Use Of Hospital Services Research Articles

Utilization of Psychiatric Hospital Services Following Intensive Home Treatment: A Nonrandomized Clinical Trial.

Home treatment (HT) has been associated with fewer inpatient treatment (IT) readmission days but lacks evidence on reducing combined psychiatric hospital service use (IT, HT, day clinic). To assess the association of intensive home treatment (IHT) compared with IT regarding readmission rate, social outcomes, and clinical outcomes. This quasi-experimental, nonrandomized trial was conducted from 2020 to 2022 in 10 psychiatric hospitals in Germany. Propensity score (PS) matching was used to compare both treatment models at the 12-month follow-up using standardized instruments and routine hospital data. All patients were screened until the target sample size was reached, based on these criteria: stable residence with privacy for sessions, no child welfare risk, primary diagnosis within International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes F0X to F6X, residence in the catchment area, no commitment order, no acute suicidality or severe aggression requiring hospitalization, capacity to consent, not participating in other interventional studies, sufficient German language skills, no substantial cognitive deficits or intellectual impairment, and no more than 7 days in IHT or IT before recruitment. Statistical analysis was performed from February to November 2023. IHT provided daily acute psychiatric treatment at home, while IT was psychiatric inpatient treatment as usual. The mean treatment duration of the index treatment was 37.2 days for IHT and 28.2 days for IT. The inpatient readmission rate was the primary outcome. Secondary outcomes were combined readmission rate, total inpatient days, job integration, quality of life, psychosocial functioning, symptom severity, and recovery. Of 1396 individuals, 200 patients receiving IHT and 200 patients receiving IT were included (264 female [65%]; mean [SD] age, 45.45 [15.83] years [range, 18-88 years]). Baseline sociodemographic and psychometric characteristics did not differ significantly between the groups. At 12-month follow-up, patients in the IHT group had lower inpatient readmission rate (IHT vs IT: 31.12% vs 49.74% IT; mean difference, 18% [95% CI, 9%-28%; P < .001), combined readmission rate (mean difference, 13% [95% CI, 4%-24%; P < .001), and fewer inpatient days (mean difference, 6.82 days; P < .001) than the IT group. This nonrandomized clinical trial found that patients receiving IHT had a lower likelihood of utilizing hospital-based psychiatric services and spent fewer inpatient days, suggesting that IHT is a viable alternative to IT. ClinicalTrials.gov Identifier: NCT04745507.

Cautionary lessons from the COVID-19 pandemic: Healthcare systems grappled with the dual responsibility of delivering COVID-19 and non-COVID-19 care.

During the COVID-19 pandemic, hospitals were challenged to provide both COVID-19 and non-COVID treatment. A survey questionnaire was designed and distributed via email to hospitals empanelled under the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana(AB-PMJAY), the world's largest National Health Insurance Scheme. Telephonic follow-ups were used to ensure participation in places with inadequate internet. We applied support vector regression to quantify the hospital variables that affected the use vs. non-use of hospital services (Model-1), and factors impacting COVID-19 revenue and staffing levels (Model-2).We quantified the statistical significance of important input variables using Fisher's exact test. The survey, conducted early in the pandemic, included 461 hospitals across 20 states and union territories. Only 55.5% of hospitals were delivering emergency care, 26.7% were doing elective surgery and 36.7% providing obstetric services. Hospitals with adequate supplies of PPE, including N95 masks, and separate facilities designated for COVID-19 patients were more likely to continue providing emergency surgeries and services effectively. Data analysis revealed that large hospitals (> 250 beds) with adequate PPE and dedicated COVID-19 facilities continued both emergency and elective surgeries. Public hospitals were key in pandemic management, large private hospital systems were more likely to conduct non-COVID-19 surgeries, with not-for-profit hospitals performing slightly better. Public and large private not-for-profit hospitals faced fewer staff shortages and revenue declines. In contrast, smaller hospitals (< 50 beds) experienced significant staff attrition due to anxiety, stress and revenue losses. They requested government support for PPE supplies, staff training, testing kits, and special allowances for healthcare workers. The inclusion of COVID-19 coverage under AB-PMJAY improved access to healthcare for critical cases. Maintaining non-COVID-19 care during the pandemic indicates healthcare system resiliency. A state-wide data-driven system for ventilators, beds, and funding support for smaller hospitals, would improve patient care access and collaboration.

