Correlates of a "do not hospitalize" designation: in a sample of frail nursing home residents in Vancouver

OBJECTIVE

To explore what nursing home resident demographic, clinical, functional, and health services utilization characteristics influence a “do not hospitalize” designation.

DESIGN

Historical cohort study.

SETTING

Vancouver, BC.

PARTICIPANTS

Extended care residents in 2 hospital-based and 4 free-standing nursing homes who died between 2001 and 2007.

MAIN OUTCOME MEASURES

The designation of “do not hospitalize” on a resident’s chart.

RESULTS

Continuity of family physician care from admission to death (adjusted hazard ratio [AHR] 2.16, 95% confidence interval [CI] 1.33 to 3.49), a sudden and unexpected death (AHR 0.43, 95% CI 0.25 to 0.73), and age (AHR 1.02, 95% CI 1.01 to 1.02) were independently associated with a “do not hospitalize” designation.

CONCLUSION

The greater than 2-fold positive association of continuity of family physician care with a “do not hospitalize” designation is an interesting addition to the literature on how continuity of physician care matters.     

Patient satisfaction with access and continuity of care in a multidisciplinary academic family medicine clinic

Objective

To determine patient satisfaction with care provided at a family medicine teaching clinic.

Design

Mailed survey.

Setting

Victoria Family Medical Centre in London, Ont.

Participants

Stratified random sample of 600 regular patients of the clinic aged 18 years or older; 301 responses were received.

Main outcome measures

Patient satisfaction with overall care, wait times for appointments, contact with physicians, and associated demographic factors. Logistic regression analysis and analysis were used to determine the significance of factors associated with satisfaction.

Results

The response rate was 50%. Overall, 88% of respondents were fairly, very, or completely satisfied with care. Older patients tended to be more satisfied. Patients who were less satisfied had longer wait times for appointments (P < .001) and reduced continuity with specific doctors (P = .004). More satisfied patients also felt connected through other members of the health care team.

Conclusion

Patients were generally satisfied with the care provided at the family medicine teaching clinic. Older patients tended to be more satisfied than younger patients. Points of dissatisfaction were related to wait times for appointments and continuity with patients’ usual doctors. These findings support the adoption of practices that reduce wait times and facilitate continuity with patients’ usual doctors and other regular members of the health care team.     

Enhancing continuity of information: Essential components of consultation reports

OBJECTIVE

To identify elements of data that have been shown to contribute to continuity of information between primary care providers and medical specialists providing care to adult asthma patients.

DESIGN

Systematic review of the literature followed by a 2-round modified Delphi consensus process.

SETTING

Province of Ontario.

PARTICIPANTS

Eight expert panelists, including 3 practising family physicians, a medical specialist knowledgeable in the treatment of asthma, a family physician previously involved in provincial initiatives related to primary care reform, an e-health technologist, a developer of evidence-based guidelines, and an operations and programs specialist.

METHODS

We completed a systematic literature review to identify important components of consultation reports. We then engaged an 8-member panel in a 2-round modified Delphi consensus process, which led to the identification of components deemed essential to good continuity of information.

MAIN FINDINGS

After 2 rounds, expert panelists reached consensus on 15 components, referred to here as minimum essential elements, of consultation reports generated by medical specialists in response to referring primary care providers’ consultation requests.

CONCLUSION

The expert panelists considered inclusion of the minimum essential elements in consultation reports essential to achieving good continuity of information. We assembled these elements in a suggested format for a consultation report. The format can be easily modified by practitioners caring for patients with other chronic diseases.     

Family physicians providing regular care to residents in Ontario long-term care homes: Characteristics and practice patterns

Objective

To describe the characteristics and practice patterns of family physicians who regularly treat long-term care (LTC) residents in order to inform quality improvement strategies.

Design

Cross-sectional study involving a 2005 province-wide census of LTC residents’ charts linked to additional health care administrative databases.

Setting

All LTC homes in Ontario.

