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BACKGROUND: Health system fragmentation directly contributes to poor health and social outcomes for older adults with multiple chronic conditions and their care partners. Older adults often require support from primary care, multiple specialists, home care, community support services, and other health-care sectors and communication between these providers is unstructured and not standardized. Integrated and interprofessional team-based models of care are a recommended strategy to improve health service delivery to older adults with complex needs. Standardized assessment instruments deployed on digital platforms are considered a necessary component of integrated care. The aim of this study was to develop strategies to leverage an electronic wellness instrument, interRAI Check Up Self Report, to support integrated health and social care for older adults and their care partners in a community in Southern Ontario, Canada. METHODS: Group concept mapping, a participatory mixed-methods approach, was conducted. Participants included older adults, care partners, and representatives from: home care, community support services, specialized geriatric services, primary care, and health informatics. In a series of virtual meetings, participants generated ideas to implement the interRAI Check Up and rated the relative importance of these ideas. Hierarchical cluster analysis was used to map the ideas into clusters of similar statements. Participants reviewed the map to co-create an action plan. RESULTS: Forty-one participants contributed to a cluster map of ten action areas (e.g., engagement of older adults and care partners, instrument's ease of use, accessibility of the assessment process, person-centred process, training and education for providers, provider coordination, health information integration, health system decision support and quality improvement, and privacy and confidentiality). The health system decision support cluster was rated as the lowest relative importance and the health information integration was cluster rated as the highest relative importance. CONCLUSIONS: Many person-, provider-, and system-level factors need to be considered when implementing and using an electronic wellness instrument across health- and social-care providers. These factors are highly relevant to the integration of other standardized instruments into interprofessional team care to ensure a compassionate care approach as technology is introduced.
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Prestación Integrada de Atención de Salud , Salud Digital , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , OntarioRESUMEN
BACKGROUND: Mental health problems, particularly anxiety and depression, are common in patients with chronic kidney disease (CKD), and negatively impact quality of life, treatment adherence, and mortality. However, the degree to which mental health and addictions services are utilized by those with CKD is unknown. We examined the history of mental health and addictions service use of individuals across levels of kidney function. METHODS: We performed a population-based cross-sectional study using linked healthcare databases from Ontario, Canada from 2009 to 2017. We abstracted the prevalence of individuals with mental health and addictions service use within the previous 3 years across levels of kidney function (eGFR$\ \ge $60, 45 to < 60, 30 to < 45, 15 to < 30, <15 mL/min per 1.73m2 and maintenance dialysis). We calculated prevalence ratios (PR) to compare prevalence across kidney function strata, while adjusting for age, sex, year of cohort entry, urban versus rural location, area-level marginalization, and Charlson comorbidity scores. RESULTS: Of 5 956 589 adults, 9% (n = 534 605) had an eGFR<60 mL/min per 1.73m2 or were receiving maintenance dialysis. Fewer individuals with eGFR < 60 had a history of any mental health and addictions service utilization (crude prevalence range 28% to 31%), compared to individuals with eGFR ≥ 60 (35%). Compared to eGFR ≥ 60, the lowest prevalence of individuals with any mental health and addictions service utilization was among those with eGFR 15 to < 30 (adjusted PR 0.86, 95% CI 0.85 to 0.88), eGFR < 15 (adjusted PR 0.81, 95% CI 0.76 to 0.86) and those receiving maintenance dialysis (adjusted PR 0.83, 95% CI 0.81 to 0.84). Less use of outpatient services accounted for differences in service utilization. CONCLUSIONS: Mental health and addictions service utilization is common but less so in individuals with advanced CKD in Ontario, Canada.
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CONTEXT: An increasing demand for kidney transplantation has enticed some patients with end-stage renal disease (ESRD) to venture outside their country of residence, but their posttransplant outcomes may be suboptimal. OBJECTIVE: We compared the risks and clinical outcomes among tourists, or patients who pursue a kidney transplant abroad, versus patients who received a transplant at the Toronto General Hospital (TGH). METHODS: A single-center, 1:3 matched (based on age at transplant, time on dialysis, and year of transplant) cohort study was conducted. Forty-five tourists were matched with 135 domestic transplant recipients between January 1, 2000, and December 31, 2011. Multivariable Cox proportional hazards models were fitted to assess graft and patient outcomes. RESULTS: Among the 45 tourists, the majority (38 of 45) traveled to the Middle East or Far East Asia, and most received living donor kidney transplants (35 of 45). Multivariable Cox proportional hazards models showed that tourists had a higher risk for the composite outcome of acute rejection, death-censored graft failure, or death with graft function (DWGF; hazard ratio [HR] 2.08, 95% confidence interval [CI]: 1.06-4.07). Tourists also showed a higher risk for the individual end points of acute rejection, DWGF, and posttransplant hospitalizations. CONCLUSION: Patients going abroad for kidney transplantation may have inferior outcomes compared to domestic patients receiving kidney transplants. Patients who are contemplating an overseas transplant need to be aware of the increased risk of adverse posttransplant outcomes and should be appropriately counseled by transplant professionals during the pretransplant evaluation process.
