Recognition of Depression in Older Medical Inpatients

BACKGROUND: Studies of recognition of depression in older (aged 65 or more) medical inpatients show low rates of recognition of depression by attending physicians. However, few studies have compared different measures of recognition of depression. OBJECTIVES: (1) To compare the validity of four indicators of recognition of depression and a global measure of recognition against a diagnosis of depression and (2) to explore the effect of patient characteristics on recognition of depression. METHODS: In a cohort of 264 medical inpatients 65 years and older (115 with major or minor depression, 78 with no depression), sensitivities, specificities, and diagnostic odds ratios (DOR) of 4 indicators of recognition (symptoms, diagnosis, treatment, and referral) and a global measure of recognition (any of the 4 indicators) were calculated. The associations between patient characteristics (age, sex, history of depression, antidepressant use before admission, severity of depression, comorbidity, duration of hospitalization, disability, and hospital of admission) and recognition were explored using multiple logistic regression. RESULTS: Less than half of the depressed patients were recognized. The indicator with the highest sensitivity was treatment (27.8%, 95% confidence interval [CI] 20.0–37.0), whereas the indicator with the best specificity was diagnosis (96.6%, 95% CI 91.9–98.7). The unadjusted DOR of global recognition was 2.6 (95% CI 1.5, 4.4). Less comorbidity, more severe depression symptoms, a history of depression, longer hospital stay, and antidepressant use before admission were significantly associated with better global recognition. CONCLUSION: Recognition of depression in elderly medical inpatients depends upon the indicator of recognition used

Transitions of People with Dementia in the Continuing Care System

Aging of the population raises a number of challenges to health care and continuing care systems around the world. One of them is ensuring that seniors with disabilities receive the best care at home and in the continuing care system, in order to avoid unnecessary transitions. Dementia is one of the major sources of disability in seniors and the literature exploring the transitions of people with dementia in the continuing care system is growing. Nevertheless, there are still important gaps in the literature pertaining to specific factors that govern these transitions, especially those related to informal caregivers. Moreover, the complexity of the continuing care system makes it difficult to meaningfully incorporate research data on transitions into policies meant to improve the outcomes of people with dementia. The work reported in this dissertation focuses on addressing these gaps and applying system thinking to policy making in continuing care. The systematic review and meta-analysis provided pooled estimates of known and less well-known risk factors for long-term care (LTC) placement in people with dementia. Also, our review highlighted the scarcity of data on resident and caregiver related factors that may delay the LTC placement in people with dementia living in supporting living (SL) settings. This gap in the literature was addressed in the second study, which found that low strength of social relationships, among other factors, significantly increases the risk of LTC placement (HR=1.57, 95% CI: 1.02 – 2.43). Also, the number of activities performed by the informal caregivers modified the effect of residents’ level of ADL impairment on the risk of LTC placement. Specifically, among residents with severe ADL impairment, those with caregivers that performed 5 to 7 activities had a significantly lower risk of LTC placement, compared to those with caregivers that performed 4 or fewer activities (p=0.017). These research findings, along with data extracted from various reports and information obtained from continuing care stakeholders, were used to build a system dynamics (SD) model that describes the Alberta Continuing Care System (ACCS). This computer simulation model was used to explore policy options in the ACCS, illustrating the applicability of system thinking to developing and testing policies in continuing care. In the particular case of modifying benchmarks for staff/resident ratios in the continuing care system, increasing the availability of trained staff in SL might help decrease costs in the system by reducing the rapid transitions of people with dementia from SL to LTC, and consequently, reducing the pressure for adding LTC beds in the system. A better understanding of the transitions of people with dementia in the continuing care system, provided by this research, may help researchers to develop and test interventions aimed at improving the outcomes of people with dementia in the continuing care system and allowing them to age in place. Moreover, it lays the foundation for future work in planning, developing and evaluating various components of continuing care using system thinking

