Hip fracture rate and osteoporosis treatment in Ontario: A population-based retrospective cohort study.

This population-based study analyzes hip fracture and osteoporosis treatment rates among older adults, stratified by place of residence prior to fracture. Hip fracture rates were higher among older adults living in the community and discharged to long-term care (LTC) after fracture, compared to LTC residents and older adults living in the community. Only 23% of LTC residents at high fracture risk received osteoporosis treatment. PURPOSE: This population-based study examines hip fracture rate and osteoporosis management among long-term care (LTC) residents > 65 years of age compared to community-dwelling older adults at the time of fracture and admitted to LTC after fracture, in Ontario, Canada. METHODS: Healthcare utilization and administrative databases were linked using unique, encoded identifiers from the ICES Data Repository to estimate hip fractures (identified using the Public Health Agency of Canada algorithm and International Classification of Diseases (ICD)-10 codes) and osteoporosis management (pharmacotherapy) among adults > 66 years from April 1, 2014 to March 31, 2018. Sex-specific and age-standardized rates were compared by pre-fracture residency and discharge location (i.e., LTC to LTC, community to LTC, or community to community). Fracture risk was determined using the Fracture Risk Scale (FRS). RESULTS: At baseline (2014/15), the overall age-standardized hip fracture rate among LTC residents was 223 per 10,000 person-years (173 per 10,000 females and 157 per 10,000 males), 509 per 10,000 person-years (468 per 10,000 females and 320 per 10,000 males) among the community to LTC cohort, and 31.5 per 10,000 person-years (43.1 per 10,000 females and 25.6 per 10,000 males). During the 5-year observation period, the overall annual average percent change (APC) for hip fracture increased significantly in LTC (AAPC = + 8.6 (95% CI 5.0 to 12.3; p = 0.004) compared to the community to LTC group (AAPC = + 2.5 (95% CI - 3.0 to 8.2; p = 0.248)) and the community-to-community cohort (AAPC - 3.8 (95% CI - 6.7 to - 0.7; p = 030)). However, hip fracture rate remained higher in the community to LTC group over the study period. There were 33,594 LTC residents identified as high risk of fracture (FRS score 4 +), of which 7777 were on treatment (23.3%). CONCLUSION: Overall, hip fracture rates have increased in LTC and among community-dwelling adults admitted to LTC after fracture. However, hip fracture rates among community-dwelling adults have decreased over time. A non-significant increase in osteoporosis treatment rates was observed among LTC residents at high risk of fracture (FRS4 +). Residents in LTC are at very high risk for fracture and require individualized based on goals of care and life expectancy.

Abuse in Canadian long-term care homes: a mixed methods study.

OBJECTIVE: To examine reported cases of abuse in long-term care (LTC) homes in the province of Ontario, Canada, to determine the extent and nature of abuse experienced by residents between 2019 and 2022. DESIGN: A qualitative mixed methods study was conducted using document analysis and descriptive statistics. Three data sources were analysed: LTC legislation, inspection reports from a publicly available provincial government administrative database and articles published by major Canadian newspapers. A data extraction tool was developed that included variables such as the date of inspection, the type of inspection, findings and the section of legislation cited. Descriptive analyses, including counts and percentages, were calculated to identify the number of incidents and the type of abuse reported. RESULTS: According to legislation, LTC homes are required to protect residents from physical, sexual, emotional, verbal or financial abuse. The review of legislation revealed that inspectors are responsible for ensuring homes comply with this requirement. An analysis of their reports identified that 9% (781) of overall inspections included findings of abuse. Physical abuse was the most common type (37%). Differences between the frequency of abuse across type of ownership, location and size of the home were found. There were 385 LTC homes with at least one reported case of abuse, and 55% of these homes had repeated incidents. The analysis of newspaper articles corroborated the findings of abuse in the inspection reports and provided resident and family perspectives. CONCLUSIONS: There are substantial differences between legislation intended to protect LTC residents from abuse and the abuse occurring in LTC homes. Strategies such as establishing a climate of trust, investing in staff and leadership, providing standardised education and training and implementing a quality and safety framework could improve the care and well-being of LTC residents.

Clinical subtypes of older adults starting long-term care in Japan and their association with prognoses: a data-driven cluster analysis.

