Relationship between health-related quality of life and, acute care readmissions and survival in older adults with chronic illness

BACKGROUND: Australia's ageing population means that there is increasing emphasis on developing innovative models of health care delivery for older adults. The assessment of the most appropriate mix of services and measurement of their impact on patient outcomes is challenging. The aim of this evaluation was to describe the health related quality of life (HRQoL) of older adults with complex needs and to explore the relationship between HRQoL, readmission to acute care and survival. METHODS: The study was conducted in metropolitan Melbourne, Australia; participants were recruited from a cohort of older adults enrolled in a multidisciplinary case management service. HRQoL was measured at enrolment into the case-management service using The Assessment of Quality of Life (AQoL) instrument. In 2007-2009, participating service clinicians approached their patients and asked for consent to study participation. Administrative databases were used to obtain data on comorbidities (Charlson Comorbidity Index) at enrolment, and follow-up data on acute care readmissions over 12 months and five year mortality. HRQoL was compared to aged-matched norms using Welch's approximate t-tests. Univariate and multivariate logistic regression models were used to explore which patient factors were predictive of readmissions and mortality. RESULTS: There were 210 study participants, mean age 78 years, 67% were female. Participants reported significantly worse HRQoL than age-matched population norms with a mean AQOL of 0.30 (SD 0.27). Seventy-eight (38%) participants were readmitted over 12-months and 5-year mortality was 65 (31%). Multivariate regression found that an AQOL utility score <0.37 (OR 1.95, 95%CI, 1.03 - 3.70), and a Charlson Comorbidity Index ≥6 (OR 4.89, 95%CI 2.37 - 10.09) were predictive of readmission. Multivariate analysis demonstrated that age ≥80 years (OR 7.15, 95%CI, 1.83 - 28.02), and Charlson Comorbidity Index ≥6 (OR 6.00, 95%CI, 2.82 - 12.79) were predictive of death. CONCLUSION: This study confirms that the AQoL instrument is a robust measure of HRQoL in older community-dwelling adults with chronic illness. Lower self-reported HRQoL was associated with an increased risk of readmission independently of comorbidity and kind of service provided, but was not an independent predictor of five-year mortality

Telemedicine for Insulin treated Gestational Diabetes Mellitus (TeleGDM): an exploratory randomised controlled trial of the effects of a web-based GDM support system on health service utilisation, maternal and foetal outcomes, costs and user experiences

