Use Of Hospital Care Research Articles

Home health agency work environments and hospitalizations.

An important goal of home health care is to assist patients to remain in community living arrangements. Yet home care often fails to prevent hospitalizations and to facilitate discharges to community living, thus putting patients at risk of additional health challenges and increasing care costs. To determine the relationship between home health agency work environments and agency-level rates of acute hospitalization and discharges to community living. Analysis of linked Center for Medicare and Medicaid Services Home Health Compare data and nurse survey data from 118 home health agencies. Robust regression models were used to estimate the effect of work environment ratings on between-agency variation in rates of acute hospitalization and community discharge. Home health agencies with good work environments had lower rates of acute hospitalizations and higher rates of patient discharges to community living arrangements compared with home health agencies with poor work environments. Improved work environments in home health agencies hold promise for optimizing patient outcomes and reducing use of expensive hospital and institutional care.

Care utilisation in the last years of life in Sweden: the effects of gender and marital status differ by type of care.

The effects of gender and marital status on care utilisation in the last years of life are highly correlated. This study analysed whether gender differences in use of eldercare (home help services or institutional care) or hospital care in the last 5years of life, and the place of death, could be attributed to differences in marital status and thereby to potential access to informal care. A longitudinal Swedish study provided register data on 567 participants (aged 83+) who died between 1995 and 2004. A higher proportion of unmarried than married people used home help services; this was true of both men and women. The likelihood of receiving home help was lower for those living with their spouse (OR=0.38) and for those with children (OR=0.60). In the 2years preceding death, the proportion receiving home help services decreased and the proportion in institutional care increased. Women were significantly more likely to die in institutional care (OR=1.88) than men. Although men were less likely to live in institutional care than women and more likely to be inpatients in the 3months preceding death, after controlling for residence in institutional care, neither gender nor marital status was statistically significant when included in the same model. In summary, the determining factor for home help utilisation seemed to be access to informal care, whereas gender differences in health status could explain women's higher probability of dying in institutional care.

PARE0012 Patient Advocacy: Standing up for Access to Physical Therapy Care for Arthritis Patients

BackgroundDutch arthritis patients, who need physical therapy care, have been severely limited in available health insurance options between 2012 and 2014. Due to a lack of scientific evidence concerning long-term...

Prescription Drug Use Among Older Adults in Italy: A Country-Wide Perspective

In Italy, prescription drug costs represent approximately 17% of total public health expenditures. Older adults commonly use multiple drugs and, for this reason, this population is responsible for a large portion of drug-related costs. In 2012, public expenditure for pharmaceuticals in primary care exceeded 11 billion Euros (approximately 15.2 billion US $), and older adults aged 65 or older accounted for more than 60% of these costs. Recently, increased attention has been focused on studies aimed at monitoring drug use and evaluating the appropriateness of drug prescribing in older adults. In this article, we examined studies that assessed these issues in different settings at a national level. Specifically, results of surveys of prescription drug use in primary care (OsMED), hospital (GIFA, CRIME, and REPOSI) and long-term care (ULISSE and SHELTER) settings are reviewed. Overall, these studies showed that the quality of drug prescribing in older patients is far from optimal. This leads to an increased risk of negative health outcomes and increased health care costs. Data from these studies are valuable, not only to monitor drug use, but also to target interventions aimed at improving the quality of prescribing. Translating the findings of clinical research and monitoring programs will be challenging, but it will lead to quantifiable improvements in the quality of drug prescribing at a national level.