The Thoughtful program: a randomized controlled study of a mentalization-based mental health education intervention in a psychiatric outpatient population

Background P-factor and mentalizing theory and research set perspectives for transdiagnostic psychiatric treatments. Aims To test the effects of a low-cost mentalization-based health education program (the Thoughtful program) in an unselected waiting list population, from a psychiatric outpatient clinic in North Norway. Methods Waiting list patients were randomized (1:1 allocation): 79 patients in the control group were offered standard individual assessment and treatment. Seventy-nine patients in the intervention group were offered a one-day (six-hour) group-based Thoughtful course, plus individual assessment, and treatment. Results During a 6-month follow-up period, the number of patients in active assessment and treatment was 66% higher in the control group than in the intervention group. Self-reported patient questionnaire scores on mentalizing, well-being and suicidal ideation scores showed no significant changes in the control group. In the intervention group, significant changes were reported: Mentalizing scores improved by 72% and well-being scores improved by 55%. Suicidal ideation scores were not significantly changed. No adverse effects were registered. Limitations The results from this study should be interpreted with caution because of a small population size and low questionnaire response rate. The follow up period was limited to 6 months. Transfer of program information from intervention group patients to control group patients could not be guaranteed. It may be considered a limitation that diagnostic pattern analysis was not included in the study. Conclusions A low-cost transdiagnostic mentalization-based educational program in an outpatient psychiatry clinic may improve patient mentalizing and wellbeing without adverse effects and reduce the use of hospital services.

Comparison of hospital treatments of the Roma settlements’ inhabitants in Slovenia

Abstract Background Roma ethnic minority in Slovenia was recognized as a vulnerable group with worse health indicators and significantly shorter life expectancy. The vast majority of Roma population in Slovenia have health insurance. We were investigating the use of hospital services in Roma population according to their age and comparing it with the rest of the population. Methods We determined the inhabitants of Roma settlements from the Slovenian register on residents. The data on hospital treatments used were from Slovenian national register on hospital treatments for the period 2018 to 2022. We compared different ratios according to certain hospital treatments within age categories of patients and co-pared those two groups. The frequency statistics, ANOVA and comparison of column proportion tests were used (p-value&amp;lt;0.005, 95% CI). Results Inhabitants of Roma settlements were more often treating in hospitals that rest of population. If comparing the frequency of hospital treatments between age groups only in Roma population, the percentage of hospital treatments steeply declines with age as well as the number of persons in age groups. The highest percentages and numbers of services are in the youngest age group of 0-15 years, and the lowest in the oldest group (75+). Therefore, significantly higher ratios of hospital treatments were detected in younger then in older age groups. Conclusions Roma children and youngsters (0-15 years old) had the highest rate of hospital treatments and it declined with the age. It was consistent with age pyramid of Roma as young population as well as emphasized care for children in culture. The steady decline rate of hospital treatments with age could be explain with delayed seeking of health care services in adult age and higher premature mortality that leads to smaller adult population. Additional and in-depth research is necessary to explain the root causes of higher premature mortality and use of primary and preventive health services. Key messages • Higher use of hospital treatments was caused by higher morbidity. It is necessary to explore the leading causes of hospital treatments and premature mortality. • It is necessary to explore the use of primary health care service, preventive service and level of health literacy of inhabitants of Roma settlements.

Adjusting the risk-adjustment: Accounting for variation between organisations in the responsiveness of their expenditure to need

There is concern that basing healthcare budgets on risk adjustment estimates derived from historical utilisation data may reinforce patterns of unmet need. We propose a method to avoid this, based on a measure of how closely local health organisations align resources to the needs of their populations. We refer to this measure as the ‘responsiveness of expenditure to need’ and estimate it using national person-level data on use of acute hospital and secondary mental health services in England. We find large variation in responsiveness in both services and show that higher expenditure responsiveness in mental health is associated with fewer suicides. We then re-estimate the national risk-adjustment model removing the data from the organisations with the lowest expenditure responsiveness to need. As expected, higher need individuals are estimated to have higher expenditure needs when less responsive organisations are removed from the estimation of the risk-adjustment. Removal of organisations with below-average responsiveness results in the neediest deciles of individuals having an extra £163 (7%) annual need for acute hospital care and an additional £79 (27%) annual need for mental health services. The application of this approach to risk adjustment would result in more resources being directed towards organisations serving higher-need populations.

