Rural-urban differences in use of health services before and after dementia diagnosis: a retrospective cohort study.

BACKGROUND: Rural-urban differences in health service use among persons with prevalent dementia are known. However, the extent of geographic differences in health service use over a long observation period, and prior to diagnosis, have not been sufficiently examined. The purpose of this study was to examine yearly rural-urban differences in the proportion of patients using health services, and the mean number of services, in the 5-year period before and 5-year period after a first diagnosis of dementia. METHODS: This population-based retrospective cohort study used linked administrative health data from the Canadian province of Saskatchewan to investigate the use of five health services [family physician (FP), specialist physician, hospital admission, all-type prescription drug dispensations, and short-term institutional care admission] each year from April 2008 to March 2019. Persons with dementia included 2,024 adults aged 65 years and older diagnosed from 1 April 2013 to 31 March 2014 (617 rural; 1,407 urban). Matching was performed 1:1 to persons without dementia on age group, sex, rural versus urban residence, geographic region, and comorbidity. Differences between rural and urban persons within the dementia and control cohorts were separately identified using the Z-score test for proportions (p < 0.05) and independent samples t-test for means (p < 0.05). RESULTS: Rural compared to urban persons with dementia had a lower average number of FP visits during 1-year and 2-year preindex and between 2-year and 4-year postindex (p < 0.05), a lower likelihood of at least one specialist visit and a lower average number of specialist visits during each year (p < 0.05), and a lower average number of all-type prescription drug dispensations for most of the 10-year study period (p < 0.05). Rural-urban differences were not observed in admission to hospital or short-term institutional care (p > 0.05 each year). CONCLUSIONS: This study identified important geographic differences in physician services and all-type prescription drugs before and after dementia diagnosis. Health system planners and educators must determine how to use existing resources and technological advances to support care for rural persons living with dementia.

The impact of alternate level of care on access block and operational strategies to reduce emergency wait times: a multi-center simulation study.

OBJECTIVES: Lengthy emergency department (ED) wait times caused by hospital access block is a growing concern for the Canadian health care system. Our objective was to quantify the impact of alternate-level-of-care on hospital access block and evaluate the likely effects of multiple interventions on ED wait times. METHODS: Discrete-event simulation models were developed to simulate patient flows in EDs and acute care of six Canadian hospitals. The model was populated with administrative data from multiple sources (April 2017-March 2018). We simulated and assessed six different intervention scenarios' impact on three outcome measures: (1) time waiting for physician initial assessment, (2) time waiting for inpatient bed, and (3) patients who leave without being seen. We compared each scenario's outcome measures to the baseline scenario for each ED. RESULTS: Eliminating 30% of medical inpatients' alternate-level-of-care days reduced the mean time waiting for inpatient bed by 0.25 to 4.22 h. Increasing ED physician coverage reduced the mean time waiting for physician initial assessment (∆ 0.16-0.46 h). High-quality care transitions targeting medical patients lowered the mean time waiting for inpatient bed for all EDs (∆ 0.34-6.85 h). Reducing ED visits for family practice sensitive conditions or improving continuity of care resulted in clinically negligible reductions in wait times and patients who leave without being seen rates. CONCLUSIONS: A moderate reduction in alternate-level-of-care hospital days for medical patients could alleviate access block and reduce ED wait times, although the magnitude of reduction varies by site. Increasing ED physician staffing and aligning physician capacity with inflow demand could also decrease wait time. Operational strategies for reducing ED wait times should prioritize resolving output and throughput factors rather than input factors.

