Impact of Gaps in Care during Adult Care Transfer in Sickle Cell Disease

The transition from pediatric to adult health care is critical to the care of young adults with sickle cell disease (SCD). Young adults with SCD, compared with children with SCD, are at risk for a marked increase in disease severity, frequency of acute complications, healthcare utilization, and mortality. 1-4 Professional societies and healthcare experts recommend that young adults with chronic health conditions should transfer to adult-centered healthcare within 6 months of their last pediatric visit. 5-8 However, the effect of a 6-month transfer interval on healthcare utilization in SCD has not been studied. Given the complex health care needs of young adults with SCD, 9-15 it remains unclear whether the recommended 6-month transfer interval 5 is optimal. We hypothesized that longer gaps between pediatric and adult care would be associated with greater healthcare utilization in the first 2 to 6 years of adult care. This study included patients with SCD who were followed by a pediatric sickle cell program in the mid-southern US, participated in a transition to adult care program, 16 and fulfilled an initial adult visit to a partner adult SCD facility during the years 2011-2017. Participants were retrospectively followed from their first adult visit through December 31, 2017. Transfer gap was defined as the time (in months) between the last pediatric and the first adult sickle cell clinic visit. We estimated the association between varying transfer gaps from pediatric to adult care and the rate of healthcare utilization (inpatient, emergency department, and outpatient visits) in the first 2 to 6 years of adult care using negative binomial regression. Transfer gaps were evaluated at <2, ≥2 to <6, ≥6 to <9, and ≥9 months to evaluate whether adult health care utilization increased as the gap in SCD-specific care increased. Transfer gaps were also dichotomized at 6 months (>6 vs ≤6) to evaluate the current recommendation to complete transfer of patients to adult care within 6 months. 6,7 Healthcare resource utilization was analyzed for the complete follow-up (up to 6 years) and for the first 2 years of adult care to assess the immediate effects of delayed transfer. In total, 172 young adults with SCD (52% male, 63% HbSS/HbSβ 0-thalassemia) transferred to adult care at a median age of 18 years during the years 2011-2017 (Table 1). Approximately 83% of the included participants transferred to adult care within the recommended 6 months. young adults with transfer gaps ≥9 months had 2.86 (95%CI: 1.32, 6.20) times the rate of acute healthcare visits (inpatient and emergency department combined) compared to those with <2 months transfer gap (Table 2). The incidence rate ratio increased (IRR: 4.06; 95%CI: 1.65, 9.94) when evaluating the first 2 years of adult care. When evaluating the recommended transfer gap (6 months) as a dichotomous variable, those with gaps >6 months had 2.27 (95%CI: 1.18, 4.40) times the rate of acute care visits compared to those with ≤6 months transfer gap (Table 3). The incidence rate ratio increased slightly (IRR: 2.37; 95%CI: 1.29, 4.37) when evaluating the first 2 years of adult care only. There were no apparent associations between transfer gap duration and outpatient visits during the first 6 years in adult care; however, when restricted to the first 2 years of adult care, those with gaps >6 months had 1.32 (95%CI: 1.01, 1.72) times the rate of outpatient visits compared to those with gaps ≤6 months. Consistent with current guidelines, transfer gaps between pediatric and adult-centered care of greater than 6 months were found to be associated with increased acute healthcare resource utilization. Therefore, SCD transition programs would be well-served to consider policies for young adults that initiate adult care within 6 months of leaving pediatric care. Future studies should continue to investigate duration of transfer gaps from pediatric to adult care for their long-term clinical effects and explore interventions to reduce the transfer gap in the SCD population. Figure 1 Figure 1. Disclosures Shah: Novartis: Consultancy, Research Funding, Speakers Bureau; GBT: Research Funding, Speakers Bureau; Alexion: Speakers Bureau; Guidepoint Global: Consultancy; GLG: Consultancy; Emmaus: Consultancy. Hankins: Bluebird Bio: Consultancy; UpToDate: Consultancy; Vindico Medical Education: Consultancy; Global Blood Therapeutics: Consultancy.

