Dataset Information

Case finding for dementia during acute hospital admissions: a mixed-methods study exploring the impacts on patient care after discharge and costs for the English National Health Service.

ABSTRACT:

Objective

Between 2012 and 2017 dementia case finding was routinely carried out on people aged 75 years and over with unplanned admissions to acute hospitals across England. The assumption was that this would lead to better planning of care and treatment for patients with dementia following discharge from hospital. However, little is known about the experiences of patients and carers or the impacts on other health services. This study explored the impact of dementia case finding on older people and their families and on their use of services.

Design

Thematic content analysis was conducted on qualitative interview data and costs associated with service use were estimated. Measures included the Mini-Mental State Examination, the EuroQol quality of life scale and a modified Client Service Receipt Inventory.

Setting

Four counties in the East of England.

Participants

People aged ?75?years who had been identified by case finding during an unplanned hospital admission as warranting further investigation of possible dementia and their family carers.

Results

We carried out 28 interviews, including 19 joint patient-carer(s), 5 patient only and 4 family carer interviews. Most patients and carers were unaware that memory assessments had taken place, with many families not being informed or involved in the process. Participants had a variety of views on memory testing in hospital and had concerns about how hospitals carried out assessments and communicated results. Overall, case finding did not lead to general practitioner (GP) follow-up after discharge home or lead to referral for further investigation. Few services were initiated because of dementia case finding in hospital.

Conclusions

This study shows that dementia case finding may not lead to increased GP follow-up or service provision for patients after discharge from hospital. There is a need for a more evidence-based approach to the initiation of mandatory initiatives such as case finding that inevitably consume stretched human and financial resources.

SUBMITTER: Burn AM

PROVIDER: S-EPMC6561413 | biostudies-literature | 2019 Jun

REPOSITORIES: biostudies-literature

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Publications

Case finding for dementia during acute hospital admissions: a mixed-methods study exploring the impacts on patient care after discharge and costs for the English National Health Service.

Burn Anne-Marie AM Bunn Frances F Fleming Jane J Turner David D Fox Chris C Malyon Alexandra A Brayne Carol C

BMJ open 20190603 6

<h4>Objective</h4>Between 2012 and 2017 dementia case finding was routinely carried out on people aged 75 years and over with unplanned admissions to acute hospitals across England. The assumption was that this would lead to better planning of care and treatment for patients with dementia following discharge from hospital. However, little is known about the experiences of patients and carers or the impacts on other health services. This study explored the impact of dementia case finding on older ...[more]

PMID: 31164367

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Project description:OBJECTIVES:In 2012-2013, the English National Health Service mandated hospitals to conduct systematic case-finding of people with dementia among older people with unplanned admissions. The method was not defined. The aim of this study was to understand current approaches to dementia case-finding in acute hospitals in England and explore the views of healthcare professionals on perceived benefits and challenges. DESIGN:Qualitative study involving interviews, focus groups and thematic content analysis. SETTING:Primary care and secondary care across six counties in the East of England. PARTICIPANTS:Hospital staff involved in dementia case-finding and primary care staff in the catchment areas of those hospitals. RESULTS:We recruited 23 hospital staff and 36 primary care staff, including 30 general practitioners (GPs). Analysis resulted in three themes: (1) lack of consistent approaches in case-finding processes, (2) barriers between primary care and secondary care which impact on case-finding outcomes and (3) perceptions of rationale, aims and impacts of case-finding. The study shows that there were variations in how well hospitals recorded and reported outcomes to GPs. Barriers between primary care and secondary care, including GPs' lack of access to hospital investigations and lack of clarity about roles and responsibilities, impacted case-finding outcomes. Staff in secondary care were more positive about the initiative than primary care staff, and there were conflicting priorities for primary care and secondary care regarding case-finding. CONCLUSIONS:The study suggests a more evidence-based approach was needed to justify approaches to dementia case-finding. Information communicated to primary care from hospitals needs to be comprehensive, appropriate and consistent before GPs can effectively plan further investigation, treatment or care. Follow-up in primary care further requires access to options for postdiagnostic support. There is a need to evaluate the outcomes for patients and the economic impact on health and care services across settings.

Project description:OBJECTIVES:Explore the impact of changes to commissioning introduced in England by the Health and Social Care Act 2012 (HSCA) on cervical screening activity in areas identified empirically as particularly affected organisationally by the reforms. METHODS:Qualitative followed by quantitative methods. Qualitative: semi-structured interviews (with NHS commissioners, managers, clinicians, senior administrative staff from Clinical Commissioning Groups (CCGs), local authorities, service providers), observations of commissioning meetings in two metropolitan areas of England. Quantitative: triple-difference analysis of national administrative data. Variability in the expected effects of HSCA on commissioning was measured by comparing CCGs working with one local authority with CCGs working with multiple local authorities. To control for unmeasured confounders, differential changes over time in cervical screening rates (among women, 25-64 years) between CCGs more and less likely to have been affected by HSCA commissioning organisational change were compared with another outcome-unassisted birth rates-largely unaffected by HSCA changes. RESULTS:Interviewees identified that cervical screening commissioning and provision was more complex and 'fragmented', with responsibilities less certain, following the HSCA. Interviewees predicted this would reduce cervical screening rates in some areas more than others. Quantitative findings supported these predictions. Areas where CCGs dealt with multiple local authorities experienced a larger decline in cervical screening rates (1.4%) than those dealing with one local authority (1.0%). Over the same period, unassisted deliveries decreased by 1.6% and 2.0%, respectively, in the two groups. CONCLUSIONS:Arrangements for commissioning and delivering cervical screening were disrupted and made more complex by the HSCA. Areas most affected saw a greater decline in screening rates than others. The fact that this was identified qualitatively and then confirmed quantitatively strengthens this finding. The study suggests large-scale health system reforms may have unintended consequences, and that complex commissioning arrangements may be problematic.