Participants

Residents aged 66 years and older (n = 50375) and the family physicians (n = 1190) most responsible for their care.

Main outcome measures

Distribution of LTC residents across family physicians, and physician demographic characteristics and practice patterns.

Results

The distribution of residents across physicians was highly skewed (median 27 residents, mean 42.5 residents). The care of 90.4% of residents was accounted for by 628 (52.8%) identified physicians. Family physicians practising in LTC facilities were more likely to be older (mean age 52.4 years vs 48.2 years, P < .001) and male (82.4% vs 61.5%, P < .001) than other family physicians. Urban physicians who provided care to LTC residents had bigger LTC practices than rural LTC physicians did (median 50 residents vs median 12 residents).

Conclusion

About 600 family physicians are responsible for the regular care of more than 90% of LTC residents in Ontario and quality improvement efforts could be aimed at this relatively small group of physicians. Half of the urban physicians who practise in LTC homes are responsible for 50 or more LTC residents. This might represent a key part of their overall practice.     

Hypoglycemia Associated With Hospitalization and Adverse Events in Older People: Population-based cohort study

OBJECTIVE

Little is known about the prognostic impact of hypoglycemia associated with hospitalization. We hypothesized that hospitalized hypoglycemia would be associated with increased long-term morbidity and mortality, irrespective of diabetes status.

RESEARCH DESIGN AND METHODS

We undertook a cohort study using linked administrative health care and laboratory databases in Alberta, Canada. From 1 January 2004 to 31 March 2009, we included all outpatients 66 years of age and older who had at least one serum creatinine and one A1C measured. To examine the independent association between hospitalized hypoglycemia and all-cause mortality, we used time-varying Cox proportional hazards (adjusted hazard ratio [aHR]), and for all-cause hospitalizations, we used Poisson regression (adjusted incidence rate ratio [aIRR]).

RESULTS

The cohort included 85,810 patients: mean age 75 years, 51% female, and 50% had diabetes defined by administrative data. Overall, 440 patients (0.5%) had severe hypoglycemia associated with hospitalization and most (93%) had diabetes. During 4 years of follow-up, 16,320 (19%) patients died. Hospitalized hypoglycemia was independently associated with increased mortality (60 vs. 19% mortality for no hypoglycemia; aHR 2.55 [95% CI 2.25–2.88]), and this increased in a dose-dependent manner (aHR no hypoglycemia = 1.0 vs. one episode = 2.49 vs. one or more = 3.78, P trend <0.001). Hospitalized hypoglycemia was also independently associated with subsequent hospitalizations (aIRR no hypoglycemia = 1.0 vs. one episode = 1.90 vs. one or more = 2.61, P trend <0.001) and recurrent hypoglycemia (aHR no hypoglycemia = 1.0 vs. one episode = 2.45 vs. one or more = 9.66, P trend <0.001).

CONCLUSIONS

Older people who have an episode of hospitalized hypoglycemia are easily identified and at substantially increased risk of morbidity and mortality.Relatively little has been reported regarding severe hypoglycemia, particularly outside the setting of diabetes and its treatments or beyond the context of strict glycemic control in the perioperative or critical care setting (1–5). Among the standard diabetes treatment arms of the ADVANCE (Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation) and ACCORD (Action to Control Cardiovascular Risk in Diabetes) trials, rates of severe hypoglycemia requiring medical attention ranged between 1.5 and 3.4% over 4–5 years (6,7), and attempts at determining population-based rates of severe nondiabetic hypoglycemia suggest a rate of 50 per 10,000 hospital admissions (5). Whether examined in diabetes-related outpatient cohorts (8–12), in trials of intensive glycemic control (13), or in the setting of acute illness (14–16), severe hypoglycemia is often associated with an increase in all-cause mortality and other major adverse events.To our knowledge, there are no reports examining the long-term prognostic impact of an episode of severe hypoglycemia associated with hospitalization that occurs in community-dwelling older adults, particularly those without diabetes. Therefore, we undertook a population-based cohort study using linked health care databases to determine the prognostic impact of severe hypoglycemia associated with hospitalization on long-term morbidity and mortality. We hypothesized that an episode of hospitalized hypoglycemia would be independently associated with an increased risk of all-cause hospitalization and all-cause mortality, and we speculated that there would be a dose-response relationship between the number of hypoglycemic episodes and major adverse events.     