Importance of telephone follow-up and combined home visit and telephone follow-up interventions in reducing acute healthcare utilization

PurposeTransitional care is increasingly important in reducing readmission rates and length of stay (LOS). Singapore is focusing on transitional care to address the evolving care needs of a multi-morbid ageing population. This study aims to investigate the impact of transitional care programs (TCPs) on acute healthcare utilization.Design/methodology/approachA retrospective, longitudinal, interventional study was conducted. High-risk patients were enrolled into a transitional care program of local tertiary hospital. Patients received either telephone follow-up (TFU) or home-based intervention (HBI) with TFU. Readmission rates and LOS were assessed for both groups.FindingsThere was no statistically significant difference in readmissions or LOS between TFU and HBI. After excluding demised patients, TFU had statistically significant lower LOS than HBI. Both interventions demonstrated statistically significant reductions in readmissions and LOS in pre–post analyses.Research limitations/implicationsTFU may be more effective than HBI in patients with lower clinical severity, despite both interventions showing statistically significant reductions in acute healthcare utilization. Study findings may be used to inform transitional care practices. Future studies should continue to examine the comparative effectiveness of transitional care interventions and the patient populations most likely to benefit.Originality/valuePrevious studies demonstrated promising outcomes for TFU and HBIs, but few have evaluated their comparative effectiveness on acute healthcare utilization and specific patient populations most likely to benefit. This study evaluated interventional effectiveness of both, which might be useful for informing allocation of resources based on clinical complexity and care needs.

Hospitalizations and emergency department visits trends among elderly individuals in proximity to death: a retrospective population-based study

Acute healthcare services are extremely important, particularly during the COVID-19 pandemic, as healthcare demand has rapidly intensified, and resources have become insufficient. Studies on specific prepandemic hospitalization and emergency department visit (EDV) trends in proximity to death are limited. We examined time-trend specificities based on sex, age, and cause of death in the last 2 years of life. Datasets containing all hospitalizations and EDVs of elderly residents in Friuli-Venezia Giulia, Italy (N = 411,812), who died between 2002 and 2014 at ≥ 65 years, have been collected. We performed subgroup change-point analysis of monthly trends in the 2 years preceding death according to sex, age at death (65–74, 75–84, 85–94, and ≥ 95 years), and main cause of death (cancer, cardiovascular, or respiratory disease). The proportion of decedents (N = 142,834) accessing acute healthcare services increased exponentially in proximity to death (hospitalizations = 4.7, EDVs = 3.9 months before death). This was inversely related to age, with changes among the youngest and eldest decedents at 6.6 and 3.5 months for hospitalizations and at 4.6 and 3.3 months for EDVs, respectively. Healthcare use among cancer patients intensified earlier in life (hospitalizations = 6.8, EDVs = 5.8 months before death). Decedents from respiratory diseases were most likely to access hospital-based services during the last month of life. No sex-based differences were found. The greater use of acute healthcare services among younger decedents and cancer patients suggests that policies potentiating primary care support targeting these at-risk groups may reduce pressure on hospital-based services.

Geographic inequalities in non-acute healthcare supply: evidence from Ireland

Background: Recent reforms in Ireland, as outlined in Sláintecare, the report of the cross-party parliamentary committee on health, are focused on shifting from a hospital-centric system to one where non-acute care plays a more central role. However, these reforms were embarked on in the absence of timely and accurate information about the capacity of non-acute care to take on a more central role in the system. To help address this gap, this paper outlines the most comprehensive analysis to date of geographic inequalities in non-acute care supply in Ireland. Methods: Data on the supply of 10 non-acute services including primary care, allied health, and care for older people, were collated. Per capita supply for each service is described for 28 counties in Ireland (Tipperary and Dublin divided into North and South), using 2014 supply and population data. To examine inequity in the geographic distribution of services, raw population in each county was adjusted for a range of needs indicators. Results: The findings show considerable geographic inequalities across counties in the supply of non-acute care. Some counties had low levels of supply of several types of non-acute care. The findings remain largely unchanged after adjusting for need, suggesting that the unequal patterns of supply are also inequitable. Conclusions: In the context of population changes and the influence of non-need factors, the persistence of historical budgeting in Ireland has led to considerable geographic inequities in non-acute supply, with important lessons for Ireland and for other countries. Such inequities come into sharp relief in the context of COVID-19, where non-acute supply plays a crucial role in ensuring that acute services are preserved for treating acutely ill patients.

