Method for Assigning Priority Levels in Acute Care (MAPLe-AC) predicts outcomes of acute hospital care of older persons - a cross-national validation

To access publisher full text version of this article. Please click on the hyperlink in Additional Links field.BACKGROUND: Although numerous risk factors for adverse outcomes for older persons after an acute hospital stay have been : identified, a decision making tool combining all available information in a clinically meaningful way would be helpful for daily hospital practice. The purpose of this study was to evaluate the ability of the Method for Assigning Priority Levels for Acute Care (MAPLe-AC) to predict adverse outcomes in acute care for older people and to assess its usability as a decision making tool for discharge planning. METHODS: Data from a prospective multicenter study in five Nordic acute care hospitals with information from admission to a one year follow-up of older acute care patients were compared with a prospective study of acute care patients from admission to discharge in eight hospitals in Canada. The interRAI Acute Care assessment instrument (v1.1) was used for data collection. Data were collected during the first 24 hours in hospital, including pre-morbid and admission information, and at day 7 or at discharge, whichever came first. Based on this information a crosswalk was developed from the original MAPLe algorithm for home care settings to acute care (MAPLe-AC). The sample included persons 75 years or older who were admitted to acute internal medical services in one hospital in each of the five Nordic countries (n = 763) or to acute hospital care either internal medical or combined medical-surgical services in eight hospitals in Ontario, Canada (n = 393). The outcome measures considered were discharge to home, discharge to institution or death. Outcomes in a 1-year follow-up in the Nordic hospitals were: living at home, living in an institution or death, and survival. Logistic regression with ROC curves and Cox regression analyses were used in the analyses. RESULTS: Low and mild priority levels of MAPLe-AC predicted discharge home and high and very high priority levels predicted adverse outcome at discharge both in the Nordic and Canadian data sets, and one-year outcomes in the Nordic data set. The predictive accuracy (AUC's) of MAPLe-AC's was higher for discharge outcome than one year outcome, and for discharge home in Canadian hospitals but for adverse outcome in Nordic hospitals. High and very high priority levels in MAPLe-AC were also predictive of days to death adjusted for diagnoses in survival models. CONCLUSION: MAPLe-AC is a valid algorithm based on risk factors that predict outcomes of acute hospital care. It could be a helpful tool for early discharge planning although further testing for active use in clinical practice is still needed.Reykjavik Hospital Research Fund St. Joseph's Research Fund, Iceland Norwegian Medical Society 2 Diakonhjemmet Hospital Diakonhjemmet University College Diakonhjemmet Research Fund, Norway Sweden's Lions Fund, Sweden Health Transition Fund Health Canada Canadian Institutes for Health Research (CIHR) Nordic Lions Red Feather Fund Nordic Council of Ministers Roikjer Fund, Denmark Finnish Lions Fund, Finland Icelandic Lions Fund Memorial Fund of Helgu Jensdottur and Sigurliða Kristjanssona

Addressing Health Care Needs For Frail Seniors In Canada: The Role of InterRAI Instruments

Fiscal pressure on the Canadian health care system results from rising numbers of frail seniors with multiple concurrent medical co-morbidities and geriatric syndromes. Improving outcomes in such seniors is contingent on a comprehensive geriatric assessment (CGA) to identify strengths and deficits and to facilitate the development of a comprehensive care plan. InterRAI instruments are standardized, reliable, and validated suites of tools to conduct CGAs; they offer several benefits, including helping clinicians identify important health issues among patients, develop appropriate care plans, and monitor patient progess. These instruments also provide several benefits beyond the bedside, including quality indicators to assess care quality, and case-mix classification algorithms to facilitate funding of health services. Finally, interRAI instruments, which are implemented in several health care settings across Canada and abroad, provide a standardized and common language that is compatible with electronic medical records and will facilitate greater integration of the health care system

Health, Health Service Use and Informal Caregiver Distress among Older Korean Home Care Clients in Canada and Korea