PCV40 - Costs Of Ischemic Stroke With And Without Atrial Fibrillation In Colombia

To estimate total costs and resource use of acute hospital care in a sample of patients with large vessel ischemic stroke treated at our University Hospital, comparing those with and without non-valvular atrial fibrillation (AF). We collected a sequential, prospective, convenience sample of patients 50 years of age or older, admitted between December 2010 and March 2013 diagnosed with ischemic stroke, excluding lacunar infarct, transitory cerebral ischemia, recurrent stroke or modified Rankin index greater than 2 prior to this episode. The presence of AF was sought with electrocardiogram and in some cases was studied with Holter. For a separate analysis, we matched for age and admission NIHSS score, in a 1:1 ratio, patients with and without AF. Variables measured in all cases were: age, gender, admission and discharge NIHSS, modified Rankin index, and CHA2DS2VASC score. Prospectively, we collected in-hospital resource use and costs incurred during the acute event. Exchange rate 1805 Colombian pesos = 1 American dollar (USD). 166 patients were analyzed, 125 without and 41 with non-valvular AF. For the paired analysis, we considered 37 patients with and 37 without AF. The average total cost of acute care for all stroke patients was USD$4,163 (SD $7,163) This value was USD$5,729 (SD $8,383) for patients with AF and for patients without AF USD$4,464 (SD $6,712). 15 patients (9%) died during the hospitalization, 9 with AF (22%) and 6 without AF (5%). Of the matched group, 9 of the 37 patients with (24%) and 4 of those without (10%) required intensive care. 25% of large vessel ischemic stroke patients had AF. Treatment costs are higher in patients with AF, since they are older and with more severe strokes. Cost difference is reduced and shows no statistical significance when adjusted for age and stroke severity.

Influence of Frailty‐Related Diagnoses, High‐Risk Prescribing in Elderly Adults, and Primary Care Use on Readmissions in Fewer than 30 Days for Veterans Aged 65 and Older

To determine the effect of two variables not previously studied in the readmissions literature (frailty-related diagnoses and high-risk medications in the elderly (HRME)) and one understudied variable (volume of primary care visits in the prior year). Retrospective cohort study using data from a study designed to examine outcomes associated with inappropriate prescribing in elderly adults. All Veterans Affairs (VA) facilities with acute inpatient beds in fiscal year 2006 (FY06). All veterans aged 65 and older by October 1, 2005, who received VA care at least once per year between October 1, 2004, and September 30, 2006, and were hospitalized at least once during FY06 on a medical or surgical unit. A generalized linear interactive risk prediction model included demographic and clinical characteristics (mental health and chronic medical conditions, frailty-related diagnoses, number of medications) in FY05; incident HRME in FY06 before index hospitalization or readmission; chronic HRME in FY05; and FY05 emergency department (ED), hospital, geriatric, palliative, or primary care use. Facility-level variables were complexity, rural versus urban, and FY06 admission rate. The mean adjusted readmission rate was 18.3%. The new frailty-related diagnoses variable is a risk factor for readmission in addition to Charlson comorbidity score. Incident HRME use was associated with lower rates of readmission, as were higher numbers of primary care visits in the prior year. Frailty-related diagnoses may help to target individuals at higher risk of readmission to receive more-intensive care transition services. HRME use does not help in this targeting. A higher number of face-to-face primary care visits in the prior year, unlike ED and hospital use, correlates with fewer readmissions and may be another avenue for targeting prevention strategies.

Measuring unexplained variation in acute hospital use by patients enrolled with northern New Zealand general practices

There is increasing concern worldwide at the steady growth in acute inpatient admissions and emergency department (ED) attendances. To develop measures of variation in acute hospital use between populations enrolled at different general practices that are independent of the sociodemographic characteristics of those populations. Two consecutive years of hospital discharge and ED attendance data were combined with primary health organisation (PHO) registers from 385 practices of over 1.5 million people to develop and test two measures of unplanned hospital use: the standardised acute hospital admission ratio (SAAR) and the standardised ED attendance ratio (SEAR). Disease-specific measures were also produced for inpatient events. The enrolled populations of a high proportion of practices had significantly higher or lower than expected acute use of hospitals and this was consistent over both years studied. Practices whose population made unexpectedly high use of acute hospital care for one condition tended to do so for others. Differences in health needs between practice populations as measured by clinical complexity, comorbidities and length of stay did not explain a significant portion of the overall variation in hospital admissions. The enrolled population's average travelling time to a 24-hour ED accounted for some of the practice variation in unplanned utilisation of hospital services. This study confirms that there is considerable unexplained practice variation in acute hospital use. Further development of the SAAR and SEAR measures may be possible to use these to identify modifiable practice-level factors associated with high unplanned hospital use.