Potentially burdensome care at the end-of-life for people who had a death from cancer: A retrospective population-level cohort study

ObjectivesTo examine factors associated with indicators of potentially burdensome care provided in hospital, and use of hospital services in the last 12 months of life for people who had a death from cancer. ApproachA population-based retrospective cohort study of people aged ≥20 years with a cancer-related cause of death during 2014-2019 in New South Wales, Australia using linked hospital, cancer registry and mortality records. Ten indicators of potentially burdensome care were examined. Multinominal logistic regression examined predictors of a composite measure of potentially burdensome care, derived by summing 4 indicators: &gt;1 ED presentation; &gt;1 hospital admission; ≥1 ICU admission within 30 days of death; died in acute care (scored as 0, 1 ≥2). ResultsOf the 80,005 cancer-related deaths, 69.1% had none, 20.0% had 1 indicator, and 10.9% had ≥2 indicators of potentially burdensome care. Compared to having no indicators of potentially burdensome care, people who smoked, lived in rural areas, were most socially economically disadvantaged, and had their last admission in a private hospital were more likely to experience potentially burdensome care. Older people (≥55 years), females, people with 1 or ≥2 Charlson comorbidities, people with neurological cancers, and people who died in 2018-2019 were less likely to experience potentially burdensome care. Conclusions and implicationsThis study shows the challenge of delivering health services at end-of-life. Opportunities to address potentially burdensome EOLC could involve taking a person-centric approach to integrate oncology and palliative care around individual needs and preferences.

Predictors of high hospital admission and criminal reoffending in adults experiencing homelessness: a retrospective cohort study

ObjectivesTo examine the costs and predictors of high hospital use and criminal reoffending in adults experiencing homelessness. ApproachRetrospective cohort study of 2,140 adults who attended homeless hostel clinics in New South Wales, Australia using linked clinic, health, criminal offence, and mortality data from 1 July 2008 to 30 June 2021. Multivariable logistic regression examined predictors of high all-cause hospital use (≥4 emergency department presentations in 12 months) and predictors of recidivism. ResultsThere were 27,466 hospitalisations at a total cost of AUD$548.2 million. Twenty-seven percent of the cohort had high hospital use. Factors associated with high use were age ≥45 years, female (AOR: 1.52; 95%CI 1.05-2.22), presence of a mental disorder, substance use disorder (AOR: 1.36; 95%CI: 1.03-1.82), or being homeless for &gt;1 year (AOR: 1.31; 95%CI: 1.06-1.62). There were 1,646 (76.9%) adults who had contact with the criminal justice system. Most (75.3%) reoffended within 24 months after index offence, and reoffenders were more likely to be younger, have a personality disorder (AOR: 1.31; 95% CI: 1.04-1.67), substance use disorder (AOR: 1.60; 95%CI 1.14-2.23), and had a previous charge dismissed on mental health grounds (AOR: 1.79; 95% CI: 1.31-2.46). Reoffenders more likely to have a principal theft-related offence (AOR: 1.85; 95%CI: 1.29-2.66). Total court finalisation costs were AUD$11.3 million. ConclusionsThe high use of hospital and criminal justice services lends support to strategies to develop models of supported housing with a focus on integrated care, mental health support, improved referral pathways, and better coordination with community-based support agencies.

Outcomes and Hospital Service Use Among Patients With COPD in a Nurse- and Allied Health–Led Clinic

