Avoidable Hospitalizations in Persons with Dementia: a Population-Wide Descriptive Study (2000–2015)

Background Whether avoidable hospitalizations in community-dwelling persons with dementia have decreased during primary care reforms is unknown. Methods We described the prevalence and trends in avoidable hos­pitalizations in population-based repeated yearly cohorts of 192,144 community-dwelling persons with incident dementia (Quebec, 2000–2015) in the context of a province-wide pri­mary care reform, using the provincial health administrative database. Results Trends in both types of Ambulatory Care Sensitive Condition (ACSC) hospitalization (general and older population) and 30-day readmission rates remained constant with average rates per 100 person-years: 20.5 (19.9–21.1), 31.7 (31.0–32.4), 20.6 (20.1–21.2), respectively. Rates of delayed hospital discharge (i.e., alternate level of care (ALC) hospitalizations) decreased from 23.8 (21.1–26.9) to 17.9 (16.1–20.1) (relative change -24.6%). Conclusions These figures shed light on the importance of the phenomenon, its lack of improvement for most outcomes over the years, and the need to develop evidence-based policies to prevent avoidable hospitalizations in this vulnerable population.

Clinical, Discharge and Psychosocial Profiles of Adolescents with Substance Use Disorder Accessing Inpatient Psychiatry in Ontario, Canada

Objective: To explore the proportion of patients with a Substance Use Disorder (SUD), their proportion of overall admissions and their psychosocial histories at a regional child and adolescent inpatient psychiatric unit. Method: A retrospective chart review was conducted on all admissions of patients with a SUD. Abstracted patient data included demographic information, diagnoses, psychosocial histories, living situation at the time of admission, legal involvement and charges, whether an alternate level of care was needed and discharge plans. Results: From September 2018 to February 2020, of the 540 patients admitted, 126 (23.3%) had a SUD recorded in their charts and accounted for 34.6% of the total number of admissions. Their mean age was 15.85 (SD 1.10; range 13 to 18) years and most were identified as female (n=81; 64%) which is consistent with the number of female patients admitted during the study period (n=366 female of 540 admitted; X2=0.56, p= 0.45). Common psychiatric diagnoses included mood, trauma and stressor-related and anxiety disorders. Most patients (124; 98.4%) had a history of psychosocial adversity, 90 (71.4%) patients had a parent with a mental illness or a SUD, 55 (44%) reported being bullied, 54 (43%) reported being sexually assaulted and several (n=41;33%) had experienced precarious living situations. Conclusions: Adolescent inpatients with a SUD were also managing a complex array of clinical and psychosocial challenges. Upon discharge from hospital, some patients were placed on waitlists and many patients were referred to specialized treatment far from home highlighting the need for additional, comprehensive programs for SUD and the constellation of psychosocial problems associated with these disorders.

Delayed Hospital Discharge–The Effect of Dementia and GP Contacts Prior to Hospitalization

Delayed hospital discharge, also known as alternate level of care (ALC) in Canada, refers to a stay in hospital when acute services are no longer needed but the patient occupies a hospital bed while waiting to be discharged to an appropriate care setting. ALC has negative consequences for both the service system (high costs, inappropriate use of hospital resources) and individuals (feelings of uncertainty, functional loss). Extensive administrative health care data from British Columbia, Canada, were employed to study differences in ALC between people with and without dementia in 2001/02, 2005/06, 2010/11 and 2015/16, and whether continuity in physician–patient relationships prior to hospitalization is associated with ALC. We analyzed designation of ALC and length of stay in ALC, using generalized estimating equations logistic regression and negative binomial regression analysis. Of all individual, residential area and health care related factors, dementia was the single most important factor increasing the odds of designation of ALC (OR 4.76, 95%CI 4.59, 4.93). Dementia also added to the length of stay in ALC. Proportion of patients designated to ALC increased over the study years. Higher number of visits to the same general practitioner (GP) prior to hospitalization decreased the odds of ALC, especially in people with dementia. As populations age, the number of people with dementia is increasing. Efforts to control ALC have resulted in greater concentration of ALC among people with dementia. Higher continuity GP care may be a way to help understand and control these trends.