We aimed to identify the clinical subtypes in individuals starting long-term care in Japan and examined their association with prognoses. Using linked medical insurance claims data and survey data for care-need certification in a large city, we identified participants who started long-term care. Grouping them based on 22 diseases recorded in the past 6 months using fuzzy c-means clustering, we examined the longitudinal association between clusters and death or care-need level deterioration within 2 years. We analyzed 4,648 participants (median age 83 [interquartile range 78-88] years, female 60.4%) between October 2014 and March 2019 and categorized them into (i) musculoskeletal and sensory, (ii) cardiac, (iii) neurological, (iv) respiratory and cancer, (v) insulin-dependent diabetes, and (vi) unspecified subtypes. The results of clustering were replicated in another city. Compared with the musculoskeletal and sensory subtype, the adjusted hazard ratio (95% confidence interval) for death was 1.22 (1.05-1.42), 1.81 (1.54-2.13), and 1.21 (1.00-1.46) for the cardiac, respiratory and cancer, and insulin-dependent diabetes subtypes, respectively. The care-need levels more likely worsened in the cardiac, respiratory and cancer, and unspecified subtypes than in the musculoskeletal and sensory subtype. In conclusion, distinct clinical subtypes exist among individuals initiating long-term care.

Survival, Function, and Cognition After Hospitalization in Long-Term Acute Care Hospitals.

Importance: More than 70 000 Medicare beneficiaries receive care in long-term acute care hospitals (LTCHs) annually for prolonged acute illness. However, little is known about long-term functional and cognitive outcomes of middle-aged and older adults after hospitalization in an LTCH. Objective: To describe survival, functional, and cognitive status after LTCH hospitalization and to identify factors associated with an adverse outcome. Design, Setting, and Participants: This retrospective cohort study included middle-aged and older adults enrolled in the Health and Retirement Study (HRS) with linked fee-for-service Medicare claims. Included participants were aged 50 years or older with an LTCH admission between January 1, 2003, and December 31, 2016, with HRS interviews available before admission. Data were analyzed between November 1, 2021, and June 30, 2023. Main Outcomes and Measures: Function and cognition were ascertained from HRS interviews conducted every 2 years. The primary outcome was death or severe impairment in the 2.5 years after LTCH hospitalization, defined as dependencies in 2 or more activities of daily living (ADLs) or dementia. Multivariable logistic regression was performed to evaluate associations with a priori selected risk factors including pre-LTCH survival prognosis (Lee index score), pre-LTCH impairment status, and illness severity characterized by receipt of mechanical ventilation and prolonged intensive care unit stay of 3 days or longer. Results: This study included 396 participants, with a median age of 75 (IQR, 68-82) years. Of the participants, 201 (51%) were women, 125 (28%) had severe impairment, and 318 (80%) died or survived with severe impairment (functional, cognitive, or both) within 2.5 years of LTCH hospitalization. After accounting for acute illness characteristics, prehospitalization survival prognosis as determined by the Lee index score and severe baseline impairment (functional, cognitive, or both) were associated with an increased likelihood of death or severe impairment in the 2.5 years after LTCH hospitalization (adjusted odds ratio [AOR], 3.2 [95% CI, 1.7 to 6.0] for a 5-point increase in Lee index score; and AOR, 4.5 [95% CI, 1.3 to 15.4] for severe vs no impairment). Conclusions and Relevance: In this cohort study, 4 of 5 middle-aged and older adults died or survived with severe impairment within 2.5 years of LTCH hospitalization. Better preadmission survival prognosis and functional and cognitive status were associated with lower risk of an adverse outcome, and these findings should inform decision-making for older adults with prolonged acute illness.

Trajectories of medical care expenditure in the last year of life associated with long-term care utilization in frail older adults: A retrospective cohort study.