Multidisciplinary disease management efforts enable the improvement in lung function among patients with chronic obstructive pulmonary disease (COPD), but there is little evidence of its association with risks of adverse health outcomes and health care service use. To examine the association between the use of a nurse- and allied health-led primary care clinic for respiratory patients, namely the Nurse and Allied Health Clinic-Respiratory Care (NAHC-Respiratory), and their risks of mortality and morbidity and health care service use. This territory-wide, population-based, propensity-matched, retrospective cohort study used data from the electronic health records of all patients who used public health care services in Hong Kong, China, from January 1, 2010, to December 31, 2019. All patients with COPD treated in public outpatient clinics between January 1, 2010, and December 31, 2014, were included. Patients who attended NAHC-Respiratory and usual care only were propensity score-matched at a 1:2 ratio. Data analyses were conducted between August 2023 and April 2024. Attendance at NAHC-Respiratory. All-cause and cause-specific mortality, incidence of COPD complications, and use of emergency department and inpatient services until the end of 2019 were compared between the NAHC-Respiratory and usual care participants using Cox proportional hazard regression, Poisson regression, and log-link gamma regression models after matching. This study included 9048 eligible patients after matching, including 3093 in the exposure group (2814 [91.0%] men; mean [SD] age, 69.8 [9.5] years) and 5955 in the reference group (5431 [91.2%] men; mean [SD] age, 69.5 [11.7] years). Compared with patients in the usual care-only group (reference), patients in the exposure group had lower risks of all-cause mortality (hazard ratio [HR], 0.84; 95% CI, 0.78-0.90) as well as pneumonia-caused (HR, 0.85; 95% CI, 0.74-0.97), respiratory-caused (HR, 0.86; 95% CI, 0.77-0.96), and cardiovascular-caused (HR, 0.74; 95% CI, 0.59-0.93) mortality. Exposure was associated with reduced rates of emergency department visits (incidence rate ratio [IRR], 0.92; 95% CI, 0.86-0.98) and hospitalization through emergency department (IRR, 0.89; 95% CI, 0.83-0.95). In this cohort study, the use of a nurse- and allied health-led clinic in primary care settings was associated with reduced risks of mortality and use of hospital services among patients with COPD. These findings emphasize the important role of health care workers other than physicians in disease management in the primary care setting. The NAHC-Respiratory model and service components can be used to help improve primary care programs to benefit more patients with COPD.

Patterns of health service use for children with mental disorders in an Australian state population cohort.

The rate of mental health services provided to children and young people is increasing worldwide, including in Australia. The aim of this study was to describe patterns of hospital and ambulatory mental health service use among a large population cohort of adolescents followed from birth, with consideration of variation by age, sex and diagnosis. Characteristics of services provided for children with mental disorder diagnoses between birth and age 17.5 years were ascertained for a population cohort of 85,642 children (52.0% male) born between 2002 and 2005, from 'Admitted Patients', 'Emergency Department' and 'Mental Health Ambulatory' records provided by the New South Wales and Australian Capital Territory Health Departments. A total of 11,205 (~13.1%) children received at least one hospital or ambulatory health occasion of service for a mental health condition in the observation period. More than two-fifths of children with mental disorders had diagnoses spanning multiple categories of disorder over time. Ambulatory services were the most heavily used and the most common point of first contact. The rate of mental health service contact increased with age across all services, and for most categories of mental disorder. Girls were more likely to receive services for mental disorders than boys, but boys generally had an earlier age of first service contact. Finally, 3.1% of children presenting to mental health services experienced involuntary psychiatric inpatient admission. The extent of hospital and ambulatory-based mental healthcare service among children emphasises the need for primary prevention and early intervention.

Cystic fibrosis patient characteristics and healthcare resource utilization in Finland using linked registries

BackgroundKnowledge of prevalence and epidemiology of cystic fibrosis (CF) and healthcare resource use among Finnish people with CF is incomplete. MethodsWe conducted a population-based matched cohort study using retrospective real-world data from linked Finnish national registries. Electronic healthcare data and drug purchases of 102 people with CF were analyzed between January 2015 and December 2019 (follow-up). A 5-fold control population was matched by sex, age, and place of residence. Comorbidities and medication use that occurred at any time during follow-up were assessed; annual rates of hospital service use were adjusted for follow-up. ResultsThe prevalence of CF in Finland was 1.85 per 100,000. Median age at diagnosis was 1 year, with 60 % diagnosed at age <2 years and 80 % at age <10 years. Median age at death in people with CF was 31.4 years (n < 5); no controls died. The most common comorbidities included chronic sinusitis (39.2 %), pneumonia (38.2 %), diabetes (20.6 %), and nasal polyps (18.6 %). The most purchased medications were antibiotics (99.0 %) and pancreatic enzymes (84.3 %). The annualized rate of hospital visits was higher in people with CF vs controls (outpatient: mean [SD], 17.4 [14.5] vs 0.9 [3.3]; median, 13.6 vs 0.4, respectively; inpatient: mean [SD], 1.0 [1.66] vs 0.03 [0.14]; median, 0.34 vs 0, respectively). ConclusionsThe prevalence of CF in Finland is remarkably low, likely reflecting unique population characteristics and, in part, delayed diagnosis. Antibiotic use is frequent among Finnish people with CF. Inpatient hospital visits are >30 times higher in people with CF than matched controls.