Effects of practice setting on GPs’ provision of care

Objective

To define a physician classification system based on practice settings and to analyze the service provision associated with those classifications.

Design

A cross-sectional, retrospective study.

Setting

Province of Quebec.

Participants

All GPs in Quebec in 2002 who had been practising for at least 2 years.

Main outcome measures

Practice setting variables were based on physician income in the different settings. Service provision was assessed using indicators related to continuity, comprehensiveness, accessibility, and productivity of services provided by the GPs. A multiple correspondence analysis with ascending hierarchical classification was conducted to construct the taxonomy of GPs based on their practice settings.

Results

Our study produced 7 practice setting models. Two were essentially single-practice models. The 5 others combined several settings. Service provision varied from one model to another. Continuity was greater in the private practice model, in which older GPs were predominant, while accessibility was greater in multi-institutional practice models, in which younger GPs were more active.

Conclusion

To ensure balance between continuity, accessibility, and comprehensiveness in primary care services provided by GPs, it is important to consider the service provision associated with different practice models.     

Secular Trends in Diabetes-Related Preventable Hospitalizations in the United States, 1998�C2006

OBJECTIVE

To examine secular trends in diabetes-related preventable hospitalizations among adults with diabetes in the U.S. from 1998 to 2006.

RESEARCH DESIGN AND METHODS

We used nationally representative data from the National Inpatient Sample to identify diabetes-related preventable hospitalizations. Based on the Agency for Healthcare Research and Quality''s Prevention Quality Indicators, we considered that hospitalizations associated with the following four conditions were preventable: uncontrolled diabetes, short-term complications, long-term complications, and lower-extremity amputations. Estimates of the number of adults with diabetes were obtained from the National Health Interview Survey. Rates of hospitalizations among adults with diabetes were derived and tested for trends.

RESULTS

Age-adjusted rates for overall diabetes-related preventable hospitalizations per 100 adults with diabetes declined 27%, from 5.2 to 3.8 during 1998–2006 (P_trend < 0.01). This rate decreased significantly for all but not for short-term complication (58% for uncontrolled diabetes, 37% for lower-extremity amputations, 23% for long-term complications [all P < 0.01], and 15% for the short-term complication [P = 0.18]). Stratified by age-group and condition, the decline was significant for all age-condition groups (all P < 0.05) except short-term complications (P = 0.33) and long-term complications (P = 0.08) for the age-group 18–44 years. The decrease was significant for all sex-condition combination subgroups (all P < 0.01).

CONCLUSIONS

We found a decrease in diabetes-related preventable hospitalizations in the U.S. from 1998 to 2006. This trend could reflect improvements in quality of primary care for individuals with diabetes.Hospitalizations related to diabetes are costly and account for a major portion of the total expenditure on diabetes. In 2007, hospitalizations in the U.S. attributable to diabetes cost $58 billion or 50% of the total direct medical expenditure for diabetes (1). Nevertheless, a large portion of hospitalizations for diabetes may be preventable if primary care is effectively delivered (2–4). Timely and effective diagnosis, treatment, and education can result in better management of diabetes, prevent the development or worsening of complications, and lead to lower hospitalization rates. Thus, diabetes is often referred to as an ambulatory care–sensitive condition, and its associated hospitalizations are often referred to as preventable hospitalizations. Examining the trends of preventable hospitalization would facilitate our understanding of how access to and quality of primary care for diabetes has or has not improved. However, few analyses of trends in preventable hospitalizations for individuals with diabetes have been published.The Agency for Healthcare Research and Quality (AHRQ) developed sets of disease and procedure codes using the ICD-9-CM to identify14 sets of preventable hospitalization conditions. Of the 14 conditions, four were for diabetes: uncontrolled diabetes, diabetes short-term complications, diabetes long-term complications, and lower-extremity amputations (5). The AHRQ also reported trends in rates of diabetes-related preventable hospitalizations from 1994 to 2000 (6). However, the rates reported by AHRQ used the total population (i.e., individuals with and without diabetes) as the denominator. Rates so calculated are sensitive to changes in diabetes prevalence and thus are not ideal for examining changes in access to and quality of ambulatory care for individuals with diabetes. Here, we used only adults with diabetes as the denominator to analyze national trends in the rates of diabetes-related preventable hospitalizations.     