BACKGROUND: Medical care and long-term care utilization in the last year of life of frail older adults could be a key indicator of their quality of life. This study aimed to identify the medical care expenditure (MCE) trajectories in the last year of life of frail older adults by investigating the association between MCE and long-term care utilization in each trajectory. METHODS: The retrospective cohort study of three municipalities in Japan included 405 decedents (median age at death, 85 years; 189 women [46.7%]) from a cohort of 1,658 frail older adults aged ≥65 years who were newly certified as support level in the long-term care insurance program from April 2012 to March 2013. This study used long-term care and medical insurance claim data from April 2012 to March 2017. The primary outcome was MCE over the 12 months preceding death. Group-based trajectory modeling was conducted to identify the MCE trajectories. A mixed-effect model was employed to examine the association between long-term care utilization and MCE in each trajectory. RESULTS: Participants were stratified into four groups based on MCE trajectories over the 12 months preceding death as follows: rising (n = 159, 39.3%), persistently high (n = 143, 35.3%), minimal (n = 56, 13.8%), and descending (n = 47, 11.6%) groups. Home-based long-term care utilization was associated with increased MCE in the descending trajectory (coefficient, 1.48; 95% confidence interval [CI], 1.35-1.62). Facility-based long-term care utilization was associated with reduced MCE in the rising trajectory (coefficient, 0.59; 95% CI, 0.50-0.69). Both home-based (coefficient, 0.92; 95% CI, 0.85-0.99) and facility-based (coefficient; 0.53; 95% CI, 0.41-0.63) long-term care utilization were associated with reduced MCE in the persistently high trajectory. CONCLUSIONS: These findings may facilitate the integration of medical and long-term care models at the end of life in frail older adults.

Sequencing analysis of SARS-CoV-2 cases in Slovenian long-term care facilities to support outbreak control.

Introduction: Residents of long-term care facilities (LTCFs) are at high risk of morbidity and mortality due to COVID-19, especially when new variants of concern (VOC) emerge. To provide intradisciplinary data in order to tailor public health interventions during future epidemics, available epidemiologic and genomic data from Slovenian LTCFs during the initial phases of the COVID-19 pandemic was analyzed. Methods: The first part of the study included SARS-CoV-2 reverse-transcription Real-Time PCR (rtRT-PCR) positive LTCF residents, from 21 facilities with COVID-19 outbreaks occurring in October 2020. The second part of the study included SARS-CoV-2 rtRT-PCR positive LTCF residents and staff between January and April 2021, when VOC Alpha emerged in Slovenia. Next-generation sequencing (NGS) was used to acquire SARS-CoV-2 genomes, and lineage determination. In-depth phylogenetic and mutational profile analysis were performed and coupled with available field epidemiological data to assess the dynamics of SARS-CoV-2 introduction and transmission. Results: 370/498 SARS-CoV-2 positive residents as well as 558/699 SARS-CoV-2 positive residents and 301/358 staff were successfully sequenced in the first and second part of the study, respectively. In October 2020, COVID-19 outbreaks in the 21 LTCFs were caused by intra-facility transmission as well as multiple independent SARS-CoV-2 introductions. The Alpha variant was confirmed in the first LTCF resident approximately 1.5 months after the first Alpha case was identified in Slovenia. The data also showed a slower replacement of existing variants by Alpha in residents compared to staff and the general population. Discussion: Multiple SARS CoV-2 introductions as well as intra-facility spreading impacted disease transmission in Slovenian LTCFs. Timely implementation of control measures aimed at limiting new introductions while controlling in-facility transmission are of paramount importance, especially as new VOCs emerge. Sequencing, in conjunction with epidemiological data, can facilitate the determination of the need for future improvements in control measures to protect LTCF residents from COVID-19 or other respiratory infections.

Mental health in nursing homes: The role of immigration in the long-term care workforce.

One-fourth of nursing home residents are diagnosed with anxiety disorders and approximately half live with depression. Nursing homes have long struggled with staffing shortages, and the lack of care has further heightened the risk of poor mental health. A key solution to both problems could be immigration. Prior studies have documented how immigrant labor could strengthen the long-term care workforce. We add to this picture by exploring the impact of immigrant inflows on the mental health outcomes of nursing home residents. Using a nationally representative dataset and a shift-share instrumental variable approach, we find empirical evidence that immigration reduces diagnoses of depression and anxiety, the use of antidepressant and antianxiety drugs, and self-assessed symptoms of depression. The results are robust to several sensitivity tests. We further find that the effect is more substantial in facilities with lower direct care staff hours per resident and with likely more immigrants without citizenship. Language barriers tend to be a minor issue when providing essential care. The findings suggest that creating a policy framework that directs immigrant labor to the long-term care sector can mutually benefit job-seeking immigrants and nursing home residents.