Job strain in the public sector and hospital in-patient care use in old age: a 28-year prospective follow-up

Background: high job strain increases the risk of health decline, but little is known about the specific consequences and long-term effects of job strain on old age health.Objectives: purpose was to investigate whether physical and mental job strain in midlife was associated with hospital care use in old age.Methods: study population included 5,625 Finnish public sector employees aged 44–58 years who worked in blue- and white-collar professions in 1981. The number of in-patient hospital care days was collected from the Finnish Hospital Discharge Register for the 28-year follow-up period.Results: rates of hospital care days per 1,000 person-years for men were 7.78 (95% confidence interval [CI] 7.71–7.84) for low, 9.68 (95% CI 9.50–9.74) for intermediate and 12.56 (95% CI 12.47–12.66) for high physical job strain in midlife. The corresponding rates for women were 6.63 (95% CI 6.57–6.68), 7.91 (95% CI 7.87–7.95) and 10.35 (95% CI 10.25–10.42), respectively. Rates were parallel but lower for mental job strain. Reporting high physical job strain in midlife increased the risk of hospital care in old age compared with those who reported low job strain, fully adjusted incidence rate ratio 1.17 (95% CI 1.00–1.38) for men and 1.42 (95% CI 1.25–1.61) for women. These associations were robust in analyses confined to hospital care that took place after the employees had turned 65 years.Conclusion: exposure to high mental and, particularly, high physical job strain in midlife may set employees on a higher healthcare use trajectory which persists into old age.

Avoidable utilisation of hospital care among elderly patients with significant health care needs – Should outcome measures be used to incentivise quality improvement in primary care?

Purpose and theory: Fragmented services and poor access to primary care physicians are important explanations behind an excessive use of hospital care by elderly patients with multiple chronic conditions. This study analyses the potential of using indicators reflecting utilisation of hospital care to incentivise primary care units to improve quality of care and coordination with community services for elderly patients. Methods: Both qualitative and quantitative data was collected from primary care services in Region Skane, Sweden. Qualitative data was collected from a sample of eight primary care units using blinded interviews and compared with indicators of hospital utilisation. In a quantitative analysis, data from 150 primary care units was analysed in regression models using utilisation of hospital care as the dependent outcome variable and a number of independent variables reflecting location and ownership of provider, socioeconomic status of registered individuals and process measures indicating good quality care towards elderly patients. Findings and discussion: Results indicate that outcome measures reflecting utilisation of hospital care are highly sensitive to the socioeconomic status of registered individuals and location of providers. With a high risk of type I (false positive) and type II (false negative) errors, outcome measures such as utilisation of hospital care should be used with great caution to incentivise quality improvements among primary care units.

P120 The impact of advance care planning of place of death, a hospice retrospective cohort study

ObjectivesThere is limited evidence of the impact of advance care planning (ACP) on outcomes. We conducted a retrospective cohort study on deaths of all patients known to a hospice in...

