New care home admission following acute hospitalisation: a mixed methods approach

Care home admission following acute hospitalisation is a lived reality across Scotland, experienced by over 8,000 people annually. The aim of this thesis was to develop an understanding of new care home admission following acute hospitalisation. Methods and findings from the mixed-methods approach are presented in three parts. Part One: Identifying relevant research – includes a review of quality assessment tools for systematic reviewing; a systematic review and meta-analysis of quantitative data from observational studies of predictors of care home admission from hospital; and a methodological chapter on developing a search filter to improve accessibility of existing research findings supported by the findings of an international survey of care home researchers. The systematic review identified 53 relevant studies from 16 countries comprising a total population of 1,457,881 participants. Quantitative synthesis of the results from 11 of the studies found that increased age (OR 1.02 per year increase; 95%CI 1.00-1.04), female sex (OR 1.41; 95%CI 1.03-1.92), dementia & cognitive impairment (OR 2.14; 95%CI 1.24-3.70) and functional dependency (OR 2.06; 95%CI 1.58-2.69) were all associated with an increased risk of care home admission after hospitalisation. Despite international variation in service provision, only two studies described the model of care provided in the care home setting. The survey identified that there is a lack of shared terminology in the published literature to describe settings for adults who are unable to live independently in their own homes and require care in a long-term institutional setting. A search filter to identify relevant research could help to overcome differences in terminology and improve synthesis of existing research evidence. Part Two: Exploring current clinical practice – reports the findings of a retrospective cohort study of new care home admissions from hospital using case-note review methodology accompanied by findings from inductive thematic analysis of a single dataset from a qualitative case study design exploring the experiences of a patient, their family, and practitioners (n=5). The cohort study (n=100) found a heterogeneous picture with long hospital admissions (range 14-231 days), frequent transfers of care (31% experienced three or more transfers), varied levels of documented assessment and a lack of documented patient involvement in the decision-making processes. The qualitative interviews allowed the patient voice to emerge, alongside the professional and family narrative which dominated case-note documentation. Inductive thematic analysis identified nine major themes exploring how decisions are made to discharge individuals directly into a care home from the acute hospital setting: biography & personality; professional role; family role; limitations in local model of care; ownership of decision; risk; realising preferences; uncertainty of care home admission process; and psychological impact of in-hospital care. Part Three: Harnessing routinely-collected data – includes the challenges of identifying care home residency at admission and discharge from hospital, presenting analysis of the accuracy of Scottish Morbidity Record 1 (SMR01) coding in NHS Fife and the Community Health Index (CHI) Institution Flag in NHS Fife and NHS Tayside. This is followed by a descriptive analysis of the Scottish Care Home Census (2013-16) as a novel social care data source to explore care home admissions from hospital and the methodology for a data linkage study using these data. Identifying care home residents in routine data sources is challenging. In 18,720 admissions to NHS Fife, SMR01 coding had a sensitivity of 86.0% and positive predictive value of 85.8% in identifying care home residents on admission. At discharge the sensitivity was 87.0% and positive predictive value was 84.5%. From a sample of 10,000 records, the CHI Institution Flag had a sensitivity of 58.6% in NHS Fife and 89.3% in NHS Tayside, with positive predictive values of 99.7% and 97.7% respectively. From 2013-16, of 21,368 admissions to care homes in Scotland, 56.7% were admitted from hospital. There was significant regional variation in rates of care home admission from hospital (35.9-64.7%) and proportion of Local Authority funded places provided to admissions from hospital (34.4-73.9%). Those admitted from hospital appeared to be more dependent and sicker than those admitted from home. This thesis has established a series of challenges in how care homes and their residents are identified. It has questioned the adequacy of the evidence to guide practitioners and sought to raise the profile of this vulnerable and complex population and how best to support them in making decisions regarding admission from the acute hospital. It has progressed our understanding of this under-explored area and proposes a programme of future mixed-methods research involving patients, families, practitioners and policy-makers

Are antidementia drugs associated with reduced mortality after a hospital emergency admission in the population with dementia aged 65 years and older?