National trends in utilisation of glucose lowering medicines by older people with diabetes in long-term care facilities.

AIMS: To examine national trends in glucose lowering medicine (GLM) use among older people with diabetes in long-term care facilities (LTCFs) during 2009-2019. METHODS: A repeated cross-sectional study of individuals ≥65 years with diabetes in Australian LTCFs (n = 140,322) was conducted. Annual age-sex standardised prevalence of GLM use and number of defined daily doses (DDDs)/1000 resident-days were estimated. Multivariable Poisson or Negative binomial regression models were used to estimate adjusted rate ratios (aRRs) and 95 % confidence intervals (CIs). RESULTS: Prevalence of GLM use remained steady between 2009 (63.9%, 95 %CI 63.3-64.4) and 2019 (64.3%, 95 %CI 63.9-64.8) (aRR 1.00, 95 %CI 1.00-1.00). The percentage of residents receiving metformin increased from 36.0% (95 %CI 35.3-36.7) to 43.5% (95 %CI 42.9-44.1) (aRR 1.01, 95 %CI 1.01-1.01). Insulin use also increased from 21.5% (95 %CI 21.0-22.0) to 27.0% (95 %CI 26.5-27.5) (aRR 1.02, 95 %CI 1.02-1.02). Dipeptidyl peptidase-4 inhibitor use increased from 1.0% (95 %CI 0.9-1.1) to 21.1% (95 %CI 20.7-21.5) (aRR 1.24, 95 %CI 1.24-1.25), while sulfonylurea use decreased from 34.4% (95 %CI 33.8-35.1) to 19.3% (95 %CI 18.9-19.7) (aRR 0.93, 95 %CI 0.93-0.94). Similar trends were observed in DDDs/1000 resident days. CONCLUSIONS: The increasing use of insulin and ongoing use of sulfonylureas suggests a need to implement evidence-based strategies to optimise diabetes care in LTCFs.

Predictors of mortality shortly after entering a long-term care facility.

OBJECTIVE: Moving into a long-term care facility (LTCF) requires substantial personal, societal and financial investment. Identifying those at high risk of short-term mortality after LTCF entry can help with care planning and risk factor management. This study aimed to: (i) examine individual-, facility-, medication-, system- and healthcare-related predictors for 90-day mortality at entry into an LTCF and (ii) create risk profiles for this outcome. DESIGN: Retrospective cohort study using data from the Registry of Senior Australians. SUBJECTS: Individuals aged ≥ 65 years old with first-time permanent entry into an LTCF in three Australian states between 01 January 2013 and 31 December 2016. METHODS: A prediction model for 90-day mortality was developed using Cox regression with the purposeful variable selection approach. Individual-, medication-, system- and healthcare-related factors known at entry into an LTCF were examined as predictors. Harrell's C-index assessed the predictive ability of our risk models. RESULTS: 116,192 individuals who entered 1,967 facilities, of which 9.4% (N = 10,910) died within 90 days, were studied. We identified 51 predictors of mortality, five of which were effect modifiers. The strongest predictors included activities of daily living category (hazard ratio [HR] = 5.41, 95% confidence interval [CI] = 4.99-5.88 for high vs low), high level of complex health conditions (HR = 1.67, 95% CI = 1.58-1.77 for high vs low), several medication classes and male sex (HR = 1.59, 95% CI = 1.53-1.65). The model out-of-sample Harrell's C-index was 0.773. CONCLUSIONS: Our mortality prediction model, which includes several strongly associated factors, can moderately well identify individuals at high risk of mortality upon LTCF entry.

Characteristics of first-time users of the nursing small-scale multifunctional home care service: a pooled cross-sectional study using Japanese long-term care insurance claims data from 2012 to 2019.