Impact of an Intensive Lifestyle Intervention on Use and Cost of Medical Services Among Overweight and Obese Adults With Type 2 Diabetes: The Action for Health in Diabetes

OBJECTIVE

To assess the relative impact of an intensive lifestyle intervention (ILI) on use and costs of health care within the Look AHEAD trial.

RESEARCH DESIGN AND METHODS

A total of 5,121 overweight or obese adults with type 2 diabetes were randomly assigned to an ILI that promoted weight loss or to a comparison condition of diabetes support and education (DSE). Use and costs of health-care services were recorded across an average of 10 years.

RESULTS

ILI led to reductions in annual hospitalizations (11%, P = 0.004), hospital days (15%, P = 0.01), and number of medications (6%, P < 0.001), resulting in cost savings for hospitalization (10%, P = 0.04) and medication (7%, P < 0.001). ILI produced a mean relative per-person 10-year cost savings of $5,280 (95% CI 3,385–7,175); however, these were not evident among individuals with a history of cardiovascular disease.

CONCLUSIONS

Compared with DSE over 10 years, ILI participants had fewer hospitalizations, fewer medications, and lower health-care costs.     

Nighttime intensivist staffing and the timing of death among ICU decedents: a retrospective cohort study

Introduction

Intensive care units (ICUs) are increasingly adopting 24-hour intensivist physician staffing. Although nighttime intensivist staffing does not consistently reduce mortality, it may affect other outcomes such as the quality of end-of-life care.

Methods

We conducted a retrospective cohort study of ICU decedents using the 2009–2010 Acute Physiology and Chronic Health Evaluation clinical information system linked to a survey of ICU staffing practices. We restricted the analysis to ICUs with high-intensity daytime staffing, in which the addition of nighttime staffing does not influence mortality. We used multivariable regression to assess the relationship between nighttime intensivist staffing and two separate outcomes potentially related to the quality of end-of-life care: time from ICU admission to death and death at night.

Results

Of 30,456 patients admitted to 27 high-intensity daytime staffed ICUs, 3,553 died in the hospital within 30 days. After adjustment for potential confounders, admission to an ICU with nighttime intensivist staffing was associated with a shorter duration between ICU admission and death (adjusted difference: –2.5 days, 95% CI -3.5 to -1.5, p-value < 0.001) and a decreased odds of nighttime death (adjusted odds ratio: 0.75, 95% CI 0.60 to 0.94, p-value 0.011) compared to admission to an ICU without nighttime intensivist staffing.

Conclusions

Among ICU decedents, nighttime intensivist staffing is associated with reduced time between ICU admission and death and reduced odds of nighttime death.     

Awareness of do-not-resuscitate orders: What do patients know and want?

Objective

To assess outpatient understanding of and previous experiences with do-not-resuscitate (DNR) orders and to gauge patient preferences with respect to DNR discussions.

Design

Cross-sectional, self-administered survey.

Setting

Four urban primary care physician offices in Vancouver, BC.

Participants

A total of 429 consecutive patients 40 years of age and older presenting for routine primary care between March and May 2009.

Main outcome measures

Awareness of, knowledge about, and experiences with DNR decisions; when, where, and with whom patients wished to discuss DNR decisions; and differences in responses by sex, age, and ethnicity, assessed using χ² tests of independence.