Introduction: People with dementia experience poor outcomes after hospital admission, with mortality being particularly high. There is no cure for dementia; antidementia medications have been shown to improve cognition and function, but their effect on mortality in real-world settings is little known. This study examines associations between treatment with antidementia medication and mortality in older people with dementia after an emergency admission. Methods: The design is a retrospective cohort study of people aged 65 years, with a diagnosis of dementia and an emergency hospital admission between 01/01/2010 and 31/12/2016. Two classes of antidementia medication were considered: the acetylcholinesterase inhibitors and memantine. Mortality was examined using a Cox proportional hazards model with time-varying covariates for the prescribing of antidementia medication before or on admission and during one-year follow-up, adjusted for demographics, comorbidity, and community prescribing including anticholinergic burden. Propensity score analysis was examined for treatment selection bias. Results: There were 9142 patients with known dementia included in this study, of which 45.0% (n 5 4110) received an antidementia medication before or on admission; 31.3% (n 5 2864) were prescribed one of the acetylcholinesterase inhibitors, 8.7% (n 5 798) memantine, and 4.9% (n 5 448) both. 32.9% (n 5 1352) of these patients died in the year after admission, compared to 42.7% (n 5 2148) of those with no antidementia medication on admission. The Cox model showed a significant reduction in mortality in patients treated with acetylcholinesterase inhibitors (hazard ratio [HR] 5 0.78, 95% CI 0.72-0.85) or memantine (HR 5 0.75, 95% CI 0.66-0.86) or both (HR 5 0.76, 95% CI 0.68-0.94). Sensitivity analysis by propensity score matching confirmed the associations between antidementia prescribing and reduced mortality. Discussion: Treatment with antidementia medication is associated with a reduction in risk of death in the year after an emergency hospital admission. Further research is required to determine if there is a causal relationship between treatment and mortality, and whether "symptomatic" therapy for demen-tia does have a disease-modifying effect

Data resource profile: the Scottish Social Care Survey (SCS) and the Scottish Care Home Census (SCHC)

Introduction: Linked health care datasets have been used effectively in Scotland for some time. Use of social care data has been much more limited, partly because responsibility for these services is distributed across multiple local authorities. However, there are substantial interactions between health and social care (also known internationally as long-term care) services, and keen policy interest in better understanding these. We introduce two social care resources that can now be linked to health datasets at a population level across Scotland to study these interdependencies. These data emerge from the Scottish Government’s centralised collation of data from mandatory returns provided by local authorities and care homes. Methods: Deterministic and Probabilistic methods were used to match the Social Care Survey (SCS) and Scottish Care Home Census (SCHC) to the Community Health Index (CHI) number via the National Records of Scotland (NRS) Research Indexing Spine. Results: For the years 2010/11 to 2015/16, an overall match rate of 91.2% was achieved for the SCS to CHI from 31 of Scotland’s 32 local authority areas. This rate varied from 76.7% to 98.5% for local authority areas. A match rate of 89.8% to CHI was achieved for the SCHC in years 2012/13 to 2015/16 but only 52.5% for the years 2010/11 to 2011/12. Conclusion: Indexing of the SCS and SCHC to CHI offers a new and rich resource of data for health and social care research

The burden of psychotropic and anticholinergic medicines use in care homes:population-based analysis in 147 care homes

Background: older people living in care-homes are particularly vulnerable to adverse effects of psychotropic and anticholinergic drugs. Methods: anonymised dispensed prescription data from all 4,478 residents aged ≥ 60 years in 147 care-homes in two Scottish health boards were analysed. Psychotropic medicines examined were antipsychotics, antidepressants, hypnotic/anxiolytics, opioids and gabapentinoids. Anticholinergic burden was measured using the modified anticholinergic risk scale (mARS). Variation between care-homes and associations with individual and care-home characteristics were examined using multilevel logistic regression. Results: 63.5% of residents were prescribed at least one psychotropic drug, and 27.0% two or more, most commonly antidepressants (41.6%), opioids (20.3%), hypnotic/anxiolytics (16.9%) and antipsychotics (16.7%). 48.1% were prescribed an anticholinergic drug, and 12.1% had high anticholinergic burden (mARS ≥ 3). Variation between care-homes was high for antipsychotics (intra-cluster correlation coefficient [ICC] 8.2%) and hypnotics/anxiolytics (ICC = 7.3%), and moderate for antidepressants (ICC = 4.7%) and anticholinergics (ICC = 2.8%). Prescribing of all drugs was lower in the oldest old. People with dementia were more likely to be prescribed antipsychotics (adjusted OR = 1.45, 95%CI 1.23–1.71) but less likely to be prescribed anticholinergics (aOR = 0.61, 95%CI 0.51–0.74). Prescribing of antipsychotics was higher in Tayside (aOR = 1.52, 95%CI 1.20–1.92), whereas prescribing of antidepressants (particularly tricyclic-related) was lower (aOR = 0.66, 95%CI 0.56–0.79). There was no association with care-home regulator quality scores. Conclusion: care-home residents have high psychotropic and anticholinergic burden, with considerable variation between care-homes that is not related to existing measures of quality of care. Research to better understand variation between care-homes and the interaction with local prescribing cultures is needed