Describing the characteristics and healthcare use of high-cost acute care users at the end of life: a pan-Canadian population-based study

Background A minority of individuals use a large portion of health system resources, incurring considerable costs, especially in acute-care hospitals where a significant proportion of deaths occur. We sought to describe and contrast the characteristics, acute-care use and cost in the last year of life among high users and non-high users who died in hospitals across Canada. Methods We conducted a population-based retrospective-cohort study of Canadian adults aged ≥18 who died in hospitals across Canada between fiscal years 2011/12–2014/15. High users were defined as patients within the top 10% of highest cumulative acute-care costs in each fiscal year. Patients were categorized as: persistent high users (high-cost in death year and year prior), non-persistent high users (high-cost in death year only) and non-high users (never high-cost). Discharge abstracts were used to measure characteristics and acute-care use, including number of hospitalizations, admissions to intensive-care-unit (ICU), and alternate-level-of-care (ALC). Results We identified 191,310 decedents, among which 6% were persistent high users, 41% were non-persistent high users, and 46% were non-high users. A larger proportion of high users were male, younger, and had multimorbidity than non-high users. In the last year of life, persistent high users had multiple hospitalizations more often than other groups. Twenty-eight percent of persistent high users had ≥2 ICU admissions, compared to 8% of non-persistent high users and only 1% of non-high users. Eleven percent of persistent high users had ≥2 ALC admissions, compared to only 2% of non-persistent high users and < 1% of non-high users. High users received an in-hospital intervention more often than non-high users (36% vs. 19%). Despite representing only 47% of the cohort, persistent and non-persistent high users accounted for 83% of acute-care costs. Conclusions High users – persistent and non-persistent – are medically complex and use a disproportionate amount of acute-care resources at the end of life. A greater understanding of the characteristics and circumstances that lead to persistently high use of inpatient services may help inform strategies to prevent hospitalizations and off-set current healthcare costs while improving patient outcomes.

Improving the Use of Healthcare Resources in Canadian Hospitals: The Impact of a Reintegration Unit in Expanding Acute Care Capacity and Resource Use in Sunnybrook Health Sciences Centre

Background: Alternate level of care (ALC) patients are those who reside in acute hospital beds but can be managed in non-hospital settings. They contribute to high occupancy levels in Canadian hospitals. Between 2017-18, Ontario spent 1.1 billion dollars on hospitalized patients waiting for alternate level of care (ALC) beds. To improve value for care, Ontario Ministry of Health (MOHLTC) invested into reintegration units which are designed to transfer ALC patients out of hospital and transition them back into the community or long-term care (LTC). Given today’s healthcare budget pressures, it is unclear if reactivation units are feasible. In 2018, the MOHLTC funded a reintegration unit, Pine Villa with an operational partner, Sunnybrook Hospital and community service providers (SPRINT Senior Care, LOFT) in Toronto, Ontario. The objective was to determine averted costs for ALC-patients and impact on Sunnybrook patient flow-through if ALC-patient Pine Villa transfers occurred on the day of ALC readiness. Methods: Retrospective, observational analysis of Sunnybrook ALC-patients discharged to Pine Villa between January 9, 2018 to February 4, 2019. From the healthcare payer’s perspective (MOHTLC), cost analysis was modelled for ALC patients designated for 1) LTC and 2) home with supports. Avoided costs at time of ALC readiness were determined by case-costing. Averted hospital ALC days were established. Results: If ALC patients were transferred to Pine Villa at time of ALC readiness for LTC, the healthcare system could have averted 5.4 million dollars from Sunnybrook. If the patients were transferred for home, 2.3 million dollars could have been averted. Both models increased acute Sunnybrook Hospital capacity by 34 beds. Conclusion: There is a business case supporting reintegration units if ALC-patients are discharged from the hospital on the day of ALC-readiness.