OBJECTIVES: In April 2012, the Japanese government launched a new nursing service called the nursing small-scale multifunctional home care (NSMHC) to meet the nursing care demands of individuals with moderate-to-severe activities of daily living (ADLs) dysfunction and who require medical care, thereby allowing them to continue living in the community. We aimed to preliminarily analyse the characteristics of first-time users of NSMHC service. DESIGN: This pooled cross-sectional study used the Japanese long-term care insurance (LTCI) claims data from the users' first use of NSMHC (from April 2012 to December 2019). SETTING: NSMHC includes nursing home visits, home care, daycare, overnight stays and medical treatment. PARTICIPANTS: The study population included LTCI beneficiaries who received their first long-term care requirement certification in Japan from April 2012 onwards, died between April 2012 and December 2019, and used any LTCI service at least once. RESULTS: Among the 836 563 individuals who used any LTCI service at least once, 3957 (0.47%) used NSMHC. We analysed 3634 individuals without any missing data regarding long-term care requirement certification. Most individuals were aged 80 years or older, with 64.3% requiring care level 3 or above, indicating complete assistance with ADLs. Regarding ADLs in individuals with dementia, 70.6% were at level 2 or below, indicating they can live almost independently even with dementia. A large proportion of NSMHC users availed the service approximately 6 months before death, with no prior use of any LTCI services; they continued using the service for around 4 months, although some people continued to use NSMHC until their month of death. CONCLUSIONS: Using individual data on nationwide LTCI, we described the characteristics of first-time users of NSMHC among those who died within 7.5 years from the first certification of care needs. Further studies are needed to investigate the effect of NSMHC use on user outcomes.

Older adults preferences for long-term caregivers in China: a discrete choice experiment.

OBJECTIVE: Understanding the preferences of old-age adults for their long-term caregivers can improve person-centred health care and the quality of long-term care (LTC). This study examines Chinese older adults' preferences for long-term caregivers. STUDY DESIGN: This is a cross-sectional study. METHODS: A national representative discrete choice experiment (DCE) surveyed 2031 adults aged 50-70 across 12 provinces in China. Each DCE scenario described five attributes: type of caregivers, place of LTC, contents of LTC, out-of-pocket payments, and quality of life (QoL). Preferences and the marginal willingness to pay (WTP) were derived using mixed-logit and latent class models. RESULTS: Older adults displayed higher preferences for long-term caregivers who improve their QoL, incur lower out-of-pocket payments, and provide medical LTC services at home, with the maximum WTP of $22.832 per month. QoL was rated as the most important LTC factor, followed by the place of LTC and the type of caregivers. When the level of QoL improved from poor to good, respondents would be willing to pay $18.375 per month more (95% confidence interval: 16.858 to 20.137), and the uptake rate increased by 76.47%. There was preference heterogeneity among older people with different sex, education, family size, and knowledge of LTC insurance. CONCLUSION: QoL was the most important factor in older Chinese adults' preference for caregivers. Home care and medical care from formal caregivers was preferred by older adults. We recommend training family caregivers, raising older people's awareness of LTC insurance, and guiding policymakers in developing people-oriented LTC and a multi-level LTC system.

Potentially inappropriate prescriptions for poly-treated patients in long-term care facilities: retrospective pharmacoutilization analysis.

BACKGROUND This study aimed to investigate, among elderly patients in long-term care (LTC) facilities, potentially inappropriate drug prescriptions, potentially interactions and verify whether they can be traced back to hospitalisations or accesses to the Emergency Department (ED). The study data were acquired by means of a case report form investigating the medication management process in LTCs. MATERIAL AND METHODS Analysis of pharmacutilisation in LTCFs patients aged ≥65 years on polypharmacy or excessive polypharmacy, January-July 2023. Data was extracted from a database (DB) containing the monthly prescriptions of medicines supplied by direct distribution (DD) to LTCs. The prevalence of PIMs was evaluated by applying the Beers and STOPP criteria to the medication profile of each patient. RESULTS The overall prevalence of polypharmacy and hyperpolypharmacy was 83% and 17%, respectively. PIMs were defined using Beers and STOPP criteria. The most frequent PIMs were proton pump inhibitors (19% e 15%), antiplatelets agent (17% e 13%) and non-associated sulfonamides (14% e 12%). Of the 1,921 PIMs, 121 were contraindicated or very serious (6%) and 1,800 were major (94%).The most common medicaments involved in drug-drug interaction are furosemide (21%), sertraline (19%), pantoprazole (16%) e trazodone (15%). LTCs participating in the study (56%) excluded polypharmacy as a cause of access to the ED and ADRs. Therefore no case was ever reported (100%). CONCLUSIONS Polypharmacy or excessive polypharmacy among elderly patients may increase PIMs and ADRs. A constant review of the therapeutic regimens and deprescribing decrease inappropriate use of medications and interactions, ADRs, and accesses to the ED with consequent reduction of pharmaceutical spending.