Patterns of acute hospital and specialist palliative care use among people with non-curative upper gastrointestinal cancer

PurposeUpper gastrointestinal (GI) cancers contribute to 16.7% of UK cancer deaths. These patients make high use of acute hospital services, but detail about palliative care use is lacking. We aimed to determine the patterns of use of acute hospital and hospital specialist palliative care services in patients with advanced non-curative upper GI cancer.MethodsWe conducted a service evaluation of hospital use and palliative care for all patients with non-curative upper GI cancer seen in one large hospital, using routinely collected data (2019–2022). We report and characterise hospital admissions and palliative care within the study time period, using descriptive statistics, and multivariable Poisson regression to estimate the unadjusted and adjusted incidence rate ratio of hospital admissions.ResultsThe total with non-curative upper GI cancer was 960. 86.7% had at least one hospital admission, with 1239 admissions in total. Patients had a higher risk of admission to hospital if: aged ≤ 65 (IRR for 66–75 years 0.71, IRR 76–85 years 0.68; IRR > 85 years 0.53; p < 0.05), or lived in an area of lower socioeconomic status (IMD Deciles 1–5) (IRR 0.90; p < 0.05). Over the 4-year period, the rate of re-admission was higher in patients not referred to palliative care (rate 0.52 readmissions/patient versus rate 1.47 readmissions/patient).ConclusionPeople with advanced non-curative gastrointestinal cancer have frequent hospital admissions, especially if younger or from areas of lower socioeconomic status. There is clear association between specialist palliative care referral and reduced risk of hospitalisation. This evidence supports referral to specialist palliative care.

Evaluation of a service introduced to support young people at risk of suicide using a cohort design, a mixed methods analysis and cost-benefit analysis

This evaluation sought to determine to what extent a suicide prevention service, designed for young people at severe risk of suicide, was successful in reducing suicide risk and distress and improving well-being outcomes. The 3-month service was co-designed at the height of the COVID-19 pandemic in Melbourne, Australia, with young people and carers who had lived experience of youth suicide. The evaluation involved a mixed methods analysis of data collected during the first 20 months of operation, from February 2022 to September 2023. Ninety one young people were admitted to the service during this period, of whom 28 agreed to participate in the evaluation. Primary data were collected by telephone or online, and secondary data for hospital service use were collected for 70 of the young people. Analysis found that there were significant reductions in suicide risk and psychological distress at discharge, associated with significant improvements in quality of life and reductions in the use of hospital services. Qualitative analysis supported these survey results, highlighting the peer and psycho-social support as particularly beneficial aspects of the service. However, the qualitative analysis also indicated that some individuals felt the service was too short and abruptly ended, with insufficient attention paid to the creation and maintenance of support services that could continue after discharge. A small sample size was a limitation of this study, particularly for the three and six month follow-up surveys. Also, the cost-benefit analysis included secondary routine hospital admission data covering only 12 months. Nevertheless, the overall findings are positive, suggesting that services of this nature can have real benefits for young people at serious risk of suicide. It is likely that an extension of the cost-benefit analysis, to allow for benefits beyond a one year period, would have suggested that the benefits outweigh the costs.

A Comparison of Ukrainian Hospital Services and Functions Before and During the Russia-Ukraine War

Since the full-scale Russian invasion, hospitals in Ukraine have been compelled to close or operate at reduced capacity due to inadequate supplies, damage, or destruction caused by war. To analyze hospital services in Ukraine during the period before and after the Russian invasion. Of the 450 hospitals currently functioning in Ukraine, a cross-sectional survey was carried out with the participation of 74 hospitals from 12 oblasts. Hospital administrators responded to an online survey with questions on the use of hospital services. Data were abstracted from hospital databases for the prewar period (before February 23, 2022) and during the war (February 23, 2022, to May 30, 2023). Hospital services (including emergency services, preventive services, screenings, laboratory tests, obstetrics, telehealth, pharmacy, and rehabilitation services) were compared during the prewar and war periods. Of 450 Ukrainian hospitals in operation, 74 hospitals (16.0%) across 12 oblasts provided data for the current analyses. During the war, daily emergency admissions increased to 2830, compared with 2773 before the war. At the same time, hospitals reported reduced laboratory testing (72 [97%] vs 63 [85%]), tobacco education (52 [70%] vs 36 [49%]), cancer screening (49 [66%] vs 37 [50%]), gynecological services (43 [58%] vs 32 [43%]), rehabilitation services (37 [50%] vs 27 [36%]), pharmacy services (36 [49%] vs 27 [36%]), and telehealth programs (33 [45%] vs 21 [28%]). Hospitals reported additional difficulties during the war, including disruptions in the supply chain for essential equipment and pharmaceuticals, shortages of laboratory test kits, delays in the delivery of crucial medications, and problems around appropriate medication storage due to power outages. The ongoing war has inflicted profound devastation on Ukraine's hospitals. The findings of this cross-sectional survey offer valuable insights into the formidable challenges that hospitals confront in war-affected regions and underscore the pressing necessity for bolstering support to sustain and enhance hospital services during wartime.