Use of hospital and long-term institutional care services in relation to proximity to death among older people in Finland

Using nationally-representative register data for older people in Finland in period 1998–2003 we study how the number of days in acute hospital and long term institutional care services varies by age and proximity to death and how these use patterns change as mortality improves. Acute health care use depends more on proximity to death than on age, a finding often interpreted as showing that the need for care services among older people will be substantially less than would be expected based on the likely increase in population numbers. We show that this assumption is too optimistic for three reasons: (1) the increase in population numbers will be concentrated mainly among the “old old” where use of services is substantial; (2) earlier findings of much lower use of acute care services by older than younger people who are close to death are not observed; and (3) any savings in acute care are more than offset by greater use of residential long-term care (LTC). The main consequences of improving mortality are: (1) to postpone rather than to reduce overall demand for health care; (2) to shift the balance of care from acute to long-term care services; and (3) to increase considerably the average age of time spent in care. We further construct a new indicator “care-free life expectancy” based on number of days in hospital and long-term care to summarise care use patterns for cohorts under a range of plausible mortality assumptions. As mortality improves, lifetime use of acute hospital and long-term care after age 65 and the proportion of life spent in LTC increases for later cohorts, but the proportion spent in acute care decreases slightly.

The impact of advance care planning of place of death, a hospice retrospective cohort study

ObjectivesThere is limited evidence of the impact of advance care planning (ACP) on outcomes. We conducted a retrospective cohort study on deaths of all patients known to a hospice in...

Alcohol-related deaths and social factors in depression mortality: a register-based follow-up of depressed in-patients and antidepressant users in Finland

BackgroundExcess mortality of depression is established for various causes of death, but evidence is scarce on alcohol-related causes. It also remains unclear whether the magnitude of the excess varies by social factors. This study aimed to quantify the contribution of alcohol-related causes of death and to assess modifying effects of socioeconomic position, employment status, and living arrangements in the excess mortality of depression. MethodsA 14% sample of community-dwelling Finns aged 40–64 at the end of 1997 was assessed for depression, using register data on psychiatric hospital care and antidepressant use in 1996–1997. Depressed in-patients (n=897), out-patients using antidepressants (n=13,658), and non-depressed individuals (n=217,140) were followed up for cause-specific mortality in 1998–2007, distinguishing between alcohol- and non-alcohol-related deaths, and testing for variation in the excess mortality according to baseline social factors. ResultsDepressed in- and out-patients had significant excess mortality for suicide (age-adjusted rate ratios RR=3.77 for men and RR=6.35 for women), all accidental and violent causes (RR=3.47 and RR=4.43), and diseases (RR=1.67 and RR=1.41). Of the excess, alcohol-related causes accounted for 50% among depressed men and 30% among women. Excess mortality varied little by social factors, particularly in non-alcohol-related causes. Where variation was significant, the relative excess was larger among those with higher socioeconomic position and the employed. Absolute excess was, however, larger among those with lower socioeconomic position, the unemployed, and the unpartnered. LimitationsDepression was measured indirectly by hospital and antidepressant use. ConclusionsThe results highlight the major role of alcohol in depression mortality.

Distance to hospital and socioeconomic status influence secondary health care use

Objective. The aim of this study was to investigate how distance to hospital and socioeconomic status (SES) influence the use of secondary health care (SHC) when taking comorbidity into account. Design and setting. A register-based study in Östergötland County. Subjects. The adult population of Östergötland County. Main outcome measures. Odds of SHC use in the population and rates of SHC use by patients were studied after taking into account comorbidity level assigned using the Adjusted Clinical Groups (ACG) Case-Mix System. The baseline for analysis of SES was individuals with the lowest education level (level 1) and the lowest income (1st quartile). Results. The study showed both positive and negative association between SES and use of SHC. The risk of incurring SHC costs was 12% higher for individuals with education level 1. Individuals with income in the 2nd quartile had a 4% higher risk of incurring SHC costs but a 17% lower risk of emergency department visits. Individuals with income in the 4th quartile had 9% lower risk of hospitalization. The risk of using SHC services for the population was not associated with distance to hospital. Patients living over 40 km from hospital and patients with higher SES had lower use of SHC services. Conclusions. It was found that distance to hospital and SES influence SHC use after adjusting for comorbidity level, age, and gender. These results suggest that GPs and health care managers should pay a higher degree of attention to this when planning primary care services in order to minimize the potentially redundant use of SHC.