ABSTRAIT: OBJECTIF: Les longs temps d'attente dans les services d'urgence (SU) à cause de blocage de l'accès à l'hôpital sont une préoccupation croissante pour le système de santé canadien. Notre objectif était de quantifier l'impact d'un autre niveau de soins sur le bloc d'accès à l'hôpital et d'évaluer les effets probables d'interventions multiples sur les temps d'attente aux départements d'urgences. MéTHODES: Des modèles de simulation aux événements discrets ont été développés pour simuler les flux de patients dans les urgences et les soins aigus de six hôpitaux canadiens. Le mod èle a été rempli de données administratives ayant plusieurs sources (avril 2017 à mars 2018). Nous avons simulé et évalué l'impact de six scénarios d'intervention différents sur trois mesures de résultats : 1) le temps d'attente pour l'évaluation initiale du médecin, 2) le temps d'attente pour un lit pour des patients hospitalisés et 3) les patients qui partent sans être vus. Nous avons comparé chaque mesure de résultats de ce scénario au scénario de référence pour chaque département d'urgences. RéSULTATS: L'élimination de 30 % des jours d'hospitalisation à un autre niveau de soins des patients médicaux a réduit le temps moyen d'attente pour un patient hospitalisé de 0,25 à 4,22 heures. L'augmentation du nombre des médecins des urgences a réduit le temps moyen d'attente pour l'évaluation initiale du médecin (∆ 0,16 à 0,46 heures). Les transitions de soins de haute qualité ciblant les patients médicaux ont réduit la période moyen d'attente des patients hospitalisés pour tous les services d'urgence (∆ 0,34 à 6,85 heures). La réduction des visites à l'urgence pour des conditions sensibles à la médecine familiale ou l'augmentation de la continuité des soins ont entraîné des réductions cliniquement insignifiantes des temps d'attente et des taux de patients qui quittent sans être vus. CONCLUSIONS: Une réduction modérée du nombre d'un autre niveau de soins pour les patients médicaux pourrait non seulement soulager le blocage de l'accès mais aussi réduire les temps d'attente aux urgences, afin de l'ampleur de la réduction varie selon le site. L'augmentation du nombre de médecins des urgences et l'harmonisation de la capacité des médecins avec la demande d'afflux pourraient également réduire le temps d'attente. Les stratégies opérationnelles destinées à réduire les temps d'attente aux urgences devraient accorder la priorité à la résolution des facteurs de sortie et de débit plutôt qu'aux facteurs d'entrée.

Utilization of Health Services Before and After Diagnosis in a Specialist Rural and Remote Memory Clinic.

Background: Limited research exists on the use of specific health services over an extended time among rural persons with dementia. The study objective was to examine health service use over a 10-year period, five years before until five years after diagnosis in the specialist Rural and Remote Memory Clinic (RRMC). Methods: Clinical and administrative health data of RRMC patients were linked. Annual health service utilization of the cohort (N = 436) was analyzed for 416 patients pre-index (57.5% female, mean age 71.2 years) and 419 post-index (56.3% female, mean age 70.8 years). Approximately 40% of memory clinic diagnoses were Alzheimer's disease (AD), 20% non-AD dementia, and 40% mild or subjective cognitive impairment or other condition. Post-index, 188 patients (44.9%) moved to permanent long-term care and were retained in the sample; 121 patients died (28.9%) and were removed yearly. Results: Over the ten-year study period, a significant increase occurred in the average number of FP visits, all-type drug prescriptions, and dementia-specific drug prescriptions (all p <.001). The highest proportion of patients hospitalized was observed one year pre-index, the highest average number of specialist visits was observed one year post-index, and both demonstrated a significant decreasing trend in the five-year post-index period (p = .037). Conclusions: A pattern of increasing FP visits and drug prescriptions over an extended period before and after diagnosis in a specialist rural and remote memory clinic highlights a need to support FPs in post-diagnostic management. Further research of longitudinal patterns in health service utilization is merited.

Osteoporosis-related fracture case definitions for population-based administrative data.