A new tool to measure acuity in the community: a case study

The provision of acute healthcare within patients own home (i.e. hospital in the home) is an important method of providing individualised patient-centred care that reduces the need for acute hospital admissions and enables early hospital discharge for appropriate patient groups. The Hospital in the Home (HitH) model of care ensures that this approach maximises patient safety and limits potential risk for patients. As HitH services have seen record numbers of patient referrals in the past 2 years, there is now a greater need to measure and understand the acuity and dependency levels of the caseload. Through an expert clinician development process at one NHS trust, aspects of procedural complexity, interdisciplinary working, risk stratification and comorbidities were used to quantify acuity and dependency. This paper uses a case study approach to present a new method of measuring this important concept.

559Health of Aboriginal children in Western Australia: Do grandparents matter?

Background Studies of select populations (e.g. pre-industrial or subsistence farming populations) suggest that children with living maternal grandmothers (MGMs) had improved survival. It is unknown if this holds for child health more generally or in Australian Indigenous communities, where care of children is commonly shared by family members. We examined associations between the health of young Aboriginal Western Australians and their grandparents. Methods Birth, death, inpatient and emergency department records of Aboriginal infants born 2000-2013 in WA and their grandparents were linked. Grandparents were classified as ‘healthy’ (alive with Charlson comorbidity index score of 0 or 1), ‘unhealthy’ (alive with a score of ≥ 2), or dead when the child was born. Results Among the 27,425 children, mortality by age 2 was lower with healthy grandparents (e.g. 11 deaths per 1000 live births with healthy MGMs; 22 with unhealthy; 16 with dead MGMs) and acute healthcare contacts were fewer (e.g. 13% with healthy MGMs spent ≥7 days in hospital by age 2 vs 19% with unhealthy or dead MGMs). However, healthcare contacts were generally unrelated to grandfathers. Outcomes were better for children with 2 living grandmothers (e.g. 1.5% with 2 grandmothers were discharged against medical advice in 2 years; 2.7% with 1 grandmother; 3.7% with none). Conclusions Children with healthy grandmothers had lower mortality and morbidity. These associations are unlikely to be due to genetic or environmental factors, as they are weaker/missing for grandfathers. Key messages Good health among older Aboriginal people may also benefit the health of subsequent generations.

Impact of Home Healthcare on End-of-life Outcomes for People With Dementia: a Systematic Review

Background: Home healthcare (HHC) may reduce acute hospital utilization, but its effect on homebound people living with dementia (PLWD) at end-of-life remains unclear. We aim to describe the impact of HHC on acute healthcare utilization and end-of-life outcomes in PLWD.Methods: Design: A systematic review of quantitative and qualitative studies regarding the association between HHC (exposure) and targeted outcomes. Interventions: HHC provided by health care professionals, including physicians or nurses. Participants: At least 80% of study participants had dementia and lived at home. Measurements: Primary outcome was acute healthcare utilization in the last year of life. Secondary outcomes included palliative care use, advance care planning (ACP), continuity of care in the last year of life, and place of death. We identified contextual information about policy changes in HHC for these outcomes.Results: We included five studies from USA, Japan, and Italy, none of which received a high-quality rating. At micro-level, HHC may be associated with a lower risk of acute healthcare utilization in the early period (e.g., last 90 days before death) and a higher risk in the late period (e.g. last 15 days) of the disease trajectory toward end-of-life in PLWD. ACP with written decisions may be an important mediator of this. HHC increases referrals to palliative care. At meso-level, HHC providers’ difficulty in making treatment decisions for PLWD at the end-of-life may require further training and external support. Coordination between HHC and social care is mentioned but not well examined in the existing literature.Conclusions: The review highlights the dearth of dementia-specific research regarding the impact of HHC on end-of-life outcomes. In PLWD, the core components of HHC for achieving better quality end-of-life, the integration between health and social care, and coordination between primary HHC and palliative care should be further investigated in future studies.