© 2017 Dr. Tshepo Mokuedi RasekabaGestational diabetes mellitus (GDM) is a condition characterised by elevated blood glucose that occurs in pregnancy and affects 11-15% of pregnant women. Tightly maintaining blood glucose levels (BGL) within target in GDM is associated with better maternal and foetal outcomes. In contrast poorly controlled hyperglycaemia is associated with adverse outcomes such as higher rates of caesarean delivery, macrosomia, foetal shoulder dystocia and admission of the new-born to a special care nursery or neonatal intensive care unit. At least 50% of women with GDM need insulin to maintain glycaemic levels within target. In the early stages of insulin commencement, women with GDM often require intensive monitoring, frequent advice and support for insulin titration. This can be difficult to manage in pregnant women who are often faced with other competing demands, including work and caring for a young family, which contribute to the challenges of managing GDM. Further, the need for intensive support, together with inconsistent attendance for appointments, contribute to difficulties with managing GDM through the out-patient setting. Telemedicine has previously been shown to enhance patient self-monitoring and enabling provision of accurate and timely data transmission and sharing between patients and clinicians. Use of telemedicine potentially enabled efficient communication with timely response by clinicians in addressing urgent situations where BGLs are outside the desired target range. As a result, telemedicine may provide an innovative approach to streamline GDM management given the intensity of support and demand for insulin-treated GDM services and burden to GDM patients to attend appointments for ongoing monitoring and support. My PhD study involved a complex intervention and as a result drew from elements of the three theoretical frameworks. First the Medical Research Council (MRC) Framework which guides the development and evaluation of complex interventions which draws attention to the steps to follow, i.e. intervention piloting and then proceeding to the exploratory phase which was the mainstay for my study. The second was the Normalisation Process Theory (NPT) which emphasises translating and embedding complex interventions in practice, noting the TeleGDM study was implemented in real practice. The third framework was the Telehealth Evaluation Framework which provides a guide to the elements to consider in order to standardise the evaluation of telehealth interventions. My PhD project aimed to explore the impact of telemedicine on the management of insulin-treated GDM at Northern Health (NH). The project which is described in detail in this thesis consisted of: i) A background literature review including a systematic literature review and meta-analysis of telemedicine for GDM management; ii) Piloting the protocol at one of the campuses of NH. The pilot was aimed at gaining insights into the flow of the recruitment process and getting feedback on the chosen telemedicine system, before proceeding to an exploratory randomised controlled trial (RCT) stage; iii) An exploratory RCT comparing an adjunct telemedicine intervention to usual care in the management of insulin-treated GDM. The study primarily looked at impact on service utilisation, i.e. outpatient GDM clinic appointments. Other outcomes included a range of maternal and foetal/new-born clinical outcomes, patient and clinician satisfaction and service provider costs; and iv) A mixed methods outcome and process evaluation of the exploratory RCT. Ninety-four patients and five CDE-RNs participated in my study. The findings showed that telemedicine support in the management of GDM produced health service and clinical outcomes similar to usual care. Adjunct telemedicine support had no significant impact on the number of face-to-face outpatient GDM clinic appointments, foetal biometrics, rates of caesarean deliveries, macrosomia, large for gestational age, admission of new-borns to the special care nursery, birth-weight or costs. The intervention had the advantage of significantly reducing the time for patients to achieve optimum glycaemic control, an important outcome in GDM management. Importantly, while not superior to usual care in terms of health service use, telemedicine did not compromise the quality and safety of care in terms of foetal and maternal outcomes. Uptake of the intervention, as reflected by the volume of GDM self-monitoring data entered into the telemedicine system by patients, showed that patients using this approach shared less data with clinicians, when compared to the usual care method of handwritten data. There was greater usage of the telemedicine system to share data in first four weeks of the intervention. Statistically, there was no difference between the intervention and control on health service provider costs. However, limitations of scaling up the intervention notwithstanding, there was potentially for a significant cost saving from a health service perspective. Themes from patient interviews showed that telemedicine as a concept, may be acceptable among patients, facilitated proactive self-management, and enabled personalised feedback. Some patients suggested telemedicine could potentially reduce face-to-face clinic attendances, thus, saving them travel time or allow them to balance work and ongoing GDM care. These views were possibly from a self-selected group of patients who engaged more with using the telemedicine system element of the intervention. Patients who engaged less with using the system were reluctant to participate in interviews. As clinicians involved in performing the clinical aspects of the study, Credentialed Diabetes Education-Registered Nurses (CDE-RNs) had mixed responses regarding telemedicine. For instance, some expressed views that telemedicine may be a supplement usual care, rather than an alternative substitute. They also cited the telemedicine system’s technical design, and lack of integration with existing ehealth systems as the negatives of telemedicine, as these factors resulted in increased work to use the system, adversely impacting on workflow and productivity. In conclusion, while my study was exploratory, telemedicine support for GDM showed no impact on service utilisation and provider costs. Telemedicine produced similar maternal and foetal clinical outcomes as usual care, suggesting no added risk to clinical quality of care, but with the possibility of a shorter time to insulin dose stabilisation. Further research in telemedicine using, user-friendly technological platforms that are fit for purpose, and including robust health economic evaluation in GDM is still needed

Chronic disease services patients in the Northern Alliance Hospital Admission Risk Program-Chronic Disease Management