Background: Immigration results in many different changes to life: diet, culture, lifestyle, and language (Hynie et al., 2011; Kim, 2006; Lee Kim, 2001). Immigration later in life is a stressful process for older adults as they are uprooted from their native society and need to readjust to a culturally different society (Hynie et al., 2011; Kim, 2006; Mui, 1996; Mui, 2001; Yoo, 2014). Challenges such as discrimination, language barriers, lack of social resources, and feelings of detachment from the new society may arise especially for elderly Asian immigrants when adapting to host environments (Bernstein et al., 2011; Hossen, 2012; Kiefer et al., 1985; Kim, 2006; Kim, 2010; Lai & Chau, 2007; Mui, 2001; Noh, 2008; Noh & Kaspar, 2003; Noh et al., 2007; Yoo, 2014). Elderly Asian immigrants often lack the information and resources to adjust to major differences between Asian and Western cultural norms and social expectations (Mui, 1996; Mui, 2001). Difficulties coping with the new society and the inappropriate use of resources can increase social isolation, depression, and other health concerns (Kang et al., 2013), which can in turn affect the lives and health of other family members as they become more dependent on these informal caregivers (Chung, 2013; Han et al., 2008; Kim & Knight, 2008; Kwak & Lai, 2012; Lee & Farran, 2004; Yoo, 2014; Wong et al., 2005). However, these struggles are often overlooked as a major issue or concern of immigration policies. Therefore, more studies are required on these Asian immigrants with limited official language proficiency. Koreans have been one of the fastest growing groups of immigrants in Canada, with a growth rate of 42% from year 2001 to 2006 (Statistics Canada, 2006; Statistics Canada, 2007). Of this group, it is estimated that approximately 6% of Korean immigrants are aged 65 and older (Kwak & Hiebert, 2010; Statistics Canada, 2006). In order to examine the possible health disparities faced by minority groups, such as Korean Canadians, an investigation into the quality of care and health service use is vital. However, only a limited amount of research on Korean immigrants has been done in Canada, and fewer than a dozen studies focused on older Korean Canadians. Purpose: This dissertation examined the health disparities in older Korean Canadian home care clients by investigating their health and health service use, informal caregiver distress, and quality of care. More specifically, it compared (1) health and health service use of Korean Canadians, native Koreans, Chinese Canadians, and other Canadians; (2) the risk and protective factors related to the onset of and improvement in caregiver distress; and (3) quality of care using the Home Care Quality Indicators (HCQIs) in Korean Canadians, Chinese Canadians, and other Canadians. Methods: This research was based on secondary data analysis of health information from two different datasets, one from Ontario and the other from Korea. The Ontario health information was based on the Resident Assessment Instrument-Home Care (RAI-HC), an assessment tool used to identify a person’s functioning and quality of life that addresses needs, strengths, and preferences in a broad range of domains (Canadian Home Care Association, 2013; Morris et al., 1997; Morris et al., 2009). This health information is managed by the Canadian Institute for Health Information (CIHI) and was made available through the partnership between CIHI and the University of Waterloo. The health information from Korea was obtained using the interRAI Home Care (interRAI HC) assessment tool. The interRAI HC is the updated version of RAI-HC but data from both can be compared with only modest adjustments (Gray et al., 2009; Hirdes et al., 2008a). The