BACKGROUND: Population-based administrative data have been used to study osteoporosis-related fracture risk factors and outcomes, but there has been limited research about the validity of these data for ascertaining fracture cases. The objectives of this study were to: (a) compare fracture incidence estimates from administrative data with estimates from population-based clinically-validated data, and (b) test for differences in incidence estimates from multiple administrative data case definitions. METHODS: Thirty-five case definitions for incident fractures of the hip, wrist, humerus, and clinical vertebrae were constructed using diagnosis codes in hospital data and diagnosis and service codes in physician billing data from Manitoba, Canada. Clinically-validated fractures were identified from the Canadian Multicentre Osteoporosis Study (CaMos). Generalized linear models were used to test for differences in incidence estimates. RESULTS: For hip fracture, sex-specific differences were observed in the magnitude of under- and over-ascertainment of administrative data case definitions when compared with CaMos data. The length of the fracture-free period to ascertain incident cases had a variable effect on over-ascertainment across fracture sites, as did the use of imaging, fixation, or repair service codes. Case definitions based on hospital data resulted in under-ascertainment of incident clinical vertebral fractures. There were no significant differences in trend estimates for wrist, humerus, and clinical vertebral case definitions. CONCLUSIONS: The validity of administrative data for estimating fracture incidence depends on the site and features of the case definition.

Health service use before and after dementia diagnosis: a retrospective matched case-control study.

OBJECTIVES: This study investigated patterns in health service usage among older adults with dementia and matched controls over a 10-year span from 5 years before until 5 years after diagnosis. DESIGN: Population-based retrospective matched case-control study. SETTING: Administrative health data of individuals in Saskatchewan, Canada from 1 April 2008 to 31 March 2019. PARTICIPANTS: The study included 2024 adults aged 65 years and older living in the community at the time of dementia diagnosis from 1 April 2013 to 31 March 2014, matched 1:1 to individuals without a dementia diagnosis on age group, sex, rural versus urban residence, geographical region and comorbidity. OUTCOME MEASURES: For each 5-year period before and after diagnosis, we examined usage of health services each year including family physician (FP) visits, specialist visits, hospital admissions, all-type prescription drug dispensations and short-term care admissions. We used negative binomial regression to estimate the effect of dementia on yearly average health service utilisation adjusting for sex, age group, rural versus urban residence, geographical region, 1 year prior health service use and comorbidity. RESULTS: Adjusted findings demonstrated that 5 years before diagnosis, usage of all health services except hospitalisation was lower among persons with dementia than persons without dementia (all p<0.001). After this point, differences in higher health service usage among persons with dementia compared to without dementia were greatest in the year before and year after diagnosis. In the year before diagnosis, specialist visits were 59.7% higher (p<0.001) and hospitalisations 90.5% higher (p<0.001). In the year after diagnosis, FP visits were 70.0% higher (p<0.001) and all-type drug prescriptions 29.1% higher (p<0.001). CONCLUSIONS: Findings suggest the year before and year after diagnosis offer multiple opportunities to implement quality supports. FPs are integral to dementia care and require effective resources to properly serve this population.

Comparing comorbidity measures for predicting mortality and hospitalization in three population-based cohorts.

BACKGROUND: Multiple comorbidity measures have been developed for risk-adjustment in studies using administrative data, but it is unclear which measure is optimal for specific outcomes and if the measures are equally valid in different populations. This research examined the predictive performance of five comorbidity measures in three population-based cohorts. METHODS: Administrative data from the province of Saskatchewan, Canada, were used to create the cohorts. The general population cohort included all Saskatchewan residents 20+ years, the diabetes cohort included individuals 20+ years with a diabetes diagnosis in hospital and/or physician data, and the osteoporosis cohort included individuals 50+ years with diagnosed or treated osteoporosis. Five comorbidity measures based on health services utilization, number of different diagnoses, and prescription drugs over one year were defined. Predictive performance was assessed for death and hospitalization outcomes using measures of discrimination (c-statistic) and calibration (Brier score) for multiple logistic regression models. RESULTS: The comorbidity measures with optimal performance were the same in the general population (n = 662,423), diabetes (n = 41,925), and osteoporosis (n = 28,068) cohorts. For mortality, the Elixhauser index resulted in the highest c-statistic and lowest Brier score, followed by the Charlson index. For hospitalization, the number of diagnoses had the best predictive performance. Consistent results were obtained when we restricted attention to the population 65+ years in each cohort. CONCLUSIONS: The optimal comorbidity measure depends on the health outcome and not on the disease characteristics of the study population.