Dan Ewald

Frequent hospital admission of older people with chronic disease: a cross-sectional survey with telephone follow-up and data linkage

BackgroundThe continued increase in hospital admissions is a significant and complex issue facing health services. There is little research exploring patient perspectives or examining individual admissions among patients with frequent admissions for chronic ambulatory care sensitive (ACS) conditions. This paper aims to describe characteristics of older, rural patients frequently admitted with ACS conditions and identify factors associated with their admissions from the patient perspective.MethodsPatients aged 65+ resident in North Coast NSW with three or more admissions for selected ACS chronic conditions within a 12 month period, were invited to participate in a postal survey and follow up telephone call. Survey and telephone data were linked to admission and health service program data. Descriptive statistics were generated for survey respondents; logistic regression models developed to compare characteristics of patients with 3 or with 4+ admissions; and comparisons made between survey respondents and non-respondents.ResultsSurvey respondents (n=102) had a mean age of 77.1 years (range 66–95 years), and a mean of 4.1 admissions within 12 months; 49% had at least three chronic conditions; the majority had low socioeconomic status; one in five (22%) reported some difficulty affording their medication; and 35% lived alone. The majority reported psychological distress with 31% having moderate or severe psychological distress. While all had a GP, only 38% reported having a written GP care plan. 22% of those who needed regular help with daily tasks did not have a close friend or relative who regularly cared for them. Factors independently associated with more frequent (n=4+) relative to less frequent (n=3) admissions included having congestive heart failure (p=0.003), higher social isolation scores (p=0.040) and higher Charlson Comorbidity Index scores (p=0.049). Most respondents (61%) felt there was nothing that could have avoided their most recent admission, although some potential avoidability of admission was described around medication and health behaviours. Respondents were younger and less sick than non-respondents.ConclusionsThis study provides a detailed description of older patients with multiple chronic conditions and a history of frequent admission in rural Australia. Our results suggest that programs targeting medication use, health behaviours and social isolation may help reduce multiple hospital admissions for chronic disease.

Admissions for chronic ambulatory care sensitive conditions - a useful measure of potentially preventable admission?

BackgroundPotentially preventable hospital admission (an admission deemed to be potentially preventable given appropriate care in the community-based healthcare setting) has been a topic of international research attention for almost three decades. Recently this has been largely driven by the imperative to reduce ever-increasing unplanned hospital admissions. However, identifying potentially preventable admissions is difficult. As a result, the population level indicator of admissions for ambulatory care sensitive conditions (ACSCs) has been used as a proxy measure for potentially preventable admission. The adoption of this measure has become common, and in Australia, the rate of admissions for chronic ACSCs is now an important component of measuring health system performance and accountability, and is directly linked to funding. Admission for a chronic ACSC is also used to identify individuals for targeting of interventions to reduce preventable admissions.DiscussionHospital admission for chronic ACSCs is a population measure based on admission diagnoses, it therefore should not be used to identify individual preventable admissions. At present we are unable to determine individual admissions that are deemed to be preventable or, therefore, articulate the factors associated with admissions which are preventable.SummaryAs we are currently unable to identify individual admissions that are preventable, little is understood about the underlying causes and factors contributing to preventable admissions. A means of assessing preventability of individual admissions is required. Only then can we explore the antecedents, and patient and clinician perspectives on preventable admissions. Until we have a clearer understanding of this, our capacity to inform policy and program development remains compromised.

Diagnosing Potentially Preventable Hospitalisations (DaPPHne): protocol for a mixed-methods data-linkage study

Introduction Rates of potentially preventable hospitalisations (PPH) are used as a proxy measure of effectiveness of, or access to community-based health services. The validity of PPH as an indicator in Australia has not been confirmed. Available evidence suggests that patient-related, clinician-related and systems-related factors are associated with PPH, with differences between rural and metropolitan settings. Furthermore, the proportion of PPHs which are actually preventable is unknown. The Diagnosing Potentially Preventable Hospitalisations study will determine the proportion of PPHs for chronic conditions that are deemed preventable and identify potentially modifiable factors driving these, in order to develop effective interventions to reduce admissions and improve measures of health system performance. Methods and analysis This mixed methods data linkage study of approximately 1000 eligible patients with chronic PPH admissions to one metropolitan and two regional hospitals over 12 months will combine data from multiple sources to assess the: extent of preventability of chronic PPH admissions; validity of the Preventability Assessment Tool (PAT) in identifying preventable admissions; factors contributing to chronic PPH admissions. Data collected from patients (quantitative and qualitative methods), their general practitioners, hospital clinicians and hospital records, will be linked with routinely collected New South Wales (NSW) Admitted Patient Data Collection, the NSW Registry of Births, Death and Marriages death registration and Australian Bureau of Statistics mortality data. The validity of the PAT will be assessed by determining concordance between clinician assessment and that of a ‘gold standard’ panel. Multivariable logistic regression will identify the main predictor variables of admissions deemed preventable, using study-specific and linked data. Ethics and dissemination The NSW Population and Health Services Research Ethics Committee granted ethical approval. Dissemination mechanisms include engagement of policy stakeholders through a project Steering Committee, and the production of summary reports for policy and clinical audiences in addition to peer-review papers.

Reducing avoidable admissions in rural community palliative care: a pilot study of care coordination by General Practice registrars

OBJECTIVE To investigate the feasibility of using a General Practice registrar (GPR) to coordinate rural palliative care services. DESIGN A quasi-experimental design was used. Intervention group participants received the GPR service, which involved liaison among the patient, family, General Practitioner, specialist palliative care team and community nurses. Specified risk assessment, care planning and continuity of care were provided. Patients in the comparison group received the standard service. SETTING Rural community palliative care. PARTICIPANTS One hundred and ninety-one rural community palliative care patients (99 intervention and 92 control patients). MAIN OUTCOME MEASURES Hospital admissions per 100 patient-days, bed-days per 100 patient-days and proportion of deaths at home. RESULTS Patients receiving standard care were twice as likely to spend ≥8 bed-days in hospital (OR 2.09 (95%CI 1.10-3.97); P = 0.02) and were more likely to have ≥ 2 admissions to hospital (OR 3.37 (95%CI 1.83-6.21); P < 0.001), per 100 patient-days than the intervention group after adjusting for diagnosis group (cancer or not) and residence in residential aged care. Controls were significantly less likely to die at home than the intervention group (OR 0.41 (95%CI 0.20-0.86); P = 0.02). CONCLUSION This is a small proof of concept pilot study limited by lack of randomisation. The results demonstrate the feasibility of using a GPR to manage continuity of care for rural community palliative care patients. Given the potential confounding factors, further investigation via a larger randomised trial is required.