Municipal acute care teams as a flexible solution for the treatment of acutely ill patients at-home: a mixed-method study of patients’ and caregivers’ experiences with an acute care team

ObjectiveDevelopment of initiatives to reduce hospitalisations is a major focus of healthcare planning. Strengthening the community with municipal acute care teams or units is a newly implemented Danish initiative aimed at preventing hospitalisations and supporting more flexible services. This study aims to describe patients treated by a municipal acute care team and to explore patients’ and caregivers’ experiences with at-home treatment.DesignA mixed-method study consisting of descriptive statistics of patients treated by an acute care team, and quantitative and qualitative data from follow-up telephone questionnaires with patients and caregivers.SettingThe acute care team, ‘Acute Team Odense’ (ATO), in the Odense Municipality, Denmark.ParticipantsPatients treated by ATO and their caregivers. ATO treated 3231 patients (5676 contacts) in the period of 2018–2019.ResultsAverage number of new contacts per day was 7.8, and the median treatment-length was 1 day. Patients were referred by various healthcare providers and most often by general practitioners, municipal staff and hospital staff. The median age of the patients was 80 years, and 20% were independent before the treatment. In total, 787/5676 contacts received at-home intravenous therapy, which corresponded to 3.6 hospital beds saved per day. The questionnaires were completed by 307/478 patients and 168/254 caregivers. Most respondents stated they would prefer at-home treatment in future similar situations as it enabled them to maintain their lives. Several respondents also experienced that ATO avoided hospitalisations or reduced hospital stays, which was described as a relief.ConclusionATO was frequently used, indicating the demand for community-based acute healthcare. The patients and caregivers experienced that this solution avoided hospitalisations and allowed them to maintain their lives, and this was described as less burdensome. As a result of these findings, this initiative has been continued with an ongoing focus on searching for possibilities aimed to prevent hospitalisations.

A Systems Study on Interprofessional Collaboration in Healthcare

This study aims to translate and adapt the Assessment of Interprofessional Team Collaboration Scale II (AITCS-II) cross-culturally for effective and systemic use in Japan, to describe floor and ceiling values, and to examine in terms of such criteria as reliability and face and content validity. The AITCS-II was translated from English into Japanese to develop the Japanese version of the Assessment of Interprofessional Team Collaboration Scale II (hereinafter referred to AITCS-II-J). Then, cross-sectional and cross-professional data analyses were carried out to seek evidence of construct validity. Analysis demonstrated good content and face validity. With a Cronbach's alpha coefficient greater than 0.9 (r varied from 0.912 to 0.940), the AITCS-II-J exhibited excellent internal consistency. The AITCS-II-J showed evidence of acceptable validity and reliability; therefore, this measurement system will be useful for informing the enhancement of interprofessional team collaboration within the Japanese acute healthcare context.

Establishing consensus on emergency department interventions that could be conducted in sub-acute care settings for non-emergent paramedic transported visits: A RAND/UCLA modified Delphi study

Background Patients transported by paramedics for non-emergent conditions are increasing in Ontario and contribute to an emergency department (ED) crisis. Redirecting certain patients to sub-acute healthcare may be beneficial and suitable. We examined if ED interventions conducted on non-emergent paramedic transported patients could be conducted in sub-acute health centres. Methods A RAND/UCLA modified Delphi study was conducted. Twenty emergency and primary care physicians rated the suitability of the 150 most frequently recorded interventions for completion in sub-acute healthcare centres and provided comments to augment ratings. Interventions were performed on non-emergent adult patients transported by paramedics to an ED, and abstracted from the National Ambulatory Care Reporting System database (January 1, 2014 to March 31, 2018). We used two rounds of a modified Delphi process and set consensus at 70% agreement. Results Consensus was reached on 146 (97.3%) interventions; 103 interventions (68.7%) were suitable for sub-acute centres, 43 (28.7%) for ED only; 4 (2.6%) did not receive consensus. For sub-acute centres, all 103 interventions were rated for urgent care centres; walk-in medical centres were applicable for 46 (30.6%) and nurse practitioner-led clinics for 47 (31.3). Diagnostic imaging availability, physician preferences and staffing were determining factors for discrepancies in sub-acute centre ratings. Interpretation The majority of included ED interventions performed on non-emergent patients transported by paramedics were identified as suitable for urgent care clinics, with one-third being suitable for either walk-in medical centres or nurse practitioner-led clinics. In combination with additional patient details and supports, knowledge of interventions suitable for sub-acute healthcare centres will inform a patient classification model for paramedic-initiated redirection of patients from ED.