation of a care planning discussion within the first month after diagnosis and those who did were significantly less likely to receive acute care at EOL (OR: 0.67; p=0.025). Documented discussions were not significantly associated with intensive interventions, chemotherapy, or hospice care. Early care planning discussions are associated with lower rates of acute care use at the EOL in a system with already low rates of intensive EOL care.

Medical comorbidity, acute medical care use in late-life bipolar disorder: a comparison of lithium, valproate, and other pharmacotherapies

Bipolar disorder is associated with high rates of medical comorbidity, particularly in late life. Little is known about medical health service utilization and potential effects of bipolar pharmacotherapy. We hypothesized that lithium use would not be associated with higher rates of medical hospitalization. Population-based retrospective cohort study of 1388 bipolar disorder patients aged ≥66years discharged from a psychiatric hospitalization in Ontario, Canada, between 2006 and 2012. Patients were divided into lithium users, valproate users, and non-lithium/non-valproate users. The main outcome was acute non-psychiatric, medical/surgical hospitalization during 1-year follow-up. The rate of medical hospitalizations was 0.22 per patient-year. Time-to-medical hospitalization did not differ among lithium, valproate, and non-lithium/non-valproate users after adjusting for age, sex, past medical hospitalization, and antipsychotic use. Lithium, valproate, and non-lithium/non-valproate users did not differ markedly in terms of reason for medical hospitalization, 1-year acute medical health utilization outcomes, and medical comorbidity rates. There were high rates of health service use for medical conditions among older adults with bipolar disorder, but this did not appear to be associated with lithium use, compared to valproate and other medication use (e.g., antipsychotics). A proactive collaborative care approach may prevent medical service utilization in severe late-life bipolar disorder.

Factors associated with acute care use among nursing home residents dying of cancer: a population-based study

Little is known about residents of long-term care (LTC) facilities who die of cancer. The authors examined factors among this cohort prognostic of greater acute care use to identify areas for improving support in LTC. The authors used administrative data representing all cancer decedents in Ontario, Canada, who had been living in LTC. Binary logistic regression was used to examine the contribution of covariates to having an emergency department (ED) visit in the last 6 months of life or to death in hospital. Among the 1196 LTC residents in the study cohort, 61% had visited an ED in the last 6 months of life and 20% had died in hospital. Cancer type, income, gender, time in LTC and rural location were not strong predictors of the acute care outcomes. However, certain comorbidities, being younger and region of residence significantly increased the odds of an ED visit and/or hospital death (all P<0.05). Determining the characteristics of LTC patients more likely to access acute care services can help to inform interventions that avoid costly and potentially adverse transfers to hospital. The study of cancer patients in LTC represents a starting point for clarifying the potential of specialised palliative care nursing and other support that is often lacking in these facilities.

Use of Post-acute Care Services and Readmissions After Left Ventricular Assist Device Implantation in Privately Insured Patients

BackgroundVery little is known about health care resource utilization, including post–acute care use and hospital readmissions, after left ventricular assist device (LVAD) implantation. Methods and ResultsAdministrative claims from a database of multiple United States health plans were used to identify patients that received an LVAD (ICD-9 code 37.66) and survived to hospital discharge from January 1–2006, through September 30–2013. Post–acute care use was defined as a skilled nursing facility or rehabilitation stay within 90 days after hospital discharge. Patients were censored at heart transplantation or end of coverage through December 31–2013. Of 583 patients (mean age 55 years, 77% male), 223 (38.3%) used post–acute care services, more commonly in patients with diabetes, who required hemodialysis, and who had LVADs implanted at hospitals in more populated areas, with more beds, and in the northeast region (P < .05 for each). The most common reasons for readmission were device complications, heart failure, and arrhythmia. Readmission risk was higher in patients who had diabetes, peripheral vascular disease, and longer hospital length of stay, but it did not differ by post-acute care use. ConclusionsUse of post-acute care services varies based on hospital characteristics. We found no association between post-acute care use and readmission risk after LVAD implantation.

Health Outcomes of Obtaining Housing Among Older Homeless Adults.

We determined the impact of obtaining housing on geriatric conditions and acute care utilization among older homeless adults. We conducted a 12-month prospective cohort study of 250 older homeless adults recruited from shelters in Boston, Massachusetts, between January and June 2010. We determined housing status at follow-up, determined number of emergency department visits and hospitalizations over 12 months, and examined 4 measures of geriatric conditions at baseline and 12 months. Using multivariable regression models, we evaluated the association between obtaining housing and our outcomes of interest. At 12-month follow-up, 41% of participants had obtained housing. Compared with participants who remained homeless, those with housing had fewer depressive symptoms. Other measures of health status did not differ by housing status. Participants who obtained housing had a lower rate of acute care use, with an adjusted annualized rate of acute care visits of 2.5 per year among participants who obtained housing and 5.3 per year among participants who remained homeless. Older homeless adults who obtained housing experienced improved depressive symptoms and reduced acute care utilization compared with those who remained homeless.

Return to the ED and hospitalisation following minor injuries among older persons treated in the emergency department: predictors among independent seniors within 6 months.

minor traumatic injuries among independent older people have received little attention to date, but increasingly the impact of such injuries is being recognised. we assessed the frequency and predictors of acute health care use, defined as return to the emergency department (ED) or hospitalisation. national multicentre prospective observational study. eight Canadian teaching EDs between April 2009 and April 2013. a total of 1,568 patients aged 65-100 years, independent in basic activities of daily living, discharged from ED following a minor traumatic injury. trained assessors measured baseline data including demographics, functional status, cognition, comorbidities, frailty and injury severity. We then conducted follow-up telephone interviews at 6 months to assess subsequent acute health care use. We used log-binomial regression analyses to identify predictors of acute health care use, and reported relative risks and 95% CIs. participants' mean age was 77.0, 66.4% female, and their injuries included contusions (43.5%), lacerations (25.1%) and fractures (25.4%). The cumulative rate of acute health care use by 6 months post-injury was 21.5% (95% CI: 19.0-24.3%). The strongest predictors of acute health care use within 6 months were cognitive impairment, RR = 1.6 (95% IC: 1.2-2.1) and the mechanism of injury including pedestrian struck or recreational injuries, RR = 1.6 (95% CI 1.2-2.2). among independent community living older persons with a minor injury, cognitive impairment and mechanism of injury were independent risk factors for acute healthcare use. Future studies should look at whether tailored discharge planning can reduce the need for acute health care use.

Long-Term Services and Supports for Older Adults: A Review of Home and Community-Based Services Versus Institutional Care

Despite a shift from institutional services toward more home and community-based services (HCBS) for older adults who need long-term services and supports (LTSS), the effects of HCBS have yet to be adequately synthesized in the literature. This review of literature from 1995 to 2012 compares the outcome trajectories of older adults served through HCBS (including assisted living [AL]) and in nursing homes (NHs) for physical function, cognition, mental health, mortality, use of acute care, and associated harms (e.g., accidents, abuse, and neglect) and costs. NH and AL residents did not differ in physical function, cognition, mental health, and mortality outcomes. The differences in harms between HCBS recipients and NH residents were mixed. Evidence was insufficient for cost comparisons. More and better research is needed to draw robust conclusions about how the service setting influences the outcomes and costs of LTSS for older adults. Future research should address the numerous methodological challenges present in this field of research and should emphasize studies evaluating the effectiveness of HCBS.