Medication Use by Alternate Level of Care Patients: A Descriptive Analysis

ABSTRACTBackground: The population of patients designated as alternate level of care (ALC) consists predominantly of frail older adults who are medically stable and awaiting discharge from hospital. They have complex medica-tion regimens, often including potentially inappropriate medications (PIMs). There has been increasing emphasis on managing the burden that ALC patients place on the health care system, but little is known about their health care needs. Objective: To characterize the medication regimens, including use of PIMs, of ALC patients at the study institution. Methods: A cross-sectional chart audit of ALC patients was conducted between May and July 2017. For all patients in the sample, each medication was categorized by therapeutic class, and PIMs were categorized according to the Beers criteria, the STOPP/START criteria, and an established list of high-alert medications. Results: A total of 82 patients met the audit criteria, for whom the mean number of chronic conditions was 6.4 (standard deviation [SD] 3.3) and the mean number of prescribed medications was 12.8 (SD 6.9). Twenty-four (29%) of the patients were receiving at least 1 drug from 7 different drug classes. All but one of the patients had PIMs in their regimen; the frequency of PIMs was highest according to the Beers criteria (mean 3.9 [SD 2.6] medications per patient). Conclusions: At the study institution, ALC patients had on average more than 6 chronic conditions managed with at least 12 medications, of which one-quarter were PIMs. These data will be used to inform next steps in making recommendations to simplify, reduce, or discontinue medications for which there is an unclear indication, lack of effectiveness, or evidence of potential harm.RÉSUMÉContexte : La population de patients désignés comme « niveaux de soins alternatifs » (NSA) se compose majoritairement d’aînés faibles, médicalement stables et en attente de leur congé hospitalier. Ils suivent des traitements médicamenteux complexes qui comprennent souvent des médicaments potentiellement contre-indiqués (MPCI). L’accent a été progressivement mis sur la gestion du fardeau que les patients NSA font peser sur le système de soins de santé, mais on connait peu de choses sur leurs besoins en matière de soins de santé. Objectif : Décrire les traitements médicamenteux, y compris l’utilisation des MPCI, des patients NSA dans l’institution où s’est déroulée l’étude. Méthodes : Une vérification transversale des dossiers de patients NSA a été menée entre mai et juillet 2017. Chaque médicament pris par les patients de l’échantillon a été classé selon sa catégorie thérapeutique, et les MPCI ont été catégorisés selon les critères de Beers, les critères STOPP/START ainsi qu’une liste établie de médicaments dont le niveau d’alerte est élevé.Résultats : Au total, 82 patients remplissaient les critères de l’audit, car le nombre moyen de maladies chroniques était de 6,4 (écart type [ET] 3,3) et le nombre moyen de médicaments prescrits se montait à 12,8 (ET 6,9). Vingt-quatre (29 %) patients recevaient au moins un médicament de sept classes médicamenteuses différentes. Tous les patients sauf un avaient des MPCI dans leur programme. La fréquence des MPCI était plus élevée selon les critères de Beers (moyenne de MPCI par patient de 3,9 [ET 2,6]). Conclusions : Sur le lieu de l’étude, les patients NSA avaient en moyenne plus de six maladies chroniques gérées à l’aide d’au moins 12 médicaments, dont un quart était des MPCI. Ces données seront utilisées pour informer les cliniciens sur les étapes suivantes et formuler des recommandations afin de simplifier, de réduire ou d’arrêter les médicaments pour lesquels l’indication n’est pas claire, dont l’efficacité est insuffisante ou sur lesquels il existe des données probantes faisant état de dangers potentiels.

Establishing an integrated model of subacute care for the frail elderly

The current health system in Ontario is not designed to meet the needs of frail older adults. This is particularly true for older adults hospitalized due to exacerbation of chronic illness or medical crisis. This article describes the Subacute Care Unit for the Frail Elderly (SAFE) program, one which is designed to serve frail older patients who are at risk of deconditioning or disability associated with prolonged hospitalization but who may safely return home or to a retirement home following up to 4 weeks of subacute care in a restorative environment. The program centres on an intense restorative and integrated care delivery model. The patient population is medically complex, requiring medical supervision and regular adjustment to the care plan to optimize medical status. Individuals are no longer acutely ill and are considered stable or stabilizing. Care and services are designed to improve outcomes for hospitalized frail older adults by proactively addressing the conditions that contribute to alternate level of care before the deconditioning associated with prolonged hospitalization is experienced.