research sample was drawn from the population of all long-stay home care clients admitted during the study period between January 2002 and March 2015 in Ontario and between February 2011 and October 2012 in the Republic of Korea. Long-stay home care clients were defined as clients who require more than 60 uninterrupted days of service through a home care agency. The sample only consisted of long-stay home care clients aged 65 and older. Using a variable for primary language, Korean and Chinese home care clients in Ontario were identified. As a result, primary languages other than Korean and Chinese were grouped as ‘others’, referring to other Canadians. For the analyses and results, Korean home care clients in Ontario were referred to as ‘Korean Canadians’, Korean home care clients in Korea were referred to as ‘native Koreans’, Chinese home care clients in Ontario were referred to as ‘Chinese Canadians’, and other Canadian home care clients in Ontario were referred to as ‘other Canadians’. Chapter 5 examined the descriptive profile of the health of older Korean Canadians compared to native Koreans, Chinese Canadians, and other Canadians, by obtaining the descriptive statistics with percentages and frequencies. Chapter 6 investigated the risk and protective factors for caregiver distress accounting for Korean Canadians, Chinese Canadians and other Canadians using bivariate and multivariate logistic regression models, and generalized estimating equations (GEE). Lastly, Chapter 7 used the second-generation HCQIs to explore quality of care by ethnicity in Ontario. Results and Discussions: This dissertation is the first cross-cultural study to examine the health disparities and caregiver distress of Korean older adults in Ontario and in Korea using the RAI-HC/interRAI HC. It is also the first study to use the second-generation HCQIs to explore quality of care by ethnicity. Health disparities were evident from the overall findings in Chapter 5 where both Korean Canadians and native Koreans generally exhibited higher impairments compared with Chinese Canadians and other Canadians. In addition, high caregiver distress was present in the three Asian groups compared to other Canadians. Upon further examination of caregiver distress, results in Chapter 6 demonstrated that being a Korean or Chinese Canadian was associated with lower odds of an improvement in caregiver distress and higher odds of an onset of caregiver distress over time. However, language barriers based on need for an interpreter appeared to be the main explanation for this effect rather than the ethnicity alone. Lastly, Chapter 7 examined quality of care using the second-generation HCQIs and identified different areas where service providers for different groups have opportunities to improve quality. For Korean Canadians, such initiatives should focus on cognitive and psychosocial factors, whereas Chinese Canadians need interventions to target pain, and other Canadians need to improve on the use of hospital, emergency department or emergent care. Most importantly, all groups exhibited an increase in continued caregiver distress over time, though the two Asian groups’ rates seemed to increase more steeply. Overall, the older Korean Canadian home care clients demonstrated substantial health needs and family caregivers had a dire need for additional supports from formal services. However, this clients tended to have a lower use of home care services (i.e., personal support/ homemaking services, and the use of hospital, emergency department or emergent care), and higher levels of caregiver distress indicated that their informal caregivers were struggling. Thus, more practical interventions or resources need to be devoted to this population