Understanding Pathways into Care homes using Data (UnPiCD study) a retrospective cohort study using national linked health and social care data: a retrospective cohort study using national linked health and social care data

Background: Pathways into care are poorly understood but important life events for individuals and their families. UK policy is to avoid moving-in to care homes from acute hospital settings. This assumes that moves from secondary care represent a system failure. However, those moving to care homes from community and hospital settings may be fundamentally different groups, each requiring differing care approaches. Objective: To characterise individuals who move-in to a care home from hospital and compare with those moving-in from the community. Design and setting: A retrospective cohort study using cross-sectoral data linkage of care home data. Methods: We included adults moving-in to care homes between 1/4/13 and 31/3/16, recorded in the Scottish Care Home Census. Care home data were linked to general and psychiatric hospital admissions, community prescribing and mortality records to ascertain comorbidities, significant diagnoses, hospital resource use, polypharmacy and frailty. Multivariate logistic regression identified predictors of moving-in from hospital compared to from community. Results: We included 23,892 individuals moving-in to a care home, 13,564 (56.8%) from hospital and 10,328 (43.2%) from the community. High frailty risk adjusted Odds Ratio (aOR) 5.11 (95% Confidence Interval (CI): 4.60–5.68), hospital discharge with diagnosis of fracture aOR 3.91 (95%CI: 3.41–4.47) or stroke aOR 8.42 (95%CI: 6.90–10.29) were associated with moving-in from hospital. Discharge from in-patient psychiatry was also a highly significant predictor aOR 19.12 (95%CI: 16.26–22.48). Conclusions: Individuals moving-in to care homes directly from hospital are clinically distinct from those from the community. Linkage of cross-sectoral data can allow exploration of pathways into care at scale

Protocol for the development of a repository of individual participant data from randomised controlled trials conducted in adult care homes (The Virtual International Care Homes Trials Archive (VICHTA))

Background: Approximately 418,000 people live in care homes in the UK, yet accessible, robust data on care home populations and organisation are lacking. This hampers our ability to plan, allocate resources or prevent risk. Large randomised controlled trials (RCTs) conducted in care homes offer a potential solution. The value of detailed data on residents’ demographics, outcomes and contextual information captured in RCTs has yet to be fully realised. Irrespective of the intervention tested, much of the trial data collected overlaps in terms of structured assessments and descriptive information. Given the time and costs required to prospectively collect data in these populations, pooling anonymised RCT data into a structured repository offers benefit; secondary analyses of pooled RCT data can improve understanding of this under-researched population and enhance the future trial design. This protocol describes the creation of a project-specific repository of individual participant data (IPD) from trials conducted in care homes and subsequent expansion into a legacy dataset for wider use, to address the need for accurate, high-quality IPD on this vulnerable population. Methods: Informed by scoping of relevant literature, the principal investigators of RCTs conducted in adult care homes in the UK since 2010 will be invited to contribute trial IPD. Contributing trialists will form a Steering Committee who will oversee data sharing and remain gatekeepers of their own trial’s data. IPD will be cleaned and standardised in consultation with the Steering Committee for accuracy. Planned analyses include a comparison of pooled IPD with point estimates from administrative sources, to assess generalisability of RCT data to the wider care home population. We will also identify key resident characteristics and outcomes from within the trial repository, which will inform the development of a national minimum dataset for care homes. Following project completion, management will migrate to the Virtual Trials Archives, forming a legacy dataset which will be expanded to include international RCTs, and will be accessible to the wider research community for analyses. Discussion: Analysis of pooled IPD has the potential to inform and direct future practice, research and policy at low cost, enhancing the value of existing data and reducing research waste. We aim to create a permanent archive for care home trial data and welcome the contribution of emerging trial datasets

New horizons in iron deficiency anaemia in older adults

Iron deficiency anaemia (IDA) is common in older adults and associated with a range of adverse outcomes. Differentiating iron deficiency from other causes of anaemia is important to ensure appropriate investigations and treatment. It is possible to make the diagnosis reliably using simple blood tests. Clinical evaluation and assessment are required to help determine the underlying cause and to initiate appropriate investigations. IDA in men and post-menopausal females is most commonly due to occult gastrointestinal blood loss until proven otherwise, although there is a spectrum of underlying causative pathologies. Investigation decisions should take account of the wishes of the patient and their competing comorbidities, individualising the approach. Management involves supplementation using oral or intravenous (IV) iron then consideration of treatment of the underlying cause of deficiency. Future research areas are outlined including the role of Hepcidin and serum soluble transferrin receptor measurement, quantitative faecal immunochemical testing, alternative dosing regimens and the potential role of IV iron preparations