© 2009 Tshepo Mokuedi RasekabaThis study was a cross-sectional epidemiologic evaluation of the clinical, sociodemographic, lifestyle and hospital utilisation characteristics of patients with diabetes, chronic obstructive pulmonary disease and chronic heart failure. Patients were enrolled in chronic disease management services of the Northern Alliance Hospital Admission Risk Program-Chronic Disease Management (Northern Alliance HARP-CDM Program). The program was established in accordance with the Department of Human Services’ (Victoria, Australia) initiative to intervene against increasing acute hospital demand by patients with chronic disease and complex needs. Amongst others, the Northern Alliance HARP-CDM Program provides services for patients with diabetes, chronic heart failure and chronic obstructive pulmonary disease. Patient cohorts with these three chronic diseases were the focus of this study. The Northern Alliance HARP-CDM Program catchment comprises of a culturally and linguistically diverse (CALD) population in the northern part of metropolitan Melbourne. Patients in this region mainly access acute hospital services at the Northern Hospital. The study sought to explore whether the CDM services enrolled patients whom based on their characteristics, fit the risk profile of the intended HARP-CDM target patient population. The study cohorts demonstrated a CALD make up of above Victorian state averages. The majority (60%) were born overseas, preferred a language other English and were over 60 years old. In contrast to previously published studies, CALD did not demonstrate a significant contribution to disease control, quality of life or level of hospital utilisation. Place of residence for these patients showed clusters within some Local Government Areas. This has implications for service location, access and disease surveillance. Also, it presents opportunities for area targeted health promotion and prevention and overall service location. The majority (77%) of those with chronic heart failure had an abnormal left ventricular ejection fraction. The diabetes cohort was characterised by higher HbA1c (9%) than the target of less than 8%. Similarly the patients had greater than recommended waist circumferences (Males 106cm vs. 94cm; Females 106 vs. 80cm) places them at an increased risk of cardiovascular disease. For those with COPD, 42% had severe pulmonary impairment (FEV%predicted ≤ 40%) while 36% were moderate in the moderate category. There was increased hospital utilisation with increasing age for those with COPD. With the exception of the diabetes cohort, there was no significant evidence as to the role of ethno-cultural factors in the study cohorts’ health, quality of life or level of hospital utilisation. However, ethno-cultural factors may contribute to the complexity of patient management processes and warrants further investigation. Prior to enrolment in the Northern Alliance HARP-CDM Program, patients who could be considered high users of emergency department services made up 20% of those in the diabetes service, 43% in the COPD service and 50% amongst those in the CHF service. Similar figures for hospital admissions ranged from 20% for the diabetes services to 56% for the CHF service cohorts respectively. Although the diabetes service was the biggest of the three the majority of patients in the service had no previous history of acute hospital utilisation. Members of the diabetes service cohort were characterised by hospital utilisation rates lower than the Northern Hospital’s (ED: 34 vs. 72 per 100 patients, Admissions: 33 vs. 68 per 100 patients in the Pre HARP-CDM Period). Patients in the COPD service (ED: 115 Pre and 158 during HARP-CDM) and CHF service (160 Pre and 159 during HARP-CDM) had ED presentation rates per 100patients that were higher than the hospital’s (72 and 69). The rates suggest the first 14 months of the Northern Alliance HARP-CDM Program were associated with increased hospital utilisation by patients enrolled the Northern Alliance HARP-CDM Program. The increments were greater than increases for the Northern Hospital for the same periods. Contrary to the intended goal of reducing acute hospital utilisation, the majority of the clientele did not fit the primary HARP-CDM Program criteria of high acute hospital users. But patients who were enrolled following previous hospital utilisation were well-targeted. However there are several patients who are likely HARP-CDM Program candidates who fall though the gaps between the acute hospital services and the program. It is recommended the program and services increase enrolments and access for the target patient populations. There is a need for early intervention chronic disease management and health promotion. This service would cater for clients who by virtue of having a chronic disease are at risk but are currently not high acute hospital users. Such a service would free up vacancies in the Northern Alliance HARP-CDM Program, thus enabling increased intake and equitable access for the target patient population, especially those who fall though the gaps as referred to earlier. Funding for such a service is available through DHS. In light of strong evidence for exercise rehabilitation and its ability to positively impact patient outcomes, quality of life, survival and hospital utilisation, consideration needs to be given to this as part of the Northern Alliance HARP-CDM Program chronic disease management care model

Exploring Telehealth Readiness in a Resource Limited Setting: Digital and Health Literacy among Older People in Rural India (DAHLIA)

An ageing population, disproportionally affecting developing countries, increases demand on healthcare systems. Digital health offers access to healthcare for older people, particularly those residing in rural areas, as is the case for 71% of older adults in India. This research examined technology uptake and digital and health literacy (eHEALS) among a sample of 150 older adults in rural Mysore and Suttur, India. The study utilised mixed-method, with descriptive analysis of quantitative data and thematic analysis of qualitative data. Low rates of digital (11%) and health literacy (3&ndash;27% across domains) were identified. Mobile phone ownership was 50%, but very few owned or used a smartphone and less than 10% used the Internet to contact health professionals. Qualitative analysis found low technology usage, driven by limited exposure and confidence in using digital devices. Barriers to usage included poor traditional literacy and physical aspects of ageing like poor vision. Social support from neighbours, family and local primary healthcare staff may enable adoption of digital health. Access to healthcare through digital means among Indian rural older adults needs to consider low rates of both digital and health literacy and leverage the value of support from family and primary healthcare providers