Socioeconomic deprivation, health and healthcare utilisation among millennials

This study estimates and decomposes components of different measures of inequality in health and healthcare use among millennial adolescents, a sizeable cohort of individuals at a critical stage of life. Administrative data from the UK Hospital Episode Statistics are linked to Next Steps, a survey collecting information about millennials born between 1989 and 1990, providing a uniquely comprehensive source of health and socioeconomic variables. Socioeconomic inequalities in psychological distress, long-term illness and the use of emergency and outpatient hospital care are measured using a corrected concentration index. Shapley-Shorrocks decomposition techniques are employed to measure the relative contributions of childhood socioeconomic circumstances to adolescents’ health and healthcare inequality of opportunity. Results show that income-related deprivation contributes to significant inequalities in mental and physical health among adolescents aged between 15 and 17 years old. There are also pro-rich inequalities in the use of specific outpatient hospital services (e.g., orthodontic and mental healthcare), while pro-poor disparities are found in the use of emergency care services. Regional and parental circumstances are leading factors in influencing inequality of opportunity in the use of hospital care among adolescents. These findings shed light on the main drivers of health inequalities during an important stage of human development and have potentially important implications on human capital formation across the life-cycle.

The Australian Health Care Homes trial: quality of care and patient outcomes. A propensity score-matched cohort study.

To assess the impact of the Health Care Homes (HCH) primary health care initiative on quality of care and patient outcomes. Quasi-experimental, matched cohort study; analysis of general practice data extracts and linked administrative data from ten Australian primary health networks, 1 October 2017 - 30 June 2021. People with chronic health conditions (practice data extracts: 9811; linked administrative data: 10 682) enrolled in the HCH 1 October 2017 - 30 June 2019; comparison groups of patients receiving usual care (1:1 propensity score-matched). Participants were involved in shared care planning, provided enhanced access to team care, and encouraged to seek chronic condition care at the HCH practice where they were enrolled. Participating practices received bundled payments based on clinical risk tier. Access to care, processes of care, diabetes-related outcomes, hospital service use, risk of death. During the first twelve months after enrolment, the mean numbers of general practitioner encounters (rate ratio, 1.14; 95% confidence interval [CI], 1.11-1.17) and Medicare Benefits Schedule claims for allied health services (rate ratio, 1.28; 95% CI, 1.24-1.33) were higher for the HCH than the usual care group. Annual influenza vaccinations (relative risk, 1.20; 95% CI, 1.17-1.22) and measurements of blood pressure (relative risk, 1.09; 95% CI, 1.08-1.11), blood lipids (relative risk, 1.19; 95% CI, 1.16-1.21), glycated haemoglobin (relative risk, 1.06; 95% CI, 1.03-1.08), and kidney function (relative risk, 1.13; 95% CI, 1.11-1.15) were more likely in the HCH than the usual care group during the twelve months after enrolment. Similar rate ratios and relative risks applied in the second year. The numbers of emergency department presentations (rate ratio, 1.09; 95% CI, 1.02-1.18) and emergency admissions (rate ratio, 1.13; 95% CI, 1.04-1.22) were higher for the HCH group during the first year; other differences in hospital use were not statistically significant. Differences in glycaemic and blood pressure control in people with diabetes in the second year were not statistically significant. By 30 June 2021, 689 people in the HCH group (6.5%) and 646 in the usual care group (6.1%) had died (hazard ratio, 1.07; 95% CI, 0.96-1.20). The HCH program was associated with greater access to care and improved processes of care for people with chronic diseases, but not changes in diabetes-related outcomes, most measures of hospital use, or risk of death.