Project description:BackgroundAlthough early follow-up after discharge from an index admission (IA) has been postulated to reduce 30-day readmission, some researchers have questioned its efficacy, which may depend upon the likelihood of readmission at a given time and the health conditions contributing to readmissions.ObjectiveTo investigate the relationship between post-discharge services utilization of different types and at different timepoints and unplanned 30-day readmission, length of stay (LOS), and inpatient costs.Design, setting, and participantsThe study sample included 583,199 all-cause IAs among 2014 Medicare fee-for-service beneficiaries that met IA inclusion criteria.Main measuresThe outcomes were probability of 30-day readmission, average readmission LOS per IA discharge, and average readmission inpatient cost per IA discharge. The primary independent variables were 7 post-discharge health services (institutional outpatient, primary care physician, specialist, non-physician provider, emergency department (ED), home health care, skilled nursing facility) utilized within 7 days, 14 days, and 30 days of IA discharge. To examine the association with post-discharge services utilization, we employed multivariable logistic regressions for 30-day readmissions and two-part models for LOS and inpatient costs.Key resultsAmong all IA discharges, the probability of unplanned 30-day readmission was 0.1176, the average readmission LOS per discharge was 0.67 days, and the average inpatient cost per discharge was $5648. Institutional outpatient, home health care, and primary care physician visits at all timepoints were associated with decreased readmission and resource utilization. Conversely, 7-day and 14-day specialist visits were positively associated with all three outcomes, while 30-day visits were negatively associated. ED visits were strongly associated with increases in all three outcomes at all timepoints.ConclusionPost-discharge services of different types and at different timepoints have varying impacts on 30-day readmission, LOS, and costs. These impacts should be considered when coordinating post-discharge follow-up, and their drivers should be further explored to reduce readmission throughout the health care system.

Project description:Residents of Residential Age Care Facilities (RACFs) have particularly high rates of Emergency Department (ED) visits, with up to 55% being potentially avoidable (e.g. not resulting in a hospital admission). This is concerning as ED visits by RACF residents are associated with negative outcomes including longer hospital stays, iatrogenic illness, complications and mortality. Limited English proficiency (LEP) has significant negative impacts on the healthcare quality and outcomes for older people but has not been studied as a factor in ED visits from RACFs. This study aimed to examine if RACF residents with LEP have a lower rate of hospital admission via the ED compared to non-LEP controls and identify any associated factors. We hypothesised that LEP-related communication difficulties would reduce the ability to manage minor health issues in the RACF, leading to a lower proportion of LEP ED transfers being admitted. We used a parallel mixed-methods design, comprising a quantitative matched cohort study of ED visit data from two Local Hospital Networks (LHNs) in South-East Melbourne, Australia and secondary thematic analysis of 25 interviews with LEP residents, family carers and staff from two RACFs in the same region. We found no differences in the proportion of hospital ED transfers that led to admission (LHN1, 87.1% LEP, 85.6% non-LEP controls, p = 0.57; LHN2, 76.0% LEP, 76.9% non-LEP controls, p = 0.41) and no direct qualitative evidence suggesting that resident LEP affected decisions to transfer residents to ED, despite communication difficulties being reported during the transfer process. These results may be due to the high level of family carer involvement in residents' care identified in the qualitative study. However, additional research using different measures of LEP is recommended to further explore a broader range of cultural and linguistic factors in both rates of ED presentations and the decision-making processes underpinning resident transfers to ED.

Project description:ObjectiveTo determine the costs and hospital resource use from all PICU patients readmitted with a PICU stay within 12 months of hospital index discharge.DesignCross-sectional, retrospective cohort study using Pediatric Health Information System.SettingFifty-two tertiary children's hospitals.SubjectsPediatric patients under 18 years old admitted to the PICU from January 1, 2016, to December 31, 2017.InterventionsNone.Measurements and main resultsPatient characteristics and costs of care were compared between those with readmission requiring PICU care and those with only a single PICU admission per annum. In this 2-year cohort, there were 239,157 index PICU patients of which 36,970 (15.5%) were readmitted and required PICU care during the 12 months following index admission. The total hospital cost for all index admissions and readmissions was $17.3 billion, of which 21.5% ($3.71 billion) were incurred during a readmission stay involving care in the PICU; of the 3,459,079 hospital days, 20.3% (702,200) were readmission days including those where PICU care was required. Of the readmitted patients, 11,703 (30.0%) received only PICU care, accounting for $662 million in costs and 110,215 PICU days. Although 43.6% of all costs were associated with patients who required readmission, these patients only accounted for 15.5% of the index patients and 28% of index hospitalization expenditures. More patients in the readmitted group had chronic complex conditions at index discharge compared with those not readmitted (83.9% vs 54.9%; p < 0.001). Compared with those discharged directly to home without home healthcare, patients discharged to a skilled nursing facility had 18% lower odds of readmission (odds ratio 0.82 [95% CI, 0.75-0.89]; p < 0.001) and those discharged home with home healthcare had 43% higher odds of readmission (odds ratio, 1.43 [95% CI, 1.36-1.51]; p < 0.001).ConclusionsRepeated admissions with PICU care resulted in significant direct medical costs and resource use for U.S. children's hospitals.

Dataset Information

Case finding for dementia during acute hospital admissions: a mixed-methods study exploring the impacts on patient care after discharge and costs for the English National Health Service.

Objective

Design

Setting

Participants

Results

Conclusions

Publications

Case finding for dementia during acute hospital admissions: a mixed-methods study exploring the impacts on patient care after discharge and costs for the English National Health Service.

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