Modeling the relationship between health and health care expenditures using a latent Markov model

We investigate the dynamic relationship between several dimensions of health and health care expenditures for older individuals. Health data from the Longitudinal Aging Survey Amsterdam is combined with data on hospital and long term care use. We estimate a latent variable based jointly on observed health indicators and expenditures. Annual transition probabilities between states of the latent variable are estimated using a Markov model. States associated with good current health and low annual health care expenditures are not associated with lower cumulative health care expenditures over remaining lifetime. We conclude that, although the direct health care cost saving effect is limited, the considerable gain in healthy lifeyears can make investing in the improvement of health of the older population worthwhile.

Overlap of hospital use and social care in older people in England

To link pseudonymous health and social care use data in order to determine what proportion of older people access hospital and social care services. Retrospective analysis of linked, pseudonymous, routine service use data of people aged 75 and over (n = 133,055) drawn from the operational systems of four primary care trusts and their corresponding local authorities in England. Fourteen percent of older people received local authority-funded social care in one year, 59% accessed NHS hospital care and 10% accessed both types of service. Most people using social care also used a hospital service (71%). This was a higher proportion than for people who did not use social care services (57%, P < 0.001). However, the use of hospitals varied by type of social care such that the residents of care homes had fewer admissions to hospital, fewer Accident and Emergency attendances and fewer outpatient visits than people receiving high intensity home care. Using routine data from large populations, we have demonstrated interactions in the use of hospital care and social care for older people. Residents of care homes tend to use hospitals less frequently than people receiving home care. More detailed work is required to explain this phenomenon.

Acute Hospital Use, Nursing Home Placement, and Mortality in a Frail Community‐Dwelling Cohort Managed with Primary Integrated Interdisciplinary Elder Care at Home

To evaluate the effect of medical Primary Integrated Interdisciplinary Elder Care at Home (PIECH) on acute hospital use and mortality in a frail elderly population. Comparison of acute hospital care use for the year before entering the practice (pre-entry) with the most-recent 12-month period (May 1, 2010-April 30, 2011, postentry) for active and discharged patients. Community. All 248 frail elderly adults enrolled in the practice for at least 12 months who were living in the community and not in nursing homes in Victoria, British Columbia. Primary geriatric care provided by a physician, nurse, and physiotherapist in participants' homes. Acute hospital admissions, emergency department (ED) contacts that did not lead to admission, reason for leaving practice, and site of death. There was a 39.7% (116 vs 70; P = .004) reduction in hospital admissions, 37.6% (1,700 vs 1,061; P = .04) reduction in hospital days, and 20% (120 vs 95; P = .20) reduction in ED contacts after entering the practice. Fifty participants were discharged from the practice, 64% (n = 32) of whom died, 20% (n = 10) moved, and 16% (n = 8) were admitted to nursing homes. Fifteen (46.9%) deaths occurred at home. Primary Integrated Interdisciplinary Elder Care at Home may reduce acute hospital admissions and facilitate home deaths.

Seven-year hospital and nursing home care use according to age and proximity to death: variations by cause of death and socio-demographic position

BackgroundProvision of hospital and long-term care services for the growing number of older people is a major policy concern. The authors estimate hospital and nursing home care use by age...

How does a history of psychiatric hospital care influence access to coronary care: a cohort study

ObjectivesEquity in physical health of patients with severe mental disorders is a major public health concern. The aim of this cohort study was to examine equity in access to coronary...

Measuring the Effects of Removing Subsidies for Private Insurance on Public Expenditure for Health Care

This paper investigates the effects of removing subsidies for private health insurance on public sector expenditure for hospital care. An econometric framework using simultaneous equation models is developed to analyze the interrelated decisions on the intensity and type of health care use and insurance. The results indicate that while privately insured individuals are more likely to seek hospital care as a private patient, they do not differ in the intensity of hospital care use compared with those without private insurance. The simulation results suggest that eliminating subsides could potentially yield substantial public sector savings.