Association between patient activation and delayed discharge in elective laparoscopic cholecystectomy: A prospective cohort analysis

BackgroundImproving patient activation may be an effective way to reduce healthcare costs and improve patient outcomes after surgery. ObjectiveTo determine whether preoperative patient activation is associated with delayed discharge (i.e., length of stay >24 h) after elective laparoscopic cholecystectomy. Postoperative symptoms, unscheduled access to healthcare facilities within seven days of surgery, unplanned hospital readmissions, and postoperative complications were analyzed as secondary outcomes. DesignThis cohort study was a secondary analysis of the DeDiLaCo study (Delayed Discharge after day-surgery Laparoscopic Cholecystectomy) collecting data of patients undergoing elective laparoscopic cholecystectomy during 2021 in Italy. Data was analyzed from June 2022 to April 2023. Setting90 Italian surgical centers participating in the study. Participants4708 adult patients with an instrumental diagnosis of gallbladder disease and undergoing laparoscopic cholecystectomy. Patient activation was assessed using the Italian translation of Patient Activation Measure in the preoperative setting. ResultsOf 4532 cases analyzed the median (IQR) Patient Activation Measure score was 80.3 (71.2–92.3). Participants were on average 55.5 years of age and 58.1 % were female. Two groups based on the activation level were created: 270 (6 %) had low activation, and 4262 had high activation. The low activation level was associated with the likelihood of delayed discharge (odds ratio [OR] 1.47, 95 % CI, 1.11–1.95; P = .008), higher symptom burden (OR 1.99, 95 % CI 1.49–2.66, P < .0001), and unplanned healthcare utilization within seven days after hospital discharge (OR 1.85, 95 % CI, 1.29–2.63; P = .001). There was no difference between the high and low activation groups in the incidence of postoperative complications (OR 1.28, 95 % CI, 0.95–1.73; P = .10) and hospital readmission after discharge (OR 0.95, 95 % CI, 0.30–3.05; P = .93). ConclusionsOur results suggest that patients with low activation have 1.47 times the risk of delayed discharge compared with patients with higher activation, almost twice the risk of the onset of postoperative symptoms, and 1.85 times the risk of unscheduled use of hospital services. Screening for patient activation in the preoperative setting could not only identify patients not suitable for early discharge, but more importantly, help physicians and nurses develop tailored interventions.

Multimorbidity Patterns, Hospital Uses and Mortality by Race and Ethnicity Among Oldest-Old Patients.

Adults aged 85 years and older ("oldest-old") are perceived as survivors resilient to age-related risk factors. Although considerable heterogeneity has been often observed in this population, less is known about the unmet needs in health and healthcare service utilization for diverse patients in healthcare systems. We examined racial-ethnic variation in patterns of multimorbidity associated with emergency department (ED), clinic visits, and mortality among the oldest-old patients with multimorbidity. Administrative and clinical data from an integrated healthcare system for five years included 25,801 oldest-old patients with two or more chronic conditions. Hierarchical cluster analysis identified patterns of multimorbidity by four racial-ethnic groups (White, Black, Hispanic, & Other). Clusters associated with ED and clinic visits, and mortality were analyzed using generalized estimation equations and proportional hazards survival model, respectively. Hypothyroidism, Alzheimer's disease and related dementia, bone & joint conditions, metabolism syndrome, and pulmonary-vascular clusters were commonly observed across the groups. While most clusters were significantly associated with ED and clinic visits among White patients, bone & joint conditions cluster was the most significantly associated with ED and clinic visits among Black (RR = 1.32, p <.01 for ED; RR = 1.67, p <.0001 for clinic) and Hispanic patients (RR = 1.36, p <.0001 for ED; RR = 1.39, p <.0001 for clinic). Similar patterns were observed in the relationship between multimorbidity clusters and mortality. Patterns of multimorbidity and its significant association with the uses of ambulatory and emergency care varied by race-ethnicity. More studies are needed to explore barriers when minoritized patients are faced with the use of hospital services.