Demand for Continuous and Long-Term Care in Transplant Recipients: Data From the Organ Transplantation Registry-Poltransplant Activity.

BACKGROUND: This study aimed to determine the number of recipients with active transplants under the care of transplant centers in 2022 and the current volume and needs for continuous and long-term care in this group of transplant recipients. Data came from the organ transplant registry, one of the registries maintained by the Polish Transplant Coordinating Center Poltransplant. We included recipients of individual organs who, on January 1, 2022, were living with an active transplant performed in previous years and recipients who received a transplant in 2022. The number of recipients under the care of transplant centers in 2022 was 20,994 (55% of all transplants performed in Poland since the beginning of activity in 1966).

Ascertaining the Francophone population in Ontario: validating the language variable in health data.

BACKGROUND: Language barriers can impact health care and outcomes. Valid and reliable language data is central to studying health inequalities in linguistic minorities. In Canada, language variables are available in administrative health databases; however, the validity of these variables has not been studied. This study assessed concordance between language variables from administrative health databases and language variables from the Canadian Community Health Survey (CCHS) to identify Francophones in Ontario. METHODS: An Ontario combined sample of CCHS cycles from 2000 to 2012 (from participants who consented to link their data) was individually linked to three administrative databases (home care, long-term care [LTC], and mental health admissions). In total, 27,111 respondents had at least one encounter in one of the three databases. Language spoken at home (LOSH) and first official language spoken (FOLS) from CCHS were used as reference standards to assess their concordance with the language variables in administrative health databases, using the Cohen kappa, sensitivity, specificity, positive predictive value (PPV), and negative predictive values (NPV). RESULTS: Language variables from home care and LTC databases had the highest agreement with LOSH (kappa = 0.76 [95%CI, 0.735-0.793] and 0.75 [95%CI, 0.70-0.80], respectively) and FOLS (kappa = 0.66 for both). Sensitivity was higher with LOSH as the reference standard (75.5% [95%CI, 71.6-79.0] and 74.2% [95%CI, 67.3-80.1] for home care and LTC, respectively). With FOLS as the reference standard, the language variables in both data sources had modest sensitivity (53.1% [95%CI, 49.8-56.4] and 54.1% [95%CI, 48.3-59.7] in home care and LTC, respectively) but very high specificity (99.8% [95%CI, 99.7-99.9] and 99.6% [95%CI, 99.4-99.8]) and predictive values. The language variable from mental health admissions had poor agreement with all language variables in the CCHS. CONCLUSIONS: Language variables in home care and LTC health databases were most consistent with the language often spoken at home. Studies using language variables from administrative data can use the sensitivity and specificity reported from this study to gauge the level of mis-ascertainment error and the resulting bias.

Long-term care needs and hospitalization costs with long-term care insurance: a mixed-sectional study.

Background: With the rapid aging of the population, the health needs of the older adult have increased significantly, resulting in the frequent occurrence of the "social hospitalization" problem, which has led to a rapid increase in hospitalization costs. This study investigates whether the "social hospitalization problem" arising from the long-term care needs can be solved through the implementation of long-term care insurance, thereby improving the overall health of the older adults and controlling the unreasonable increase in hospitalization costs. Methods: The entropy theory was used as a conceptual model, based on data from the China Health and Retirement Longitudinal Study (CHARLS) in 2015 and 2018. The least-squares method was used to examine the relationship between long-term care needs and hospitalization costs, and the role that long-term care insurance implementation plays in its path of influence. Results: The results of this study indicated that long-term care needs would increase hospitalization cost, which remained stable after a series of tests, such as replacing the core explanatory variables and introducing fixed effects. Through the intermediary effect test and mediated adjustment effect test, we found the action path of long-term care needs on hospitalization costs. Long-term care needs increases hospitalization costs through more hospitalizations. Long-term care insurance reduces hospitalization costs. Its specific action path makes long-term care insurance reduce hospitalization costs through a negative adjustment of the number of hospitalizations. Conclusion: To achieve fair and sustainable development of long-term care insurance, the following points should be achieved: First, long-term care insurance should consider the prevention in advance and expand the scope of participation and coverage; Second, long-term care insurance should consider the control in the event and set moderate levels of treatment payments; Third, long-term care insurance should consider post-supervision and explore appropriate payment methods.