Transitions in care of people with dementia

YesAXA Research Fun

Recognition of depression in elderly medical inpatients

Background. Studies of recognition of depression in elderly (aged 65 or more) medical inpatients showed low recognition of depression by attending physicians. However, few studies have compared different measures of recognition of depression.Objectives. To evaluate the validity of four recognition indicators and a global measure of recognition against a diagnosis of depression and the effect of patient characteristics on recognition of depression.Methods. In a cohort of 264 medical inpatients 65 years and over (115 with major or minor depression, 78 with no depression), using data from two previous studies, sensitivities, specificities, and diagnostic odds ratios (DOR) of four indicators of recognition (Diagnosis, Symptoms, Treatment and Referral) and a global measure of recognition (any of the four indicators) were calculated. Stratified analysis was conducted to assess recognition by age, gender, history of depression, antidepressant use before admission, severity of depression, comorbidity, duration of hospitalization, disability and hospital of admission. The associations of patient characteristics with recognition were described among patients with major or minor depression using multiple logistic regression.Results. Less than half of the patients were recognized according to the global measure of recognition. The indicator with the highest sensitivity was Treatment (27.8%, 95% CI: 20.0-37.0), while the indicator with the best specificity was Diagnosis (96.6%, 95% CI:91.9-98.7). The unadjusted DOR of global recognition was 2.6 (95% CI: 1.5, 4.4). Comorbidity, severity of depression, history of depression, duration of hospitalization, antidepressant use before admission and hospital of admission were significantly associated with global recognition.Conclusion. Recognition of depression in elderly medical inpatients is low. Identifying factors that hinder recognition may guide interventions aimed at improving diagnosis and treatment of depression in elderly medical inpatients

A multi-step approach to developing a health system evaluation framework for community-based health care

Abstract Background Community-based health care (CBHC) is a shift towards healthcare integration and community services closer to home. Variation in system approaches harkens the need for a conceptual framework to evaluate outcomes and impacts. We set out to develop a CBHC-specific evaluation framework in the context of a provincial ministry of health planning process in Canada. Methods A multi-step approach was used to develop the CBHC evaluation framework. Modified Delphi informed conceptualization and prioritization of indicators. Formative research identified evaluation framework elements (triple aim, global measures, and impact), health system levels (tiers), and potential CBHC indicators (n = 461). Two Delphi rounds were held. Round 1, panelists independently ranked indicators on CBHC relevance and health system tiering. Results were analyzed by coding agreement/disagreement frequency and central tendency measures. Round 2, a consensus meeting was used to discuss disagreement, identify Tier 1 indicators and concepts, and define indicators not relevant to CBHC (Tier 4). Post-Delphi, indicators and concepts were refined, Tier 1 concepts mapped to the evaluation framework, and indicator narratives developed. Three stakeholder consultations (scientific, government, and public/patient communities) were held for endorsement and recommendation. Results Round 1 Delphi results showed agreement for 300 and disagreement for 161 indicators. Round 2 consensus resulted in 103 top tier indicators (Tier 1 = 19, Tier 2 = 84), 358 bottom Tier 3 and 4 indicators, non-CBHC measure definitions, and eight Tier 1 indicator concepts—Mortality/Suicide; Quality of Life, and Patient Reported Outcome Measures; Global Patient Reported Experience Measures; Cost of Care, Access to Integrated Primary Care; Avoidable Emergency Department Use; Avoidable Hospitalization; and E-health Penetration. Post Delphi results refined Tier 3 (n = 289) and 4 (n = 69) indicators, and identified 18 Tier 2 and 3 concepts. When mapped to the evaluation framework, Tier 1 concepts showed full coverage across the elements. ‘Indicator narratives’ depicted systemness and integration for evaluating CBHC. Stakeholder consultations affirmed endorsement of the approach and evaluation framework; refined concepts; and provided key considerations to further operationalize and contextualize indicators, and evaluate CBHC as a health system approach. Conclusions This research produced a novel evaluation framework to conceptualize and evaluate CBHC initiatives. The evaluation framework revealed the importance of a health system approach for evaluating CBHC