Potentially burdensome care at the end-of-life for cancer decedents: a retrospective population-wide study

BackgroundVariation persists in the quality of end-of-life-care (EOLC) for people with cancer. This study aims to describe the characteristics of, and examine factors associated with, indicators of potentially burdensome care provided in hospital, and use of hospital services in the last 12 months of life for people who had a death from cancer.MethodA population-based retrospective cohort study of people aged ≥ 20 years who died with a cancer-related cause of death during 2014–2019 in New South Wales, Australia using linked hospital, cancer registry and mortality records. Ten indicators of potentially burdensome care were examined. Multinominal logistic regression examined predictors of a composite measure of potentially burdensome care, consisting of > 1 ED presentation or > 1 hospital admission or ≥ 1 ICU admission within 30 days of death, or died in acute care.ResultsOf the 80,005 cancer-related deaths, 86.9% were hospitalised in the 12 months prior to death. Fifteen percent had > 1 ED presentation, 9.9% had > 1 hospital admission, 8.6% spent ≥ 14 days in hospital, 3.6% had ≥ 1 intensive care unit admission, and 1.2% received mechanical ventilation on ≥ 1 occasion in the last 30 days of life. Seventeen percent died in acute care. The potentially burdensome care composite measure identified 20.0% had 1 indicator, and 10.9% had ≥ 2 indicators of potentially burdensome care. Compared to having no indicators of potentially burdensome care, people who smoked, lived in rural areas, were most socially economically disadvantaged, and had their last admission in a private hospital were more likely to experience potentially burdensome care. Older people (≥ 55 years), females, people with 1 or ≥ 2 Charlson comorbidities, people with neurological cancers, and people who died in 2018–2019 were less likely to experience potentially burdensome care. Compared to people with head and neck cancer, people with all cancer types (except breast and neurological) were more likely to experience ≥ 2 indicators of potentially burdensome care versus none.ConclusionThis study shows the challenge of delivering health services at end-of-life. Opportunities to address potentially burdensome EOLC could involve taking a person-centric approach to integrate oncology and palliative care around individual needs and preferences.

Impact of vertical integration on patients' use of hospital services in England: an analysis of activity data.

Debate surrounding the organisation and sustainability of primary care in England highlights the desirability of a more integrated approach to patient care across all settings. One such approach is 'vertical integration', where a provider of specialist care, such as a hospital, also runs general practices. To quantify the impact of vertical integration on hospital use in England. Analysis of activity data for NHS hospitals in England between April 2013 and February 2020. Analysis of NHS England data on hospital activity, which looked at the following seven outcome measures: accident and emergency (A&E) department attendances; outpatient attendances; total inpatient admissions; inpatient admissions for ambulatory care sensitive conditions; emergency admissions; emergency readmissions; and length of stay. Rates of hospital use by patients of vertically integrated practices and controls were compared, before and after the former were vertically integrated. In the 2 years after a GP practice changes, for the population registered at that practice, compared with controls, vertical integration is associated with modest reductions in rates of A&E attendances (2% reduction [incidence rate ratio {IRR} 0.98, 95% confidence interval {CI} = 0.96 to 0.99, P<0.0001]), outpatient attendances (1% reduction [IRR 0.99, 95% CI = 0.99 to 1.00, P = 0.0061]), emergency inpatient admissions (3% reduction [IRR 0.97, 95% CI = 0.95 to 0.99, P = 0.0062]), and emergency readmissions within 30 days (5% reduction [IRR 0.95, 95% CI = 0.91 to 1.00, P = 0.039]), with no impact on length of stay, overall inpatient admissions, or inpatient admissions for ambulatory care sensitive conditions. Vertical integration is associated with modest reductions in use of some hospital services and no change in others.

The Use of Hospital Services by Patients With Muscle Invasive Bladder Cancer in the Last Year of Life: Identifying the Areas to Improve Care.

Muscle-invasive bladder cancer (MIBC) is associated with significant morbidity. However, patients' specific health needs have not been well defined. This study analyses the utilisation of hospital resources by MIBC patientsin the 12 months beforedeath, informing healthcare modelling and enabling service redesign to improve their quality of life. All patients who died after being diagnosed with MIBC at a single hospital in the United Kingdom within four years were included. Patients' electronic health records were reviewed to collect data on all interactions with hospital services in their last year of life. A total of 41 patients were included, with survival times ranging from one to 88 months (with a median of nine months). In the last year of life, a patient from this cohort had an average of 5.2 outpatient appointments and 2.3 emergency admissions leading to 17.1 days of inpatient stayand 1.3 operations/procedures. The most commonreasons for emergency admission were for the management of haematuria (23%), urinary tract infection (23%), or chest infection (12%). Patients with MIBC demonstrate significant utilisation of healthcare resources in their last year of life. An awareness of this should inform honest discussions with patients, earlier provision of palliative care, and proactive management of haematuria and urinary tract infections to improve care in this important stage of life.