Costs of care trajectories of people with dementia compared with matched controls. Longitudinal analysis of linked health and administrative data.

OBJECTIVES: To provide insight into the health and social care costs during the disease trajectory in persons with dementia and the impact of institutionalization and death on healthcare costs compared with matched persons without dementia. METHODS: Electronic health record data from family physicians were linked with national administrative databases to estimate costs of primary care, medication, secondary care, mental care, home care and institutional care for people with dementia and matched persons from the year before the recorded dementia diagnosis until death or a maximum of 4 years after the diagnosis. RESULTS: Total mean health and social care costs among persons with dementia increased substantially during the disease trajectory, mainly due to institutional care costs. For people who remained living in the community, mean health and social care costs are higher for people with dementia than for those without dementia, while for those who are admitted to a long-term care facility, mean health and social care costs are higher for people without dementia than for those with dementia. CONCLUSIONS: The steep rise in health and social care costs across the dementia care trajectory is mainly due to increasing costs for institutional care. For those remaining in the community, home care costs and hospital care costs were the main cost drivers. Future research should adopt a societal perspective to investigate the influence of including social costs.

Trends in Life Expectancy in Residential Long-Term Care by Sociodemographic Position in 1999-2018: A Multistate Life Table Study of Finnish Older Adults.

OBJECTIVES: Residential long-term care (LTC) use has declined in many countries over the past years. This study quantifies how changing rates of entry, exit, and mortality have contributed to trends in life expectancy in LTC (i.e., average time spent in LTC after age 65) across sociodemographic groups. METHODS: We analyzed population-register data of all Finns aged ≥65 during 1999-2018 (n = 2,016,987) with dates of LTC and death and sociodemographic characteristics. We estimated transition rates between home, LTC, and death using Poisson generalized additive models, and calculated multistate life tables across 1999-2003, 2004-2008, 2009-2013, and 2014-2018. RESULTS: Between 1999-2003 and 2004-2008, life expectancy in LTC increased from 0.75 (95% CI: 0.74-0.76) to 0.89 (95% CI: 0.88-0.90) years among men and from 1.61 (95% CI: 1.59-1.62) to 1.83 (95% CI: 1.81-1.85) years among women, mainly due to declining exit rates from LTC. Thereafter, life expectancy in LTC decreased, reaching 0.80 (95% CI: 0.79-0.81) and 1.51 (95% CI: 1.50-1.53) years among men and women, respectively, in 2014-2018. Especially among women and nonmarried men, the decline was largely due to increasing death rates in LTC. Admission rates declined throughout the study period, which offset the increase in life expectancy in LTC attributable to declining mortality in the community. Marital status differences in life expectancy in LTC narrowed over time. DISCUSSION: Recent declines in LTC use were driven by postponed LTC admission closer to death. The results suggest that across sociodemographic strata older adults enter LTC in even worse health and spend a shorter time in care than before.

Factors associated with dietitian referrals to support long-term care residents advancing towards the end of life.