Iäkkäiden henkilöiden toimintakyvyn mittaaminen palvelutarpeen arvioinnin yhteydessä

TOIMIA-suositusTämän julkaisun korvaa uusi, päivitetty versio osoitteessa: http://urn.fi/URN:NBN:fi-fe2020060540983</a

Application of interRAI Assessments in Disaster Management: Identifying Vulnerable Persons in the Community

Background: Several studies have shown the increased vulnerability and disproportionate mortality rate among frail community dwelling older adults as a result of disasters. Parallel to an escalating number of disasters, Canada is faced with an aging demographic and a policy shift emphasizing aging at home. This results in a greater vulnerability of this group of high needs community dwelling individuals to the effects of events that lead to interruption of home health care services and/or displacement. Despite the growing vulnerability it has proven to be difficult to identify those most vulnerable older adults and their characteristics. This makes it challenging for emergency managers, first responders and health care providers to develop targeted preparedness, response and recovery strategies aimed at the most vulnerable older adults living at home. Relatively recent developments in electronic health records provide an unprecedented opportunity to use comprehensive assessment information collected as part of routine clinical practice in the home care sector to identify vulnerable community dwelling older adults. In Ontario, the Resident Assessment Instrument for Home Care (RAI-HC) is the mandated primary assessment tool for long-stay home care clients. Objective: The three specific objectives of this dissertation are to examine: 1. The application of the New Zealand Priority Algorithm used during the Christchurch earthquake to the Ontario Home Care Client database. 2. Determinants of Emergency Response Level (ERL) designation within CCACs. 3. The person-level factors that contribute to increased vulnerability of home care clients to power interruptions through examining the health effects of the power outage that occurred as a result of the December 2013 Ice Storm including emergency department (ED) visits, hospitalization and service utilization. Conceptual Framework: The person-environment fit model is used as the conceptual framework for this dissertation. This model views individual vulnerability as a product of the interaction between individual competence, adaptive behavior and the strength of the environmental stress (the emergency or disaster). Where the demands of an emergency or disaster exceed the ability of the older adult to cope, a person- environment misfit may lead to negative health outcomes. Methodology: All research questions were addressed using RAI-HC datasets in combination with other datasets. Chapter three used the RAI-HC database by selecting unique home care clients with assessments closest to December 31st 2014 (N=275,797). For chapter four Emergency Response Level (ERL) codes were provided by the Hamilton Niagara Haldimand Brant (HNHB) and Toronto Central (TC) Community Care Access Centre (CCAC) and matched with a RAI-HC assessment in both CCACs (N=70,292 and N=8,996 respectively). In addition, linkages were made with data regarding death, hospitalization and long term care (LTC) admission. Lastly, chapter five uses information on Toronto Hydro power outages and an estimation of outage areas based on outage mapping in addition to the HC database. The exposure group (N=10,748) was compared to two comparison groups. Group one included clients with HC assessments in the same period and receiving services during the same week but were unaffected by the hydro outage (N=12,072). The second comparison group was comprised of clients residing in the same area as the hydro outage one year prior to the storm (N=10,886). Service utilization was collected from the Client Health Related Information System (CHRIS). Statistical analyses were done using SAS version 9.4 and methods used include frequency tabulation, bivariate logistic regression, multivariate logistic regression as well as Kaplan-Meier survival plotting and Cox proportional hazards ratios calculations. Results: When comparing four decision support algorithms (University of Waterloo, Canterbury, Vulnerable Persons at Risk (VPR) and VPR Plus) to identify high priority clients, the VPR and VPR Plus were most predictive of mortality, LTC admission and hospitalization. The high priority groups were significantly more impaired than lower priority clients with both the VPR and VPR Plus. They had higher levels of health instability, experienced more falls, required more assistance with Activities of Daily Living (ADL), were more cognitively impaired and had higher levels of depression ratings. When comparing the chosen algorithms, the VPR and VPR Plus, with ERL levels assigned by care coordinators the analysis showed considerable overlap in predictive variables. The ERL was highly predictive of mortality and LTC admission, but less predictive of hospitalization. C-stats of logistic regression modeling with ERL and VPR/VPR Plus in predicting mortality showed that the VPR and VPR Plus models were a better or equal fit as models with the ERL. Finally, when examining the characteristics of clients that were affected by the 2013 power outage with the two comparison groups, a significant difference was found for the non-exposed group in the year of the outage in relation to numbers of nursing and personal support worker (PSW) visits, hospital admission and emergency department (ED) visits as well as mortality, LTC admission and hospitalization rates. The analysis showed that clients in the non-affected areas in the year of the outage were more likely to decline in Depression Rating Scale (DRS), Changes in Health, End-Stage Disease, Signs and Symptoms Scale (CHESS) and Instrumental Activities of Daily Living (IADL). This is consistent with the higher rates of LTC admission and hospitalization within six months after the outage for non-exposed clients as well as higher frequency of nursing and PSW visits during and 30 days after the outage. In contrast to the expectation that exposed clients would do worse during and after the outage, the analysis showed that exposed clients showed in fact less health decline than non-exposed clients. However, when looking at those clients that would have been considered high and medium risk clients based on the VPR and VPR Plus, the analysis showed that those clients in areas with hydro outages were more likely to die and to be admitted to long term care (LTC) than the high and medium risk clients living in unaffected areas. Conclusions: The analyses in this dissertation have shown the usefulness of information collected as routine clinical practice using interRAI assessment tools. The current system of designating Emergency Response Levels (ERL) by care coordinators is highly dependent on consistent updating of the ERLs in the system whenever a new home care assessment is completed. The analyses showed that this is not consistently done, and may render the ERL code obsolete overtime. The VPR and VPR Plus have been shown to be valid and reliable alternatives to ERL codes and they are kept up to date as new assessments are completed on home care clients. Incorporating these decision support algorithms into the RAI-HC assessment system software enables an automatic and up to date vulnerability assessment of clients. This can make it possible for emergency managers, first responders and health care providers to use a comprehensive priority system before, during and after emergency, ultimately preventing unnecessary death or health deterioration

Trajectories of long-term exposure to anticholinergic and sedative drugs: A latent class growth analysis