Results

The response rate was 90%, with 386 of 429 patients completing the surveys. Most (84%) respondents had heard of the terms do not resuscitate or DNR. Eighty-six percent chose family physicians as among the people they most preferred to discuss DNR decisions with; 56% believed that initial DNR discussions should occur while they were healthy; and 46% thought the discussion should take place in the office setting. Of those who were previously aware of DNR orders, 70% had contemplated DNR for their own care, with those older than 60 years more likely to have done so (P = .02); however, only 8% of respondents who were aware of DNR orders had ever discussed the subject with a health care provider. Few patients (16%) found this topic stressful.

Conclusion

Most respondents were well informed about the meaning of DNR, thought DNR discussions should take place when patients were still healthy, preferred to discuss DNR decisions with family physicians, and did not consider the topic stressful. Yet few respondents reported having had a conversation about DNR decisions with any health care provider. Disparity between patient preferences and experiences suggests that family physicians can and should initiate DNR discussions with younger and healthier patients.     

Monitoring of international normalized ratios: Comparison of community nurses with family physicians

Objective

To determine whether community-based, nurse-led monitoring of the international normalized ratio (INR) in patients requiring long-term warfarin therapy was comparable to traditional physician monitoring.

Design

A retrospective cohort analysis of patients taking long-term warfarin therapy.

Setting

The study used data gathered from 3 family medicine clinics in a primary care network in Edmonton, Alta.

Participants

Medical records of patients currently taking warfarin were examined.

Intervention

Implementation of nurse-led monitoring in a primary care network in place of standard family physician INR monitoring.

Main outcome measures

The degree of INR control before and after the implementation of nurse-run INR monitoring was assessed. The average proportion of time spent outside of therapeutic INR ranges, as well as the average number of days between successive INR readings, was calculated and compared. The degree of control placed patients into either a good-control group (out of range ≤ 25% of the time) or a moderate-control group (out of range > 25% of the time) and these groups were compared.

Results

Before nurse monitoring, INR values were out of range 20.4% of the time; after nurse monitoring they were out of range 19.2% of the time (P = .115); the time between sequential INR readings also did not differ before and after implementation of nurse monitoring (23.9 vs 21.6 days, P = .789).

Conclusion

Nurse-led monitoring of INR is as effective as traditional physician monitoring. Advantages of nurse-led monitoring might include freeing family physicians to see more patients or to spend less time at work. It might also represent potential cost savings.     

Absence of disparities in the quality of primary diabetes care for South Asians and Chinese in an urban Canadian setting

OBJECTIVE

To examine whether quality of diabetes care is equitable for South Asian and Chinese patients in an urban Canadian setting.

RESEARCH DESIGN AND METHODS

Process and intermediate measures of quality of care were compared between 246 South Asians, 170 Chinese, and 431 patients from the general population with type 2 diabetes selected from 45 family physicians’ practices.

RESULTS

A total of 61% of Chinese achieved A1C ≤7.0% versus 45% of South Asians and 49% of the general population (P < 0.05). They were also more likely to achieve LDL cholesterol ≤2.0 mmol/L, while South Asians were more likely to achieve blood pressure ≤130/80. There was only one significant process of care deficiency: fewer foot examinations among South Asians (34 vs. 49% for the general population, P < 0.01).

CONCLUSIONS

Quality of diabetes care in a Canadian urban setting was equitable, with ethnic minorities somewhat more likely to achieve recommended targets than the general population.Racial and ethnic minority populations in the U.S. achieve worse health outcomes and have greater mortality than whites (1). The experience of ethnic minorities in Canada is different because of a publicly funded universal health care system that may mitigate some socioeconomic and insurance barriers to care. Canadian minorities also represent different ethnic groups, with the two largest being South Asians (from the Indian subcontinent) and Chinese (2). We examined quality of type 2 diabetes care in an urban family practice setting, comparing South Asians and Chinese with the general population.