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Rechazo de Injerto/epidemiología , Supervivencia de Injerto , Fallo Renal Crónico/cirugía , Trasplante de Riñón , Turismo Médico , Enfermedad Aguda , Adulto , Canadá , Estudios de Casos y Controles , Estudios de Cohortes , Femenino , Rechazo de Injerto/prevención & control , Hospitalización/estadística & datos numéricos , Humanos , Inmunosupresores/uso terapéutico , Masculino , Persona de Mediana Edad , Mortalidad , Análisis Multivariante , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
The Kidney Transplant Program (KTP) at the Toronto General Hospital has taken great strides in preparing to meet the needs of patients and health care providers, as the number of end-stage renal disease patients in Ontario increases. The KTP has begun the process of increasing engagement and collaboration with various stakeholders from the pre- to the post-transplant phase through (1) the development of innovative programs to increase the number of live kidney donations, (2) the development and maintenance of information technology solutions that work simultaneously to provide data to manage and treat patients, and conduct research, and (3) the development, implementation, and delivery of educational presentations and tools to various stakeholders both at the referring centres and the transplant program. Future steps for the KTP include evaluating the impact of these programmatic tools and activities on the number of referrals received and the subsequent effect on the number of transplants performed.
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Personal de Salud , Fallo Renal Crónico/terapia , Trasplante de Riñón/normas , Guías de Práctica Clínica como Asunto/normas , Rol Profesional , Indicadores de Calidad de la Atención de Salud , Derivación y Consulta/normas , Hospitales Generales , Humanos , Ontario , Evaluación de Procesos, Atención de SaludRESUMEN
Given the increasing number of patients with end-stage renal disease in Ontario, there is a need to improve the efficiency and effectiveness of the pretransplant evaluation, to allow for a seamless progression through the various steps in the process. Toronto General Hospital's kidney transplant program is evaluating various performance measures, specifically looking at waiting times from referral to initial evaluation and initial evaluation to final disposition, to use as metrics for monitoring program performance and stimulate quality improvement.
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Hospitales Generales , Trasplante de Riñón , Periodo Preoperatorio , Indicadores de Calidad de la Atención de Salud , Listas de Espera , Adolescente , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Ontario , Estudios Retrospectivos , Adulto JovenRESUMEN
BACKGROUND: Early hospital readmissions (EHRs) after kidney transplantation range in incidence from 18%-47% and are important and substantial healthcare quality indicators. EHR can adversely impact clinical outcomes such as graft function and patient mortality as well as healthcare costs. EHRs have been extensively studied in American healthcare systems, but these associations have not been explored within a Canadian setting. Due to significant differences in the delivery of healthcare and patient outcomes, results from American studies cannot be readily applicable to Canadian populations. A better understanding of EHR can facilitate improved discharge planning and long-term outpatient management post kidney transplant. AIM: To explore the burden of EHR on kidney transplant recipients (KTRs) and the Canadian healthcare system in a large transplant centre. METHODS: This single centre cohort study included 1564 KTRs recruited from January 1, 2009 to December 31, 2017, with a 1-year follow-up. We defined EHR as hospitalizations within 30 d or 90 d of transplant discharge, excluding elective procedures. Multivariable Cox and linear regression models were used to examine EHR, late hospital readmissions (defined as hospitalizations within 31-365 d for 30-d EHR and within 91-365 d for 90-d EHR), and outcomes including graft function and patient mortality. RESULTS: In this study, 307 (22.4%) and 394 (29.6%) KTRs had 30-d and 90-d EHRs, respectively. Factors such as having previous cases of rejection, being transplanted in more recent years, having a longer duration of dialysis pretransplant, and having an expanded criteria donor were associated with EHR post-transplant. The cumulative probability of death censored graft failure, as well as total graft failure, was higher among the 90-d EHR group as compared to patients with no EHR. While multivariable models found no significant association between EHR and patient mortality, patients with EHR were at an increased risk of late hospital readmissions, poorer kidney function throughout the 1st year post-transplant, and higher hospital-based care costs within the 1st year of follow-up. CONCLUSION: EHRs are associated with suboptimal outcomes after kidney transplant and increased financial burden on the healthcare system. The results warrant the need for effective strategies to reduce post-transplant EHR.
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OBJECTIVE: The objective was to compare home care episode, standardised assessment, and service patterns in Ontario's publicly funded home care system during the first wave of the COVID-19 pandemic (i.e., March to September 2020) using the previous year as reference. STUDY DESIGN AND SETTING: We plotted monthly time series data from March 2019 to September 2020 for home care recipients in Ontario, Canada. Home care episodes were linked to interRAI Home Care assessments, interRAI Contact Assessments, and home care services. Health status measures from the patient's most recent interRAI assessment were used to stratify the receipt of personal support, nursing, and occupational or physical therapy services. Significant level and slope changes were detected using Poisson, beta, and linear regression models. RESULTS: The March to September 2020 period was associated with significantly fewer home care admissions, discharges, and standardised assessments. Among those assessed with the interRAI Home Care assessment, significantly fewer patients received any personal support services. Among those assessed with either interRAI assessment and identified to have rehabilitation needs, significantly fewer patients received any therapy services. Among patients receiving services, patients received significantly fewer hours of personal support and fewer therapy visits per month. By September 2020, the rate of admissions and services had mostly returned to pre-pandemic levels, but completion of standardised assessments lagged behind. CONCLUSION: The first wave of the COVID-19 pandemic was associated with substantial changes in Ontario's publicly funded home care system. Although it may have been necessary to prioritise service delivery during a crisis situation, standardised assessments are needed to support individualised patient care and system-level monitoring. Given the potential disruptions to home care services, future studies should examine the impact of the pandemic on the health and well-being of home care recipients and their caregiving networks.