Introduction: A variety of drugs, which are frequently prescribed to older people, have anticholinergic and sedative effects whereby they may impair cognitive and physical function. Although substantial inter-individual variation in anticholinergic and sedative exposure has been documented, little is known about subpopulations with distinct trajectories of exposure. Methods: Data from the Longitudinal Aging Study Amsterdam (LASA), an ongoing Dutch population-based cohort study, collected over 20 years (1992-2012) at seven occasions, were analyzed. On each occasion, cumulative anticholinergic and sedative exposure was quantified with the Drug Burden Index, a linear additive pharmacological dose-response model. The most likely number of trajectories were empirically derived with Latent Class Growth Analysis using "Goodness of fit" statistics. Trajectories were then compared on physical and cognitive function. Results: A total of 763 participants completed all follow-ups (61% women; mean age 83, ±6). "Goodness of fit" statistics (Bayesian In-formation Criterion = 22916, Bootstrapped Likelihood Ratio Test of 3 vs. 2 classes = 514.12

Clinical pathway modelling: A literature review

Hospital information systems are increasingly used as part of decision support tools for planning at strategic, tactical and operational decision levels. Clinical pathways are an effective and efficient approach in standardising the progression of treatment, to support patient care and facilitate clinical decision making. This literature review proposes a taxonomy of problems related to clinical pathways and explores the intersection between Information Systems (IS), Operational Research (OR) and industrial engineering. A structured search identified 175 papers included in the taxonomy and analysed in this review. The findings suggest that future work should consider industrial engineering integrated with OR techniques, with an aim to improving the handling of multiple scopes within one model, while encouraging interaction between the disjoint care levels and with a more direct focus on patient outcomes. Achieving this would continue to bridge the gap between OR, IS and industrial engineering, for clinical pathways to aid decision support

Pohjanmaan palveluohjaus kuntoon : Toimintamalli ja tietojohtamisen tunnusluvut

Maantieteellisesti pitkän ja kapean Pohjanmaan maakunnan väestöpohja on noin 180000. Kaksikielisen Pohjanmaan väestö on terveempää, keski-ikä on korkeampi, koulutustaso on parempi ja työelämässä pysytään pitempään koko maahan verrattuna. Toisaalta palvelujen käyttö on runsaampaa. Pohjanmaan palveluohjaus kuntoon tarkoituksena oli luoda maakunnallinen palveluohjauskeskus toimintamalleineen ja tunnuslukuineen. Hanke kuului kansalliseen kärkihankkeeseen ”Kehitetään ikäihmisten kotihoitoa ja vahvistetaan kaikenikäisten omaishoitoa (I&O). Kehittämistyö toteutettiin I&O muutosagentin koordinoimana asiantuntijatyönä. Kehitetty palveluohjauksen toimintamalli sisältää kolme osiota: (1) yleinen informaatio ja neuvonta/matalan kynnyksen ikäpiste, (2) kertaluontoinen palvelutarpeen arviointi ja palvelusuunnitelma sekä (3) pitempiaikainen/intensiivinen palveluohjaus ja Case managerin antama tuki. Palvelutarpeen arviointia ja -ohjausta toteuttaa ydintiimi, joka tarvittaessa konsultoi erityisasiantuntijoita. Palveluohjauksen työvälineinä toimii tarvepohjaiset, RAI tietoon perustuvat asiakassegmentit. Palveluihin ohjautumista seurataan ja arvioidaan RAI tunnusluvuin. Palveluohjauksen sisäisten tuotteiden ns. kuntahinnat vaihtelevat 30-600 euronvälillä. Palveluohjaus on asiakkaille maksutonta. Tämä julkaisu on tapauskuvaus, jossa esitetään palveluohjauksen toimintamalli ja keskeisiä tietojohtamisen tunnuslukuja maakunnassa toteutetun I&O kehittämistyön näkökulmasta RAI tietoa hyödyntäen. Julkaisussa nostetaan esille myös kehittämistyön kriittiset pisteet ja kehittämishaasteet. Julkaisu on tarkoitettu kaikille, jotka ovat kiinnostuneita palveluohjauksesta ja RAI tiedon hyödyntämisestä siinä. Palveluohjauksen toimintamalli tunnuslukuineen on luotu, jotta se soveltuu Pohjanmaan maakuntaan ja on hyödynnettävissä RAI tietojohtamisen jatkokehittämistyössä maakunnassa. Kehitettyjen mallien valmiusaste vaihtelee