BACKGROUND: Dietitians are central members of the multidisciplinary long-term care (LTC) healthcare team. The overall aim of this current investigation is to gain a better understanding of dietitian involvement in LTC resident's end-of-life care via referrals. METHODS: Retrospective chart reviews for 164 deceased residents (mean age = 88.3 ± 7.3; 61% female) in 18 LTC homes in Ontario, Canada, identified dietitian referrals and documented eating challenges recorded over 2-week periods at four time points (i.e., 6 months, 3 months, 1 month and 2 weeks) prior to death. Nutrition care plans at the beginning of these time points were also noted. Logistic mixed effects regression models identified time-varying predictors of dietitian referrals. Bivariate tests identified associations between nutrition orders and dietitian referrals that occurred in the last month of life. RESULTS: Nearly three-quarters (73%) of participants had at least one dietitian referral across the four observations. Referrals increased significantly with proximity to death; 45% of residents had a referral documented in the last 2 weeks of life. Dietitian referrals were associated with the number of eating challenges (odds ratio [OR] = 1.42, 95% confidence interval [CI] = 1.27, 1.58). Comfort-focused nutrition care orders were significantly more common when a dietitian was referred (25%) compared with when a dietitian was not referred (12%) in the final month of life (p = 0.04). CONCLUSIONS: Our findings suggest that dietitians are involved in end-of-life and comfort-focused nutrition care initiatives, yet they are not engaged consistently for this purpose. This presents a significant opportunity for dietitians to upskill and champion palliative approaches to nutrition care within the multidisciplinary LTC team.

Long-term care use, hospitalizations and mortality during COVID-19 in Finland and Sweden: A nationwide register-based study in 2020.

AIM: To describe long-term care (LTC) use in Finland and Sweden in 2020, by reporting residential entry and exit patterns including hospital admissions and mortality, compared with the 2018-2019 period and community-living individuals. METHODS: From national registers in Finland and Sweden, all individuals 70+ were included. Using the Finnish and Swedish study populations in January 2018 as the standard population, we reported changes in sex- and age-standardized monthly rates of entry into and exit from LTC facilities, mortality and hospital admission among LTC residents and community-living individuals in 2020. RESULTS: Around 850,000 Finns and 1.4 million Swedes 70+ were included. LTC use decreased in both countries from 2018 to 2020. In the first wave (March/April 2020), Finland experienced a decrease in LTC entry rates and an increase in LTC exit rates, both more marked than Sweden. This was largely due to short-term movements. Mortality rates peaked in April and December 2020 for LTC residents in Finland, while mortality peaked for both community-living individuals and LTC residents in Sweden. A decrease in hospital admissions from LTC facilities occurred in April 2020 and was less marked in Finland versus Sweden. CONCLUSIONS: During the first wave of the pandemic mortality was consistently higher in Sweden. We also found a larger decrease in LTC use and, among LTC residents, a smaller decrease in hospital admissions in Finland than in Sweden. This study calls for assessing the health consequences of the differences observed between these two Scandinavian countries as part of the lessons from the COVID-19 pandemic.

Tracking long-term services and supports rebalancing through workforce data.

OBJECTIVE: To understand trends in the long-term services and supports (LTSS) workforce and assess workforce data as a measure of progress in shifting LTSS resources from institutional to community-based settings. DATA SOURCES/STUDY SETTING: Workforce data from the American Community Survey from 2008 to 2022. STUDY DESIGN: Measures of LTSS rebalancing and institutional and community workforce supply per 1000 persons with LTSS needs were constructed. After showing national trends over the study period, state fixed effects regressions were used to evaluate the within-state relationship of these measures with existing measures of LTSS utilization. Workforce supply measures were compared to the percentage of state Medicaid LTSS spending spent in the community to assess their utility for across state comparisons. Each state's progress in LTSS rebalancing over the study period was then shown using workforce data. DATA COLLECTION/EXTRACTION METHODS: A sample of 336,316 LTSS workers and 3,015,284 people with LTSS needs over the study period was derived from American Community Survey data. PRINCIPAL FINDINGS: From 2008 to 2022, the percentage of the LTSS workforce employed in the community rose from 44% to 58%. Thirty states saw more than a 10 percentage point increase. From 2008 to 2013, the size of the community workforce expanded dramatically but has since stagnated. In contrast, the institutional workforce entered a long-term decline beginning in 2015 that accelerated during the COVID-19 pandemic. State fixed effects regressions showed that measures of workforce supply have a strong relationship with LTSS utilization measures for older adults, but not for younger people with disabilities. CONCLUSIONS: Workforce data can serve as an effective measure of changes in LTSS utilization for older adults. This offers researchers and policymakers a useful alternative to administrative claims, bypassing threats to comparability from coding changes and the shift to managed care. Additional data is needed on workforce trends in services for younger LTSS consumers.